Photo by Hatcher & Fell

By Phil la Duke

Note: I am posting about 18 hours early this week.  (in other words I won’t have another post until a week from tomorrow.

Yesterday I posted a link my latest column in darn near all the LinkedIn groups to which I belong. In one, a clearly deluded reader (who admitted that he hadn’t actually READ the article but felt compelled to comment none-the-less, asked the question, why do so few CEO’s rise from the ranks of safety professionals. I admit I am hard on safety professionals. But would YOU promote a professional who comments on the substance of an article he didn’t read? Please someone slap this man. Seriously, a couple of open handed whacks upside the head would probably do him good. But before I could launch into a venomous poison toner post (the digital equivalent of the poison pen letter) another group member had to spoil it by posting a very good and well thought out point—CEOs need business skills and a host of other skills beyond safety skills. This got me thinking, and mercifully NOT about why safety professionals need business skills but the opposite: why do successful business professionals need safety skills? So this week I am going to cut the safety professionals some slack, and focus instead on the C+ suite.

1. A poor safety record is a symptom of far more serious risks. Injuries happen most frequently when a process fails (the process was not designed to intentionally injure workers). The more robust and tightly controlled the process the more likely process variation will produce unexpected and unwanted results. Business leaders who dismiss safety as overkill, overly protective, and unnecessary are highly likely to view quality, productivity, and efficiency in a similar vein. These dolts don’t understand the concept of process control and are likely to run the business into the ground. Poor Safety Record=Inability to properly manage. In a well-managed operation, process defects are typically discovered long before someone is injured. Near miss reporting, Total Productive Maintenance (TPM), Layered Process audits, and 5S all have the potential for identifying containing and correcting the causes of injuries; worker injuries mean those efforts are not being properly managed and tell the savvy executive that changes need to be made.
2. Safety is a strategic business element. World-class manufacturers manage their operations using a balanced score card that visually manages the key indicators in Safety, Quality, Delivery, Cost, Morale. Some forward thinking businesses include Environment as one of their business measures as well. The point of a balanced score card is two-fold, 1) it creates visual representations of the most important trends of these elements and 2) it seeks to maintain a balance between these elements. So while an initiative may increase the safety of the workplace by 20% but would greatly inhibit quality and delivery or be prohibitively expensive, the benefit is off-set by the imbalance it creates in the overall system. The need for organizational balance is often lost in those of us, including safety professionals, who work in a silo or an area of functional specialty. But a good executive also knows how to balance the needs of the specialists against the needs of the generalist.
3. Safety must be owned at the C+ Level. More and more CEOs who believe that when it comes to safety they “have people for that” are finding themselves inside of a jail cell. I typically work with CEOs or at a minimum COOs and I am yet to meet one who isn’t acutely aware that they are legally culpable for safety. But fear of prison is a poor motivator for owning safety. Safety has to be owned at the C-level because the safety function is often in conflict with other functions and it is incumbent on executives to find the balance between the departments. Safety doesn’t win every dispute and cannot be allowed to see itself as somehow outside the organization’s goals and strategy.
4. Safety supports operations not impedes it. Executives who kowtow to every recommendation that comes out of safety end up destroying the organization. Some safety professionals have zero business acumen and following their recommendations without questioning them can ruin a company. The safest companies around are those that went out of business because they couldn’t compete. A good executive understands that safety must support operations not impede it. That’s not to say that executives should let Operations ignore legitimate safety concerns. There are risks on both sides of any issue and it falls to the executive to carefully weigh them before deciding.
5. Safety isn’t a goal, it’s a criteria for success. Far too often safety is expressed as a goal, and that is wrong. Safety isn’t our goal it’s a criteria for fulfilling a goal. A smart executive knows that a goal that throws the organization out of balance really hasn’t been successfully met. Far too often greedy executives game the system by meeting the goals on which their bonuses are based to the detriment of the overall health of the organization. These tend to be high profile news stories in which a fired executive is given a golden parachute or a bankrupt company pays out an obscene bonus. I can’t say I blame the execs for cashing in, but it’s a bit like malicious obedience (the practice of doing something exactly the way your boss tells you to knowing full well that doing so will end in disaster). In Detroit, where I live, there is something tantamount to a cottage industry in bankrupting automotive suppliers; it’s become a bona fide niche for some of these brain dead Baby Boomer executurds. But I wouldn’t exactly describe these executives as bright or capably. More cunning, wily, or shrewd; like some hyena or an obese rat, but yet again, I digress.
6. Safety is not exempted from the demand for ROI. A good executive doesn’t take the safety department’s word on things, rather he or she expects a risk assessment, an assessment of the cost and risk of the current state (and doing nothing) and an expected Return On Investment. Too many safety professionals get themselves all consternated at the thought that they might be held accountable for a financial result. Sharp executives understand that while the organization might not have all the parts of this equation figured out, that doesn’t mean that the safety professional should be able to make a calculated estimate from which to work. Not only is measuring the effectiveness of safety possible, it’s essential.
7. Safety isn’t your number one priority. If safety is your number one priority you have no business being CEO. Keeping the organization viable is your number one priority. That having been said, a poor safety record subjects the organization to needless risk so while it may not be the top priority it’s pretty damned important. Show me an executive who thinks that safety is the number one priority and I will show you an ineffectual, and perhaps stupid, executive. I believe that managing risk is essential to keeping the organizational viable and making it successful. A safe, effective workplace has the best chance of remaining in business.
8. It might be time to clean house in the safety function. There are a lot of imbeciles working in safety, perhaps some at your organization. Furthermore, there are a lot of safety professionals who mean well but cling to outmoded, unproven, and junk-science based safety practices. Some of these people can change and some of these people need to be encouraged to explore other opportunities.  The good news is that there are a ton of smart, forward looking, pragmatic safety professionals waiting for an opportunity.
9. Deming applies to safety. I’ve already written volumes on how Deming applies to safety so I won’t retread the topic here. Read my other articles and posts on the subject if you want to know how Deming applies to safety
10. Safety is about Risk, not behavior. Perhaps the most persistently popular safety quackery is rooted in the belief that most workers get hurt because they are lazy, stupid, or reckless. There was a time when people believed the same thing about quality. Top executives don’t expect the workers to keep themselves safe, rather they expect workers to actively engage in finding ways to make the workplace safer. Smart executives aren’t taken in by safety fads and shortcuts.

Photo taken by Phil La Duke, Atlantic City Boardwalk

I have no hope of posting this post on time, and no one will hold me accountable.  Understanding the lexicon of safety is tough and without understanding there can be no communication.

Safety, these days, is full of the mealy mouthed;  people who use the same words but in a context so esoteric that a common understanding is a complete impossibility.  One of these words that get bantered around fairly frequently is “accountability”.  There is an increasing call for “accountability” by safety professionals who have been rendered impotent by operations leadership who fail to “hold workers accountable” for failing to work safe.

Defining accountability is central to any safety process, and in fact, central to any process.  Safety professionals and engineers can institute as many administrative controls and policies in place all they want but unless people are held accountable for following the rules.  But accountability is more than just punishing the guilty or misfortunate.  Accountability means that all involved must be called to answer for whatever consequences happen.  If sounds ominous it too often is.  As safety professionals we need to rethink accountable.  Safety has to be above punishing people for their mistakes, the risks they took, and in some cases even their recklessness.

I don’t want this post to be another post about Just Culture.  A fair and just culture is essential to encouraging people to be forthright about their near misses, minor injuries and general screw-ups.  There is something deep in the definition of the word accountable that is at the heart of safety.  As I said, accountable should be seen as synonymous with the word “answerable”. When we hold someone accountable, we are holding him or her responsible for the answers associated with an incident. So instead of interpreting “accountable” as paying one’s debt to society or being subject to punishment, we should look to them as leading the efforts to learn from our mistakes.  Someone is accountable to the organization for learning what can be done to prevent future incidents and what can be done to improve the process so that future mistakes will not result in injuries.

When we hold someone accountable it is because we respect him or her and count on him or her to do the right thing.  We hold a person answerable because we know he or she will take the responsibility seriously and will work toward an honorable solution.  Accountability is different from blame. Blame is a tool for cowards and bullies.  Blame is a way of kicking someone when he or she is down.  Self righteous hypocrites love to shame and blame, for them blame is a way belittling the guilty and making themselves feel superior; that may work on the playground, but it is a sorry excuse for a grown up that relies on shame and blame to solve problems.

Accountability transcends the offender.  It may not be popular to absolve an individual in favor of blaming the system. Blaming the system is no more productive than blaming an individual.  Because when once we have assigned blame, we really don’t have to do anything else but to exact vengeance, and how can we punish a system, instead, we throw up our hands and say “the system is broken” or “it’s our culture”.  If we seek accountability instead of blame, we can seek answers from manufacturing engineers, human resources, and even leadership itself. These answers can lead us to process improvements and real and substantial safety innovations.

As long as we are holding people accountable, we should take a hard look at our culpability in workplace injuries.  We are all accountable for making the workplace safer.  As safety professionals we bear the responsibility for making our process more efficient, more profitable, and more cost effective.  Only by turning the lens on ourselves and holding ourselves answerable for a more robust and agile safety function can we ever expect to take safety forward.

By Phil La Duke

W. Edward Deming (source http://alanpippenger.com/?page_id=11)

I typically don’t do back-to-back themed posts, preferring instead to intersperse a topic like Deming On Safety with something topical on safety. Truth be told, I should be writing my column for the March Fabricating and Metalworking, but last week’s post on how Demings 14 points relates to Safety was so popular and well received that I just couldn’t resist writing one more post.

This week I thought I would explore Deming’s fifth point, “Institute Training On the Job” As with the other points on which I’ve written, this too applies fairly directly to safety. In the interest of full disclosure I should tell you that I am a training nerd, a lean nerd, a manufacturing nerd and a performance improvement nerd. I hold a certificate in Training, Design and Development from the University of Michigan and have worked for many years helping companies to improve. When I was ultimately hired to help UAW-DaimlerChrysler to develop the Bringing Excellence to Safety Teams (B.E.S.T.) initiative I was able to connect and bring to bear all I knew about Lean and Performance Improvement to the world of Worker Safety.

Years later, as I designed and built SafetyIMPACT! for my employer I took pains to consider how Deming would view all the innovations we were making to safety. For the record, this isn’t a commercial. I’m not trying to get any of you to hire me (although it wouldn’t kill you to hire me to consult, would it?) But I have found it astonishing how few safety professionals are able to understand that Deming’s principles not only apply to safety, but they make the job of the safety professional easier.

Nowhere is the connection between Deming’s 14 points and worker safety better illustrated than in point 4: Institute training on the job. It sounds pretty rudimentary doesn’t it? Is there anyone working in any industry today that doesn’t intuitively understand the link between the quality of the product and the efficacy of the training the worker receives? In fairness to Deming, effective training has not always been the norm. In 1985 I was hired as a hardware installer in the cushion room of the General Motors Fleetwood Plant. The building was built circa 1890 and originally produced coaches for horse-and-buggy carriages. It was a six-story hulking brute that sat hunched at the base of the Rouge River Bridge. My job was to install seat locks (the—often jagged—pieces of metal about a foot long that held the seat bottom to the back.) The job was literally back breaking work at a time when OSHA was a neophyte and little was done to protect workers. My training consisted of shadowing Randy, a good natured, burly, seldom sober, experienced worker. Randy had just won his bid on a plumb assignment (assembling arm rests) that he could do in 5 hours while drunk or high on cocaine. To be fair, Randy taught me well. In those days safety glasses weren’t required so if I wasn’t careful tiny metal slivers would blow into my eyes. Randy also recommended that I get a pair of steel toed shoes even though they too weren’t required. Not everything that Randy taught me was sterling. I learned that my unusually long air hose (procured using charm and back channel connections so I could work out of station, or up the line and get a couple more seconds of butt time) was a trip hazard by doing just that and cracking my wrist on a the metal frame of conveyor belt. I learned that installing a recliner frame incorrectly would spiral the seat or the 15lb metal part at my head. And most painfully, I learned that the sharp metal parts would easily destroy my cloth gloves and I needed to steal a fresh pair for after lunch.

So Deming’s advice wasn’t so condescending after all. But maybe there is more to Deming’s fifth point than something so obvious. Safety training, and the odorous Behaviour Based Safety, has become more than a cottage industry; its big business. And Government regulations mean that many organizations (fearful that customized training might not meet the requirements) exclusively use training designed for the widest possible audience. I don’t think Deming would not be happy with safety training that is conducted in a classroom without any context. I prefer to interpret this particular point literally, that is, I think Deming would recommend that safety training, to the extent possible be conducted at the workstation under the exact working conditions. This means that if there are hazards associated with a particular chemical used in a given job, the worker should be trained in how to read the Material Safety Data Sheet for that chemical as he is using the chemical for the first time.

Just the term, “Safety Training” would probably give Deming the willies. Is there any training in production that isn’t related to safety? Even an office job has ergonomic considerations that should be addressed in word processing or spreadsheet software training. In fact, there are scarce few instances where safety shouldn’t be a principle concern in training of any sort. Years ago I was a consultant to Ford where I helped it develop a hybrid focus factory approach in the U.S. and Hungary. I began every training course, I developed with an exploration of the safety in the context of performing the specific tasks being performed. Sure we had training that we purchased, but it was to augment (and truthfully to ensure compliance) training that we custom-designed for the operation. I believe now as I believed then that the most powerful and effective safety training is that which is seamlessly embedded into the job aids, Standard Work Instructions, and training courses used to teach workers how to successfully do their jobs.

My personal experience with safety goes even further back, however. Prior to my job at General Motors I worked as a security guard at a Nuclear Power Plant. While I can’t tell you much about my experiences there for obvious reasons, I can say unequivocally that every bit of training I received not only had safety embedded but had safety overtones. Some of you might be surprised just how dangerous some ordinarily innocuous conditions can be in a nuclear context. Learning to do my job and learning to do my job safely were the same thing.

There is a growing movement in worker safety to create a “safety culture” and unfortunately most of the people selling these services no less than squat about organizational change or culture. You already have a safety culture, in that your company has some view of safety. Safety is a value within your organizations. Some organizations place a great deal of value on safety and other do not. I guess I am just arguing semantics here so please forgive me. If you want your culture to place a higher value and importance on safety start by improving your training. Training is where respect and demand for safety is fostered, reinforced, and where the demand for it is created.

W. Edward Deming (source http://alanpippenger.com/?page_id=11)

I am posting this 7 hours early this week.  I no longer trust the schedule feature of WordPress (I’m sure it’s user error but I haven’t been too sucessful of late so I thought I would err on the side of caution. ) The long and the short of it is I won’t be posting tomorrow, having posted here today.—Phil

“Improve constantly and forever the system of production and service, to improve quality and productivity, and thus constantly decrease costs.”—W. Edward Deming’s Fourth Point.

This is the fifth work I have done that explores the relationship between Deming’s 14 points and safety.  Deming’s fourth point, “Improve constantly and forever the system of production and service, to improve quality and productivity, and thus constantly decrease costs” applies fairly directly to safety.

Safety professionals often lose sight of their responsibility for increasing efficiency and increasing profitability, preferring instead to see their job as a noble calling removed from the vulgarities of making money. At the same time that safety professionals bemoan the their lack of credibility in the eyes of Operations leadership, many safety professionals either stand idly disconnected from operations or actively promoting junk science and the latest in safety fads,

The safety function, not only can contribute to cost reductions and process improvement, it can lead it. Worker injuries are expensive and wasteful.  No one derives any benefit from a workplace injury and beyond the cost of treating the injury the costs are considerable and can make the cost of doing business significantly higher. From increased insurance rates to negative publicity the costs associated with a single injury can have tentacles that touch many areas.

There are several areas in which safety professionals can reduce costs and increase efficiency, both within the safety function and without.  Safety professionals should begin measuring the cost of operating its own function.  Establishing a baseline serves several purposes.  First, a baseline makes it easy to see, in real costs how much safety costs the operation.  Once the safety professional has identified the expenses associated with running the department he or she should express the costs in a way that is meaningful to the organization.  For some organizations the cost should be expressed as a percentage of sales, while for others it can be described in terms of the product or service the company sells. But whatever the trigger, describing the cost in terms that matter is paramount to a safety professional’s success. From there, the safety professional should chart and display the cost in an area of the organization where management decisions are made.

Advertising how much the safety function costs to maintain may seem foolhardy to some, but this kind of data sharing shows the organization that the safety function understands how business works and sees itself as accountable for delivering at least as much value as any other function.  Of course once the safety function has announced the amount it costs the organization the safety professionals need to quickly take action to reduce those costs, and the fastest way to reduce costs is to eliminate waste.

There is waste in any process, and what’s more, there is even more non-value-added activities.  Waste is anything that costs money but return nothing worthwhile. Safety professionals need to identify the things that are unnecessary, overly costly, or where the cost is disproportionate to the savings. It can be tough to quantify the return on investment for safety, but it is easy to take a look at discretionary purchases and dial back the ones that you know intuitively aren’t worth it.

Sawing the pencils in have will only take you so far, and eventually the safety professional will have to improve the processes that safety uses to support operations.  Process inefficiencies are a major contributor to costs, and the safety function is far from immune from these costs.  Fortunately, most companies have process improvement processes and teams that can help the safety function to fine-tune the way it does business and reduce the cost of doing business.

Outside of the safety function, safety professionals need to quantify the costs of the organization’s safety record and demonstrate improvements over time that directly correlate to the initiatives planned and executed by the safety department.  Things like the safety BINGO, children’s safety poster contests, and similarly flakey feel good programs that cost more than they can ever hope to return don’t qualify for consideration and should be scrapped. Safety professionals need to be careful not to be overly protective of their pet projects or to claim responsibility for improvements that they can’t cleanly proof.  Deming would perhaps take things even further and recommend that safety avoid any undertaking that cannot be directly linked to process, improvement productivity improvements and cost reductions.

Just as with the cost reductions within the safety function, safety professionals should track and display the savings of reduced injuries.  Communicating the contributions that the safety function makes to the company’s bottom line or the organization’s efficiency increases is an important way to link the goals of the safety function with the overall goals of the organization.  As Deming observed, continuous improvement is everyone’s job.

The idea that safety should shift its focus away from saving lives in favor of saving money may seem distasteful to some, even insulting perhaps. But as long as safety professions view themselves at philosophical loggerheads safety professionals will never be seen as equal partners in the organizations success.  If the goal of safety is to save lives while the goal of the organization remains to make money, the two set themselves at odds and as Abraham Lincoln once said, “a house divided against itself cannot stand.”

Just[juhst] adjective

1. guided by truth, reason, justice, and fairness: We hope to be just in our understanding of such difficult situations.
2. done or made according to principle; equitable; proper: a just reply.
3. based on right; rightful; lawful: a just claim.
4. in keeping with truth or fact; true; correct: a just analysis.
5. given or awarded rightly; deserved, as a sentence, punishment, or reward: a just penalty.

jus·tice [juhs-tis] noun

1. the quality of being just; righteousness, equitableness, or moral rightness: to uphold the justice of a cause.
2. rightfulness or lawfulness, as of a claim or title; justness of ground or reason: to complain with justice.
3. the moral principle determining just conduct.
4. conformity to this principle, as manifested in conduct; just conduct, dealing, or treatment.
5. the administering of deserved punishment or reward.

In the context of the Costa Concordia cruise ship disaster it’s probably a good time to revisit the concept of Just Culture.  Borne of the air transportation industry, Just Culture is also widely associated with patient safety in the healthcare industry (When many people hear the term “Just Culture” it conjures up images of a nurse or physician inappropriately taken to task for an honest mistake).  But it Just Culture runs deeper than zero-blame, and it runs deeper, in fact, than safety. Just Culture is a management philosophy regarding how the organizations view mistakes.

It’s been long and well-known fact that people make mistakes; it’s why we have erasers on pencils and spell-check in word processing software. To err is human. In fact, research has shown that the average American makes 5 mistakes an hour on average. Researchers believe that these mistakes are not the cause of sloppy work or carelessness, but are the result of a basic function of the human brain. Shy of changing the structure of the human central nervous system, little can be done to prevent people from making mistakes. Research has also uncovered a natural tendency of human behavior to vary, and ultimately drift into at risk behavior. Is it just to punish a person for actions that are unintended and in some cases uncontrollable? Certainly not. On the other hand, some people act in deliberately reckless ways that unnecessarily put themselves and others at significant risk.

Everyone Makes Mistakes
Just Culture is a new way of dealing with mistakes, at risk behavior, and recklessness that shifts the focus away from blame and towards process improvement. Of course some situations, like repetitive mistake making or deliberate recklessness must be addressed through a formal disciplinary process, but Just Cultures see these situations as exceedingly rare.

Demanding Justice versus Demanding that Somebody Pay the Price

In many cases, people say they want justice when they really want to punish the person who screwed up.  People are predatory animals and weakness in others triggers our prey reflex.  We want blood. When people make mistakes—especially big, high profile mistakes—they are vulnerable and communicate this weakness by exhibiting prey nonverbals. We can’t help it and neither can they.

It is easy to blame the media for getting us all riled up(when did the media become a boogieman responsible for all mankind’s ills?) but while the media may fuel our bloodlust, our bloodlust fuels the media.  It’s a vicious circle: the media gives its audience what the audience responds to and in so doing exposes its audience to more and more titillation.  But blaming the captain of the cruise ship for running aground and killing 11 (and it’s looking more and more like that death toll will rise) will not make us whole, it will not right the wrong, it will just sate our palate for blood.

If we succumb to the temptation to demand blood over justice we lose a lot, and what we lose is important.  Unless the captain and crew can feel free from recrimination, they will not (assuming they have a least the intelligent of the average gibbon) be forthcoming about the mistakes they made, both that caused the initial incident and the errors in how they responded to the problem.

Who Cares Who Is At Fault?

Do we care who caused this? Well, speaking like a true consultant, it depends.  We, as a society need to think about what will bring us the most good. Do we want to incarcerate a captain and maybe some crew members for making a mistake? Do we want to fine a cruise line for negligence? Do we want to increase the penalties for violating procedures? Do we want greater oversight of the cruise industry by governments? Or do we want to prevent this from happening again? Personally, I would love to be able to take a cruise and not die, and there is only one of these questions that help to make that happen.  We  need to set aside our most primal urges and forgo the demand for immediate consequences so that we can instead focus on prevention.

Let’s Not Let Them Off The Hook Just Yet

Part of avoiding rushing to judgment is not rushing to the conclusion that the captain, crew and cruise liner don’t have to be held accountable. There may well be criminal acts committed or grossly negligent actions on the part of the parties involved, we don’t know.  But that’s the point.  Let’s not hang anyone until we understand the entire climate in which decisions (which admittedly resulted in harm and probably in retrospect weren’t wise) so we can understand not only what happened, but what enabled the bad decision making.

 Sorting It All Out

Until we decide to be a just society, we probably can’t expect anything more than a lynch-mob mentality.  But as we watch as things unfold, let’s remember that details that are reported the closest to the event are the most sketchy and it may take years to sort everything out.

Here’s an excerpt:

A New York City subway train holds 1,200 people. This blog was viewed about 5,700 times in 2011. If it were a NYC subway train, it would take about 5 trips to carry that many people.

Click here to see the complete report.

Think about a bottle—the kind of plastic bottle used to dispense soda or bottled water. Not too much to the design right? Well both the bottle and its cap are typically manufactured independently and eventually the cap is installed onto the bottle, simple right? Well the bottle mouth has measurements the outer rim has to be x circumference and the inner rim must be y circumference.  Similarly, the cap must have a specified measurement for it’s inner and outer surfaces. (Believe it our not there are far more sizes that have to be specified—the length of the spout of the bottle, the depth of the cap, the size of the screw threads.) Manufacturers know that we live in an imperfect world and no process is without variation, so the design will call for a measurement ± a bit of variation.  So the specifications will read something like .02 mm ±.0003. This ± number indicates how much larger or smaller the bottle’s spout can be before it will no longer fit into the cap.  But suppose the cap is .0003 larger and the spout is .0003 smaller and the cap is .0003 shallower and the spout is .0003 longer than it is supposed to be? Now the combined variance, even though within specification, it is hopelessly out of whack.  This phenomenon is called, “tolerance stacking”.

So what has any of this to do with safety? Recently, in Detroit, there were two fatal traffic accidents where pedestrians died after being struck by motorists.  In both cases, that happened within 24 hours of each other, multiple elements were present that in themselves, while dangerous, were not intrinsically high risk activities. (I explore what we can learn from these cases in this week’s post to my personal blog, www.philladuke.wordpress.com). As I reflected as these two tragedies, it occurred to me that we could learn a lot about worker safety from the concept of tolerance stacking.  At this point I should point out that I tend to be biased toward process safety in general and don’t have much good to say about the quasi-religious fanaticism that has grown up around Behaviour Based Safety. I don’t think this bias in any way clouds this post, but I feel it appropriate to acknowledge it nonetheless.

Hazard Stacking parallels Tolerance Stacking quite neatly.  Like Tolerance Stacking, Hazard Stacking builds up as more hazards are present.  Also, like Tolerance Stacking small bits of process variation aren’t likely to produce catastrophic system failures (although the probability does exist.) Finally, both Tolerance Stacking and Hazard Stacking will continue to build until they reach a failure threshold after which the system breaks down.

I suppose I should define a term or two here.  A hazard is anything that has the potential either to cause harm, or to increase the severity of harm caused by another element.  Hazards can be physical hazards like the air hose draped across a walkway that creates a trip hazard; behavioural hazards like the worker who is working out of station so he can have a couple of minutes extra on his break; or  procedural like the lack of a requirement for PPE when working with hazardous chemicals.

Hazards in and of themselves do not cause injuries.  All hazards must have some interaction before they can injure someone.  Safety professionals often mistake interaction with unsafe behaviours and the point has been quibbled by myself and others to the point that I really can’t muster the energy to have yet another discussion about it.  Researchers have perpetuated this ignorance by announcing findings that x% of injuries are caused by unsafe acts. Sufficed to say, if people aren’t interacting with hazards they aren’t being injured by them.

The final element that must be present for an injury to occur is a catalyst.  A catalyst is some element that finally breaks the system; it accelerates changes in the system for the worse and leads to the catastrophic outcome.

If we think about safety in terms of hazards, interactions, and catalysts our job of keeping workers safe gets a good bit easier.  We really have some combination of three courses of action—we can reduce hazards, prevent interaction with hazards, we can anticipate likely catalysts and guard against them, or we can do some combination of all three.

Hazard Management

The first, and most common, approach to ensuring worker safety is to remove hazards. This highly effective method involves considerable research into exactly why a hazard occurred in the first place.  Understanding the source of the hazard is essential because unless we know why it occurred we run the risk of merely treating symptoms and any progress we make will be temporary.  Additionally, a lack of knowledge regarding the root causes of a hazard allows the roots to manifest as other hazards elsewhere in the organization; the hazards grow like hydra heads cropping up unexpectedly and dangerously.

Another challenge associated with hazard management is the organization’s inability to predict new hazards as the organization adjusts to a dynamic business environment.  As things change benign elements can invisibly become lethal hazards and go undetected until a worker is seriously injured or worse.

Restricting Access To Hazards

The second strategy for reducing injuries comes to us right out of the good old hierarchy of controls; if you can’t remove a hazard keep people away from it.  Avoiding interacting with hazards is often more easily said than done, however.  Too often, safety professionals rely on the worker’s active participation in avoiding interaction with hazards and this too often results in disaster.  I am reminded of the road signs in Michigan that warn the bridge may be icy.  Despite the July heat, the signs still stand in absurdist vigil. “Danger High Voltage” and similar “warnings” aren’t terribly effective and in some cases quite literally laughable.

Predicting and Avoiding Catalysts

The last strategy of improving worker safety, predicting and avoiding catalysts requires data and discipline. When trying to predict catalysts, safety professionals need to look for factors in his or her organization that tend to widely increase the likelihood of process variation—things like falling behind in production, part shortages, manpower shortages, or low worker morale are often catalysts for injuries.

I can’t tell you which hazards are most likely to cause injuries in your environment, nor can I predict catalysts for you, I can’t even tell you the best way to restrict access to hazards, you know your process better than anyone else and you are uniquely qualified to do these things.  But what I can perhaps do, is to get you to think of safety not as the absence of injuries, but as the presence of risk. In this paradigm shift, you will likely find that you can be more effective looking forward instead of backward.

It’s my pleasure to announce that ISHN has selected Rockford Greene International associate, Phil La Duke, for inclusion to its Power 101, a list of the most globally  influential people in worker safety. Phil joined us full time last October in his 15-month tenure he has penned something like 25 peer-reviewed articles, brought in 3 of Rockford Greene’s biggest clients, posted over 100 blog articles, and made numerous speeches.

I’ve enjoyed getting to know Phil, as I know many of you have.  His quick, acerbic wit and shoot-from-the-hip, no bullshit (pardon the term, but I honestly don’t know how else to accurately describe him) opinions on everything from behaviour based safety to kale have won him friends and made him enemies.  But that is the quintessential Phil; a man with passion for things that most of us don’t even notice.

It’s good to see Phil get the recognition that we at Rockford Greene deeply believe he so deserves.  According to its website, ISHN is a business-to-business monthly trade publication targeted at 71,400 key safety, health and industrial hygiene buying influencers at manufacturing facilities of all sizes. This publication is designed for the busy professionals with early mail dates and short articles backed by dynamite graphics. We pack each issue with vital editorial on OSHA and EPA regulations, how-to features, safety and health management topics, and the latest product news. Our safety and health managers at high-hazard worksites in manufacturing, construction, health facilities, and service industries know they will learn something new each and every month.

The editors of ISHN used the following criteria for naming individuals to the Power 101:

1. Ability to reach a national and/or international audience;
2. Ability to create a community of pros with shared interests (via conferences, seminars, associations & special interest groups; branded media products; websites, web forums, etc.)
3. Current, active participant and contributor as subject matter expert
4. Ability to draw and/or generate national media coverage
5. Personal access to corporate management executives; ability to create, manage and/or change large corporate EHS cultures
6. Personal access to Washington federal safety and health policy makers
7. Ability to influence federal safety and health policy; corporate policy; professional society policy; labor union policy; international policy
8. Ability to facilitate collaboration and cooperation between safety and health stakeholders at the national and/or international level
9. Longevity in the public eye — years of service; media coverage; development of audience following
10. Ability to start up and/or manage a successful safety-related business; volunteer organization; display of commitment and management acumen
11. Followership — size of legacy; respect of peers;
12. Innovation and creativity — development of EHS-related research, theories; models; performance measures; communications products; best practices

“When I was a young man I was given a check for a million dollars.  I tore it up and went to the top of a mountain where I pondered the mistakes of mankind…one man in particular”—Joe Martin, Cartoonist.

A couple of days ago I read an article on Forbes on-line edition by Peter Cohan, a contributor to the magazine.  The article Learning From Brilliant Mistakes http://www.forbes.com/sites/petercohan/so11/12/29/learning-from-brilliant.mistakes/ covered Paul Schoemaker’s new book, Brilliant Mistakes.  According to the article 99% of successes come from failures, and Shoemaker asserts that the road to success is through screw-ups.

This has some pretty profound implications for the safety industry; after all, safety professionals spend a fair amount of time and energy trying to prevent mistakes and even more trying to prevent mistakes from causing injuries. According to Schoemaker, mistakes should be planned and seen as a great learning opportunity.  I’m not sure Schoemaker has a workable theory here, at least not as far as safety is concerned—I’m not ready to advocate deliberately imperiling people just so we can learn how to prevent injuries elsewhere, but I do think he might be on to something.

Before we can apply anything that Schoemaker has to say we have to agree to a couple of universal (or near enough so as to be legitimately considered universal) truths:

Truth 1: Nobody wants to get hurt. I freely and completely acknowledge that there are people in the workplace who want to fake an injury, and many who would like to extend injury-related absences beyond that which is medically necessary, and heck, I can even allow for the possibility of some mentally ill masochists who may enjoy an injury, but let’s be grown ups here and agree that by and large people don’t want to get hurt. By definition an accident is unintentional.

Truth 2: People don’t expect to get hurt. Again I will allow for the statistical outliers, but in general, I think the population of people who don’t expect to get hurt is so large that this is universally true.

Truth 3: Something that injures one person is likely to injure many more if left uncontained and uncorrected. Too often safety professionals forget to address the underlying contributing factors that either cause injuries or worsen the severity of the injuries.

Truth 4: The deadliest hazards are the ones that no one ever envisioned.  Often the most grizzly fatalities leave us scratching our heads and wondering how anyone could ever have envisioned such a complex conflagration of contributing factors; the act of God, the freak accident, the “million to one shot”.

Truth 5: Our system is not deliberately designed to hurt workers. Worker injuries cost money, waste time, stop production, and generally disrupt the things we are in business to do.

Truth 6: Everyone makes mistakes.  Studies have shown that the average U.S. worker (sorry folks the only studies of which I am aware were conducted in the U.S. specifically in healthcare, but the studies examined non-healthcare workers as well so that the studies would have a baseline of comparison.) makes between 5–8 mistakes an hour and there is scant little that can be done about it. It makes sense, from an evolutionary standpoint we are hardwired to resist change; change is stupid, reckless, and dangerous.  On the other hand, we live in a dynamic and rapidly changing environment, and an inability to adapt to the changes around us leads to extinction. Our subconscious causes us to make these mistakes to test the safety of the environment around us.  Most often these mistakes are fairly innocuous—we turn left into a hallway instead of turning right—but in other cases they have lethal, even fatal outcomes. For more on this subject check out my recent posts on www.philladuke.wordpress.com

So if these five universal truths exist, what can we infer and apply from Shoemaker’s work? How can we cause the mistakes and learn from them?  Obviously, causing people to make mistakes that are highly likely to injure them is reckless and beyond irresponsible, but what about the mistakes people have already made?

I was recently interviewed about near miss reporting by Safety+Health Magazine who had seen my presentation, Understanding Why People Don’t Report Near Misses at the National Safety Council which was not so loosely based on the article, Four Choices, Eight Lessons which I wrote for Facility Safety Management magazine which was based on a blog post I made based on my own experiences.  The fact that I was able to explore this topic in so many venue attests to the intense curiosity in this topic worldwide.  Why the fierce interest? because near miss reporting is the first step toward near miss analysis which, when done correctly, garners key insights into the dangers of our operation.

Learning from our mistakes, whether it be near misses or injuries, begins with identifying the mistake and as I have explored ad nasuem is no mean feat.

I have devoted reams of virtual ink to why people don’t report near misses, and I won’t revisit it here.  If that is of interest to you, follow one or more of the many links posted on here and www.philladuke.wordpress.com. Sufficed to say, we struggle to get people to admit their mistakes and when we fail to identify the mistake we learn nothing. Near miss reporting requires an environment where it’s okay to make a mistake. (See my articles on Just Culture for more on this topic). But even in those rare cases where people do indeed “fess up when they mess up” many organizations lack the infrastructure to learn anything from the mistake.  Learning from a mistake requires planning, analysis, and infrastructure.

Planning

I preach about planning like some people preach repentance for the forgiveness of sin.  I believe in it, I live it, and I have fanatical devotion to it.  As a co-worker once put it, “the best thing about not planning is that failure comes as a complete surprise and is not proceeded by a period of fear and anxiety.” But how can an organization plan for mistakes? Well they aren’t, not really, rather the organization should be planning to identify, analyze, learn, and internalized.  If our people are truly making 8 mistakes an hour that means there is an incredible opportunity to learn about our organization’s shortcomings and for most organizations this opportunity is being squandered.

Planning for mistakes isn’t the same as identifying contingency planning or mistake proofing (the practice of lessening the severity of failure modes.)

Analysis

Another topic that I have spent a fair amount of my attention is the need for safety professionals to do more than just gather data.  Mistakes have to be analyzed and safety professionals need to take the investigation beyond “what happened?” and “who did what?” When we analyze mistakes we have to focus more on the mindset of the person who erred and less on the more obvious “what went wrong?” factors.  Even in fairly good incident investigation there is a strong tendency to stop before realizing a complete understanding of how the system broke down.  If we are going to truly understand why mistakes were made we need to ascertain the mental reasoning at the time of the mistake.  We can’t accept “I just wasn’t thinking” or “I don’t know” as the reasons for a mistake.  We have to understand what drove the person to make the choices they made and why they thought what they did would result in a better outcome.  The analysis can’t be about blame.  Once we understand the thought processes of the person who made the mistake we have the opportunity to remedy our process.

Fixing the cause of one mistake is of negligible value, but cascading the lessons learned across the larger organization in the form of effective read across can create profound organizational advancements in safety across the entire operation.

Infrastructure

Even though these things I’ve described are fairly easy, most organizations fail to do them effectively.  Simply knowing what to do isn’t enough; without an infrastructure for institutionalizing the process for identifying, analyzing, and implementing changes based on lessons learned. No single infrastructure or approach will work for everyone, and in general, it helps to have help from outside when developing a process that will work for you. But without a means for putting what you learn from mistakes into practice the entire exercise is a fruitless waste of time.

First let me apologize for being late; it’s Christmas, and let’s face it whatever meager value you derive from this site you do so for free, and sometimes you get what you pay for, or at least you get on time.

Some of you who are less familiar with me and my work may well be expecting some syrupy Christmas or (lacking the balls to align myself with Christianity) some sort of bland generic “holiday” message.  If you that’s what you were expecting, you will be disappointed.

I guess loosely continuing on my theme of who’s to blame for worker injuries.  Process based safety advocates will blame a lack of a robust process for workers getting injured.  Behaviour Based Zealots see the blame in poor choices and reckless decisions, although they loudly protest that they never, EVER blame a worker. Lean zealots blame waste and process variation.  And Just Culturists blame no one.

Frankly, I blame us.  It’s time for each of us who played a role in the injury to stand tall before the man and swallow the bitter pill; we did this—by our actions and our omission there is blood on our hands.  Whether we are the process engineer who failed to address design for manufacturing issues, the manufacturing engineer who ignored ergonomic issues, the materials manager who allowed unqualified workers access to dangerous chemicals, we all played a role.  We all failed to protect.

I’m  not trying to make anyone feel bad, I don’t expect anyone to become so overcome with guilt and shame that they go off and hang themselves.  So what then do I want? Am I just some whiney malcontent who wants to ruin our holiday? Perhaps, but that’s not what this is about.  We, as professionals have become too complacent, to cavalier about the inevitability of injuries.  When a worker is injured we are quick to point fingers and to cluck tongues about how much a shame it was for this to have happened.  But it is not enough! Damn it when a worker is injured we have failed in our most basic duty: the duty to protect.  We took money and delivered services for one purpose to protect.  Did any of us give that money back (and no, I am not offering to)? We have a duty to protect and when we fail to do so we must forever and first look at ourselves and ask, how did we fail so miserably to fulfill our most basic and sacred duty? When an injury occurs we must never, even secretly, believe that the worker somehow had it coming, that the worker needs to be more careful (no kidding! With people like us assigned to protect them, it would seem that they need to do their utmost to remain alive).

As you read this and feel your panties start to wad, let me remind you that we alone, among professionals, get to consistently fail (well weathermen, too I guess) and perform horribly without recrimination or consequence.  If we are incompetent, workers die.  But unlike the incompetent surgeon who is sued for his shoddy work, or the lawyer who is similarly disbarred, when we fail to protect we are seldom called to account.

For those of you who question my motives, who have questioned both publicly and privately my motivations and ethics, let me spell things out for you: I AM TIRED OF WATCHING PEOPLE DIE AT WORK.  You are paid to protect workers so start doing it.  Stop arguing about Safety Observations, and behavior versus process, and whether or not the latest safety fad is way cool, and get back to basics.  Stop spouting  100 year old behavioral science and get to work.

I lost my father to mesothelioma a decade ago, and this year a brother-in-law to lung cancer several months ago.  All these two, and tens of thousands like them wanted nothing more than to return home alive.  But they had the misfortune to begin their careers in a pre-enlightened world where OSHA (and its overseas equivellants)

And now we must stand sentinel and watch as a generation dies from exposure to chemicals that we don’t even know are dangerous yet. And now, in the face of this all, efforts to keep workers safe are being propagandized as job-stealing, unnecessary expenses. We must all, management and union, first world and third world, all of us everywhere recognize that we must protect workers not just from the hazards of the workplace but also from the greedy governments and corporations who will move a job rather than make it safe and who will extort workers with threats that they can either have a job, or they can work safely.  No one should ever have to choose between life and livelihood.

And so as we continue our work to protect, let us remember that while we can forgive ourselves for failing to protect workers we can never forget our culpability.

Merry Christmas, and do something to make the world a safer place.