Monday, June 28, 2010

It Happens

While on a safari drive vacation in Tanzania there was a day which confirmed a safety paradigm about most injuries occurring away from work.

Our group was in a four wheel drive vehicle viewing cheetahs, wildebeests, gazelles and the like when our driver entered a marshy area and made a mistake. As the muddy situation became apparent he did a Simama (stop in Swahili) instead of a Twende (let’s go!) and our vehicle slogged to a stop.

Of course the four Africans and I did a JSB (job safety briefing, in a mixture of English, Swahili and Maasai) before we broke out the bush jack, spare tire, shovels, chain and various tree limbs that were around. An hour later we faced the reality that there was just no safe way for us to un-mire the vehicle. With a smile and a shrug of the shoulders I told them “It happens.” They smiled, added two more letters in front of my phrase, and then called for a back up recovery vehicle as we piled into the two other vehicles that had not made the mistake.
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About two kilometers down the muddy track one of the vehicles lost a rear wheel and of course we did an immediate Simama. Another mixed language JSB and gwe carefully jacked up the vehicle in the mud, put back on the wheel and tightened all lug nuts we could find, all the way round. We did another “It happens” with extra letters and headed off for another kilometer before the same vehicle got off track and ended up high centered over a Hyena borough. And another opportunity for a mixed language JSB and another “It happens” with extra emphasis and off we went the final 3 “klicks” to camp.

Once in camp the five of us held a lessons learned session about our last two hours of vehicle challenges with the aid of a bottle or two of African brew. I then called for a 20 liter (5 gallon bucket) shower to wash off all the nutrient rich mud that makes the Savannah (grass lands) grow so richly in the Serengeti (endless plains). After all there have been untold centuries of zebras, gnus, lions, etc., that have fully fertilized all the mud we dug ourselves out of this day.

Yes “It happens” events can occur wherever you are. Don’t rush into actions that can get you, your family, or your associates hurt when a few minutes of pre-planning are all that it takes to stay injury free. You truly need this kind of never ending personal safety culture no matter where you find yourself on this planet because you just don’t know where or when an “It happens” moment will occur.

The Doc

Monday, June 21, 2010


My wife and I enjoy avocados. As we moved into a home in southern California we were excited to see a young avocado tree in the yard. Each year we anxiously awaited the crop of avocados and made sure they had the best chance by watering, fertilizing, weeding and the like. Each year we got some fruit that never matured. So off my wife went to the nursery and asked for advice. “Lady, you need to beat the base of the tree with a baseball bat. It bruises the outer layer of the tree and then the nutrients go to growing the avocado instead of growing the tree.”

Out came the baseball bat and we excitedly anticipated our first crop…which once again did not mature. Back she went back to the nursery with some of the small fruit that just wasn’t right.

“Lady, this fruit is an olive and no matter how hard you beat that tree you can’t convince an olive to become an avocado.”

And now a lesson or two in life; ‘Guess we need to grow where we are planted and produce what we were designed and made to do. If you are a good safety pro don’t worry about the other folk that move up the ladder, be the best you can be at what you do well. Spend some personal introspective time to find out what you really do well and are happiest at, then continue to pursue that passion.

If you feel a calling to branch out it is OK to try a new path, but if it doesn’t work no amount of beating will turn you into what you were not meant to be.

The Doc

Thursday, June 17, 2010

The Never Ending Heinrich Controversy

Recently, I recieved an email asking me this question. Below is the email, and my response:

Bill wrote:
I wondered if you had any comments or thoughts on the attached study by ORC worldwide which appears to negate the correlation between injury incident rates and fatalities. I would really like to implement a near-miss reporting program, but I don't think that I will have much credibility if someone were to question me on the attached study. The study, although not exhaustive seems to make sense, but I wanted to get your input.

I replied:
I have heard of a number of research reports that come to similar conclusions about the kind of risk leading to a fatality is different from those which lead to a medical injury. I have seen and heard presentations on causal factors for high severity incidents not being the same as for low severity injuries. This makes some sense to me as well, considering things like random work that is infrequent and tends to be higher risk due to unfamiliarity, lack of knowledge, etc.

When Dan Petersen was alive we had this discussion in some of our one-on-one talks. Certainly the early, less scientific research of what Heinrich did has come under attack by those who do in depth, statistically validated research like those of ORC. Frank Bird redid the Heinrich work with better technique in the 80’s and got similar results. It seems there is a cultural injury reality predictability for many organizations. My belief is that we should stop squabbling over the probability numbers and get down to what it takes to eliminate the injuries no matter whether they are first aids or potential fatalities or any in between.

On occasion I have had discussions along these lines with company safety pros that went something like this:
“We reviewed our injuries, and first aid injuries are about 12-18 inches away from a lost time and lost times are about 6 inches off a fatality. If the event had moved just a little in one direction we would have lost the person.”

“We keep track of all medical injuries and it is our experience that, on average over the last 15 years or so, for every 100 medical injuries we have a fatality somewhere in the world at one of our many operations. Sometimes it occurs at 93 medicals other times at 112, but on average it is a fatality for every 100 medical treatment cases even though our recordable rate is currently running at about 0.32.”

The ORC report seemed to say to me that more research was important in three areas;
"The results of the ORC Fatality and Serious Injury Task Force Survey have convinced us that as professionals we must change how we view:
  • The relationship between incident investigations and corrective action;
  • Employee behavior and risk management;
  • Employee behavior and engineering controls.”
I would agree that:

  • Incident investigation and associated corrective actions are a part of a safety culture that, from my practical experience, seems often to be more of a “check in the box” than a strong process
  • Employee behaviors and risk management are important considerations that are also not typically considered or addressed in the average workface level safety culture
  • Employee behavior goes beyond the hourly ranks. Management behaviors (or lack thereof) greatly affect the workface safety culture and performance, even though the managers don’t usually realize this
  • Engineering controls by classical safety theory are often the first thing to be considered
  • And now my personal conclusion to this "chicken or the egg" type of controversy;
  • It is a good idea to keep a probability type of chart for a LARGE organization which has a significant volume of incidents. Personally I'd use more of a control chart and focus on what we are doing to ever lower all injury rates and track this change over time
Behaviors are significantly affected by a good safety accountability system and this is lacking in most companies. If we develop good safety accountabilities at all levels of the company and live them at all levels of the company, medical and more serious injuries will go down. This is classic Dr. Dan Petersen and in my experience his "Six Criteria of Safety Excellence" which have a focus on accountabilities work very well. This kind of safety accountability system also addresses engineering controls, risk assessments, near misses, etc.

When Dr. Deming started his assault on quality gaffs (errors) I believe he ran on to the same statistical navel gazing syndrome, which in turn lead to never ending academic hypotheses. His solutions to this dilemma included:
  • Chart the errors (control charts and the like)
  • Engage people from all levels of the organization in a kaizen culture of the endless pursuit of perfection
  • Do a risk assessment of all designs with both engineers and people from the floor who have practical experience
Analyze every error (incident) which has occurred and do meaningful corrective actions which get to root causes and deliver both engineering and accountability improvements

His mantra "DMAIC" (Define, Measure, Analyze, Improve, Control) had these Elements

We need a safety culture which does something similar with our errors (incidents, including close calls). This works in organizations when there is leadership which engages just like they do in the quality revolution. Some leading edge safety focus organizations have joined this kind of safety revolution and are doing very well at eliminating both minimal and more serious incidents.

Regardless of the risks, a good near miss system/process is an excellent tool to do this. Our field experience with companies who have done this is astounding! However, you must do a good job of error proofing the near miss process so it fits your culture and your objectives. Just dropping in a "program of the month" does not work well at all. You need to have a system which:
  • Generates 100’s of near miss reports/month
  • Grades each near miss by risk as Red, Yellow, or Green
  • Solves 90+% of all near misses, no matter the risk, within 3-5 days by the people who turn them in
When organizations have their employees live this kind of error proofing, the resultant near miss system is able to reduce both lesser and serious injury rates significantly. Indeed, they develop a culture that doesn’t take any kind of noticeable risk on their own, without needing a 24/7 supervisor. It is not a matter of the kind of risk; rather it is about a safety culture that eliminates all risks. And a good, practical near miss system does this very well. If you would like to discuss how to implement this kind of near miss success, please give me a call

Monday, June 14, 2010

A Level One World

I use a concept called the Six Levels of Safety Performance as a practical model that takes the organization from a fundamental safety regs approach all the way through to an organization that is passionately engaged in leading the relentless pursuit of a zero incident safety culture.

The levels are briefly described as:
  • Level One: The regulations are mostly about reacting to condition related items in the work place. These are a necessary fundamental to safety, but really don’t make for a proactive safety culture that focuses on the activities that seem to cause most injuries
  • Level Two: What we see in the workplace and react to in order to prevent future incidents. This area deals with programs like Behavior Based Safety, Job Safety Analysis, Near Miss Reporting and Inspections
  • Level Three: What we do to proactively prevent injuries, i.e., Safety Accountabilities for personnel throughout the organization
  • Level Four: Safety culture diagnostics that dig deep into what all our personnel believe to be the strengths and weaknesses of our organization.
  • Level Five: How we engage our people in solving the problems that exist in the first four levels. Here the focus in on Continuous Improvement (CI) teams made up from across, as well as up and down the organization. They are the analyze, focus, execute groups that are “fix it” oriented
  • Level Six: How we develop and engage an ever expanding cadre of leaders that relentlessly pursue a culture of zero incident performance
For decades the safety profession has had a level one, with some amount of level two, mindset. This is analogous to living in a one dimensional world, it just doesn’t make sense. There is just not enough performance horsepower technology available with a reactive government regs approach. The level one world has time and again proven to give disappointing results that don’t deliver a sustained zero incident safety culture. To get there you will have to diagnose what the real issues are (level 4), engage your people in solving the problems (level 5) that include safety accountabilities (level 3) for employees who must live the solutions the teams deliver. Only then can you develop an ever expanding passionately involved leadership (level 6) up and down and across the whole organization that lives to deliver zero incident excellence.

What have you got to loose by breaking the decades old disappointing lockstep one dimensional world of regs and observations?

The Doc

Wednesday, June 9, 2010


The world is once again aghast at a man made disaster. This time it is the oil drilling “Deep Horizon” tragedy in the Gulf of Mexico. Every time I learn of one of these significant disasters I consider once again the work done by Dr. Edwin Zebroski and his “11 Indicators of Impending Doom.”


Back in the 1990’s Dr. Zebrowski made a detailed analysis of four significant man made tragedies (the Chernobyl nuclear reactor fire, the Piper Alpha oil rig fire, the first space shuttle explosion, the Bhopal gas release). Each was initially classified as an “accident.” However, his in depth research uncovered 11 common threads (human decisions) to each of these disasters. Here they are:

1. Diffuse responsibilities with rigid communication channels and large organizational distances between decision makers and the plant

2. Mindset that success is routine and neglect of severe risks that are present

3. Rule compliance that this is enough to ensure safety

4. Team player emphasis with dissent not allowed even for evident risk

5. Experience at other facilities not processed systematically for application of lessons learned

6. Lessons learned disregarded and neglect of precautions widely adopted elsewhere

7. Safety analysis and responses subordinate to other performance goals in operating priorities

8. Emergency procedures, plans, training and regular drills for severe events lacking

9. Design and operating procedures allowed to persist even though recognized as hazardous elsewhere

10. Project and risk management techniques available but not used

11. Organization with undefined responsibilities and authorities for recognizing and integrating safety matters

Only a detailed analysis over time will determine if the BP oil rig fire and subsequent oil leak disasters have any, or all, of Dr. Zebroski’s “11 Indicators of Impending Doom.” You and I will have little or nothing to do with this research and “search for the guilty parties.” However, as safety professionals for our own organizations we can, and must, analyze our own operations for the presence of any of these “Ticking Time Bombs.” Once you are convinced that one or more of these potentially dooming realities exist the next question is what to do about it? An approach I have used for this reads a little like a fault tree diagram, i.e., what does it take to eliminate this issue? For Item #6 an overview might read something like this:

• Continuous Improvement (CI) team error proofs Accident Investigation process so it delivers multiple root cause analyses, active work group participation, Action Item Matrix tracking of needed tasks, Safety Accountability reviews, condition fixes and the like

• CI team error proofs Communication process that delivers an active communication channel throughout the whole organization whereby Near Miss lessons & corrective measures are disseminated and discussed with employees within XXX number of days of a Near Miss

• CI team error proofs Near Miss process including proper easy to use forms in appropriate languages, easy tracking system, red/yellow/green work team risk assessment, etc.

• Action Item Matrix from Accident Investigation and significant Near Miss teams are meaningful and end results are communicated appropriately

• All design team have safety accountabilities and an active line level operations/safety member

• Method Of Change a serious, error proofed, well utilized process with accountabilities for each work group

You and your organization need to relentlessly pursue “Doom” eradication before personal disasters have a chance to occur. However, your organization may very well need some culture improvement training before taking on such a task. Most do as they fit this excellent continuous Improvement team error proofing process into their zero incident safety culture.

The Doc

Monday, June 7, 2010

1000 Loaves of Bread

While working in the Middle East I was asked one of the many “world hunger” types of questions that come not all that infrequently in the safety world.

“We have large projects and many sites. These projects require the hiring of thousands of temporary employees from areas of the world that have no safety culture whatsoever. Injury probability for this kind of work is very high, but there is so much need and so much pressure to complete the projects on time and on budget, what do we do?”
The question brought to mind another day when my papa once told me his thoughts on a somewhat similar matter: “Son, is it better to give out a 1000 loaves of bread, or teach five people how to farm?” A simple question, a simple answer and yet not a simple application.

As we discussed the issue in the Middle East we headed toward doing both;
  • Picking a few sites that were open to “learning to farm” and giving them the majority of the available resources
  • Doing some risk assessment at the “loaves of bread” sites and thus trying to limit the possibilities of serious injuries here to the best of the limited resources.
This forced me into a retrospective mode as I contemplated past years when I either taught farming or just handed out loaves. The first priority was to teach my children how to farm, and that has been an on going pleasure (and challenge) even after they got married and moved away. Then there have been the few business situations that presented on-going relationships with people who really wanted to do the long term work necessary to end the “hunger problems” they faced on a day-to-day basis. To this about 10% of the population, I have dedicated much time and effort. In turn I have enjoyed experiencing them become both self sufficient and also a passer on of the “farming” techniques.

The 90% or so who just wanted a quick fix generally got the quick answer and, as they were unwilling to spend the time and dedication to learn how to farm, I sadly watched them hustle off to the other more pressing tasks common to the world of the expedient. All the time I sadly knew full well that their organization’s starvation efforts would never really end.

Have you developed any “farmers” in the safety world; in other worlds? How many? Who is the next “farmer” you plan to develop? I have found another one in the group I worked with in the Middle East and am looking forward to the long term engagement that really makes a difference in a world of safety excellence.

The Doc

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