Buddy Benches

buddy-benchThere was a video on Facebook a few weeks ago about Buddy Benches being placed in schoolyards. The video explained the importance of the communication and training that is essential to their use and effectiveness.

The essence of the Buddy Bench is for inclusion and safety. Kids who feel alone and have no one to enjoy their recess time with are encouraged to sit on the bench – as a signal that he/she is in need of a friend, a buddy, a playgroup to join. Conversely, when the Buddy Bench has a person sitting on it, the kids who are enjoying their recess time, are chartered to practice being a Buddy…by sharing friendship, to invite the person into their group, to ask what might be troubling the bench-sitter, to provide protection from a bully; the list of helpful acts extended from the community of kids towards the person in need of a buddy is heartwarming.Buddy Benches serve as a safe place for kids who are feeling bullied or for kids to make new friends.

In exploring Buddy Benches, I learned that they are multiplying; they are in many school districts across the country. Some Boy Scout troops are now making Buddy Benches for schools for their badge-earning credits. The Buddy Bench is a simple idea to lessen loneliness, to counter bullying, and to foster friendship and a sense of belonging. Buddy Benches provide the symbolic learning space for both asking for help and, in return, receiving the extended hand of friendship.

After learning about this uplifting idea, I thought about inclusion within our workplaces and about being our brother’s/sister’s keeper – simply because it is the right thing to do – ensuring we have each other’s back. I thought about OSHA’s workplace bullying guidance, the connection to the General Duty Clause, and knowing that escalating workplace bullying, harassment, and intimidation is linked to poorer safety performance as well as employee mental and physical wellbeing. And, of course, I thought about employee accountability – we are each accountable for our behaviors. I thought about the culture of our workplaces being strongly related to the worst behaviors we are willing to tolerate. I thought about that old book, “All I Really Need to Know I Learned in Kindergarten,” by Robert Fulghum. Remember those simple truths?

How our work worlds would be improved if we all adhered to the same basic rules as children: sharing, being kind to one another, no hitting, cleaning up after themselves, learning together, etc. Maybe we need to place something like Buddy Benches in our workplaces. What do you think?

We do “Safety” Because We Care

Bok-Tower-GardensAt one of the highest geographical points in Florida, at Lake Wales, is a large, 205-ft high, carillon tower. It is beautiful, as are the gardens surrounding this tower structure, made of glistening coquina stone. The tower and gardens were a gift from benefactor Edward W. Bok, who cared deeply about nature, beauty and sanctuary spaces. Millions of visitors have traversed this place of solace since it opened in 1929. Edward Bok was all about CARING for future generations – to be able to enjoy peace and beauty. His tribute signature is this:

Make you the world a bit better or more beautiful because you have lived in it.
~ Edward W. Bok (1929)

Our safety work (at R.N. Knowles & Associates) has taken us to many places over the last few months. We’re reminded, as we’ve interacted with many people, and visited many workplaces, that Safety is about caring deeply. Likened to Edward Bok’s inspiration about caring about the world of beauty and leaving his legacy, let’s substitute the word safety for beauty, and leave our positive safety legacy for our respective workplaces. What if everyone in our workplaces chose to care deeply about safety?

What if this statement became your chosen signature phrase?

Make your work-world a bit better and more safe because you have lived in it.” (2016)

We all make choices – every day – as we live and work in our workplaces. We do “Safety” because we care deeply – stemming from a core concern for others.

Awakening the Third Force – In Safety – It’s time!

No, this isn’t about Star-Wars! And it is not about following the Jedi Path. This is a way of thinking with roots going back to Maslow around unifying forces.

For our workplaces, this is about the way we think about safety, the way we engage around safety, and the way we bring a third unifying force to the whole culture of safety.It’s the missing link in our respective workplaces. Without it, we tend to stay engulfed in a culture of compliance, yet despite trying and trying, we never reach excellence. Without it, we keep repeating the same mistakes – round and round we go.

With it, however, we intentionally move forward. We establish the culture that is committed to safety, inclusively cares about and connects with everyone, continually learns, and develops a depth of safety.

With it, safety has a constant aliveness. Without it, safety remains a by-the-way.

Read on to learn more about this “IT”…the Third Force of Safety!

The Awakening of the Third Force

I spoke at the American Society of Safety Engineers, Region IV, Professional Development Conference in Tampa, Florida on February 27, 2016.

Dick Knowles with Pamela PerrichI spoke about Partner-Centered Safety™ and the importance of this as the quickest way to achieve sustainable safety excellence. As many of you know, I have written and spoken about this many times over the last several years. The information and data I share clearly shows that this approach to leading safety is very powerful, producing improved results quite quickly. Many of you have seen the terrific results the people at the DuPont, Belle Plant achieved. This approach has a very strong scientific basis in complex adaptive systems theory.

It was exciting to see and hear one of the speakers at this PDC also beginning to talk about improving safety using a complex adaptive systems approach. This speaker had heard Sydney Dekker speak about this way of engaging the organization at an ASSE National PDC in 2014 and had gone to Australia to meet with Dekker. While they like the ideas of this approach, they do not have the tools to make the connections and bring the networks of people effectively connect with the physical work and come to life.

Several other speakers spoke about the importance of working more closely with the people, developing more trust and interdependence. There is developing excitement about this way of working together.

The Awareness is Growing!

There seems to be a growing awareness that working with the people makes a positive difference. While no one has developed the tools to actually engage and bring the people together into a highly focused and purposeful conversation as we do using the Process Enneagram©, a positive shift to fully engaging the people and achieving safety excellence appears to be starting to happen.

In my presentation, that was very well received, I introduced a new diagram about bringing the safety and business technology together with the people side of the enterprise releasing the Third Force (Partnering) to achieve Total Business and Safety Excellence. For over 100 years, the business, productivity, and the safety technology (the quantitative, rules, procedures, machines, etc.) of our work has driven our organizations. The people have often been pushed and driven to function like they were just parts of a great machine. When we shift our way of thinking and doing, we can effectively bring the people into the work using a complex adaptive systems approach and specifically the Process Enneagram Safety Excellence workshops, a whole new level of sustainable performance is created.

Total business excellence

In the Safety Excellence Workshops, using the Process Enneagram© (seeSafetyExcellenceForBusiness.com and RNKnowlesAssociates.com), the people discover and co-create new ways to work together and develop the excitement and commitment for sustainable safety excellence to be achieved.

The Third Force in Safety is Partnering – bringing the strengths of our business and safety knowledge and tools together with the goodness of and power of the people to achieve sustainable, excellent results. It is an active force, a compelling force – collaborative, focused, conversational, committed, and caring…and it works!

Part 1: The Background on the Cruise Line International Association Conference

On December 16-18, 2015, I was able to attend the Cruise Line International Association Safety Conference in Miami. The focus was on improving the safety culture and Bridge Resource Management. This is a very interesting business for me to learn about. I was there to give some perspective from the chemical industry.

This cruise line industry is doing a lot to keep improving their safety performance. Their safety challenges range from slips, trips and falls all the way to navigation, building effective teams on the bridge and crew communications challenges. Ken Koves from the Institute of Nuclear Power Operations spoke about safety culture from their perspective. The level of regulation in that industry is quite impressive. There is just no question about doing things safely, yet they still have their challenges.

I spoke about moving towards a stronger safety culture by sharing more information, building trust and helping people to see the importance of their work to the success of the whole effort. I showed the 35 attendees a slide about the layers of the safety process effort, which they found quite interesting. I also gave them some cards with tips that the officers at different levels could use to help them when they go out to talk with their people. These were seen as quite helpful as well.

The second day focused on training, bridge resource management and simulation so that the captains and their bridge officers could develop stronger skills relating to navigation, ship piloting and management skills.

There is some very sophisticated work being done with large simulators being used by several companies. There are also several institutes providing skills, refresher training and qualification for the officers. Their training loads are very heavy.

Two test pilots from Boeing spoke about their training and the use of simulators. Their simulators are so advanced that, after a month of simulator training, a person could fly an airplane even though they never had seen it before. The basic ideas about the way simulators help them are quite alike even though the differences between a single seat jet fighter and a cruise ship are huge.


Part 2 – Integrating this Learning into all Safety Leadership

There is a big need to be sure the managers of chemical plants are qualified so that their employees and neighboring communities do not suffer the consequences of chemical releases and spills. Many manufacturing businesses that do hazardous work, aside from chemical manufacturing, should heed this thinking too.

As I was listening to these talks, I got to thinking about my chemical industry experiences. When I was a DuPont Plant Manager 20 years ago, we were very strong in operating discipline and safety. Managers were carefully selected and a lot of attention was paid to doing safety and everything else right. Training and integrating safety into every task, every day, was paramount.

Over the years, since I retired in 1996, a lot has changed, with the terrific pressure on cost control and efficiency. The safety standards fell terribly and accidents occurred like the four LaPorte, Texas deaths that DuPont had in October, 2014. In reading the reports of that accident it was sad to see that standards had slipped so far that even their company fire truck broke down on the way to respond to the incident.

This isn’t just a DuPont problem. Many companies are being broken up and purchased by finance and fund managers who know nothing about manufacturing and the high standards that need to be met. Just look at the First Chemical Company spill in West Virginia, when their poorly maintained storage tanks failed, spilling chemicals into the Elk River near Charleston shutting down the city water system for weeks. The people who owned this facility had no idea about their safety responsibilities. Their tanks were leaking for some time, yet the owners ignored them; the size of the leaks increased over a considerable period of time, then the dikes finally failed.

I am beginning to think that the people who manage facilities using highly hazardous materials, like those on the TSCA list, should have some sort of licensing requirements to certify that they are qualified and that their companies know how to fulfill their safety responsibilities. Ship Masters have licenses and certifications. Nuclear plant people are certified. My barber has to have a license. Professional Engineers must be licensed.

While this may sound like just more red tape, I think it is time to open the conversation about this. Plants that handle chemicals like chlorine are hard to run, can fall into a backwater and not receive the attention and support they need – yet a big chlorine spill would be a disaster.

There are lots of questions related to getting this going, but we, as a society, need to address it. What are your thoughts? What areas in your specific business, (chemical or not), are such that being certain that your managers and owners know what they’re doing and have the required knowledge and demonstrated operating discipline, are paramount? Where do you need to put some marked attention in 2016?

Are Your Fingers Crossed…hoping that December will be a good safety month, and that you’ll finish the year in the “good stats” column?

I’m reminded about the organization that thought their safety performance was always good, because they were primarily an office environment. They scoffed over how bad could a paper cut be? Or, what’s the worst that could happen if someone fell off their chair? Little did they expect that one of their office workers, when on a healthy outdoor walk during her scheduled break time, tripped over some roped off tape that had been blown by the wind. She actually walked into it – not paying attention to her surroundings – got caught up in it as it wrapped about her feet. She fell, twisted her knee, required surgical repair, etc., etc. Try to explain that office worker lost-time injury! (The good: healthy walk; The bad: not paying attention; The ugly: lost time injury).

Here’s another real example. A guy stood up in his desk chair and reached over his desk to open a window. The chair rolled out, the guy fell and suffered a severe back injury. Or, what about the guy standing in the office doorway talking with his boss? He was leaning against the doorframe when someone tried to close the door – severely mutilating one of his fingers. The thoughtless – the unexpected – the unobserved – these can happen in any environment.Stay aware!


Want to “get it right?” Get Out of Your Office and into the Workplace. Walk your Safety Talk!

We see organizations as complex adapting networks of people who are the vital keys to its success. When the people in the various parts of the network are sharing information and helping each other, all aspects of EHS Performance rapidly improves, resistance to change disappears and the energy bubbles up spilling over into all other parts of the work lifting the organization to new, higher levels of performance.

The quickest way to make this shift happen is to get out of your offices, go into your organization and talk with the people. Listen, learn together, treat them with respect, ask for their help, offer your help to support their work and together, explore creative ways to achieve the sustainable performance we all need.

Safety Never Takes A Holiday…Not in Hunting Season Either!

Safety Never Takes A Holiday…Not in Hunting Season Either!

In many places, the hunting season is underway or just beginning. This is always a time of change and hazard. Some years when I was a plant manager, we would have one or two serious hunting-related, off-job injuries – like falling from a tree stand or tripping over something and breaking a leg. There is a lot of change as people go into the woods and fields looking for game. Many have not done this for a while. Others may not be fully prepared for a sharp change in the weather where a heavy rain could come in or the temperatures drop below freezing and hypothermia becomes a worry. It is often dark and visibility is poor. I have read of hunters getting killed with their own weapon when they have tripped and accidentally shot themselves. Don’t load your gun until you are ready to use it.

There’s a certain excitement that pervades hunting season, especially with newbies to the sport, so hunting safety cautions and reminders are good to reinforce. Be especially careful and safety-instructive when you have hunting novices with you!

Safety never takes a holiday – not in hunting season either!

Checklists Really Can Save Lives!

BrochuresI have been talking about checklists in my previous newsletters and they can be useful as people go out hunting.

Consider this mental checklist:

  • What sorts of special hazards do you face when you go out into nature and experience the thrill of the season?
  • Are you alone?
  • Do you have a flashlight if necessary?
  • A compass?
  • A cell phone?
  • Do people know where you will be and when to expect you to return home again?
  • Is your equipment really ready to do what you need?
  • Are your weapons in excellent working order?

Too many questions????? My wife’s father died while he was doing what he loved – deer-hunting; but his heart was not strong enough for the exertion required in that terrain.

What about you? Are you healthy enough for the hunt? Do you have your emergency meds with you? Could you get help if you needed it?

Another change for many of you will be related to Thanksgiving and the travel to be with family. Here again checklists would be useful.

Consider this mental checklist:

  • Is the car in good condition and serviced properly?
  • For those up north, do you have a few blankets and emergency rations in case you get into a surprise storm?
  • Are your maps and plans well thought out for the routes and times of travel?
  • Are your tires in good shape?
  • Do you have your ice scraper?
  • Is your cell phone charged?

For the hunters and seasoned travelers, you probably have a pretty good fix on these things. However, in the hurry to get into the field and woods or get moving on your trip when people are anxious and a little uptight, it is easy to miss a critical thing. How many times in the past have you started out and remembered you left something important behind? A simple checklist, written or mental, could make a big, positive difference in your adventures! Remember, safety never takes a holiday!


Checklists in the Workplace

I recently read of a fatal accident where a man was killed while working on a lathe. It was properly shielded and okay for the normal conditions, but the unexpected happened. The part he was working on exploded apart under the high rotating speed when he engaged the cutter. The parts from the exploding piece went right through the shield and gave him terrible, fatal wounds.

As you get ready to start your jobs – talking together about being fully prepared – it is important to imagine the unimaginable. What unlikely thing can happen that can get one of you killed if things go in unexpected ways? For many of these unexpected events there are no safety procedures developed. They lurk just outside of the normal path of events for which we have plenty of rules.

We often discover these lurking tragedies by talking together and thinking out loud about things. This requires a culture where it is expected that you will talk together, listen carefully to what you are hearing, asking questions and being open to something new. Sometimes when two seemingly unrelated ideas come together new insights emerge that could reveal a potentially serious accident. Often when we are listening to comics, two seemingly unrelated ideas are put together can be really funny. Conversely, thinking of two, seemingly unrelated things or events could save a life.

Thinking about the unexpected can be a powerful thing. (Put that on your mental checklist!)


Backfilling: The Hazard of Temporary Workers

Another thing that can happen around hunting season and the holidays is the need to hire temporary people to backfill for those who are out. These people need extra care and attention, but things are often so busy that it is hard to give it to them. These people just don’t know the hazards.

I heard a story about a high school aged fellow who came into a box making plant as a temporary employee and was assigned to a box-making machine. He was told to push the red button and the cardboard would be fed into the machine, scored, cut, folded and glued, then the finished box would be ejected from the machine. They also told him that now and then the machine would jam so he would have to quickly crawl into it to pull the cardboard out. Over the next few weeks, he successfully pull out some jammed boxes, but one day he did not move quickly enough and got pinned in the machine. Fortunately his heavy sweater got caught in the machine, jammed it and saved his life. He did get a long cut in his leg. He was stuck in the machine for about 30 minutes before someone discovered him and got him out and to medical help.

This is a pretty extreme example, but it illustrates the point. Look out for the temporary employees and help them. They are people too!

Checklists Really Can Save Lives!

BrochuresIn many of my newsletters, I have talked about the importance of sharing information abundantly, building relationships of trust and interdependence, and helping people to see the importance of their own work in building the success of the whole organization.

I have also talked about the importance of each person being centered, having the best available information, and help at the specific time when they have to make a decision and do their work. When they turn that wrench, press a switch, or open a valve, they need to be fully present to their work and have teammates who will help them to think through the immediate issues so that the likelihood of an injury, incident or fatality is very low.

This is really important:

In recently reading Atul Gawande’s book, “The CheckList Manifesto” (2009), which is a NY Times Best Seller, it occurred to me that there was something here that could be very useful for the people doing the work in our plants and factories.

Dr. Gawande is a fine surgeon who has a deep interest in improving the success of surgeries by eliminating the things that can easily go wrong and result in a serious injury or death to the patient. These wonderfully trained surgeons are working in a highly complex environment where things can be missed and mistakes made. In working in all sorts of operating rooms across the world, they:

  1. found that simple steps, like knowing each other on the operating team, the timing of giving the antibiotics and anesthesia or having a backup plan, were missed about 25% of the time and
  2. that by using checklists, mistakes dropped around 35% and deaths fell 47%.

These checklists are quick, simple tools to support highly-trained professionals and produce very significant improvements in safety at essentially no additional costs or time required. (Nothing complicated!)

When he looked at how airplane pilots used checklists in their highly complex situations, he found that they were used to avoid missing critical steps in the preparation of their aircraft before takeoff to ensure the safety of these highly trained professionals crews and passengers in both military aviation and the airline industry.


How Can the Use of Checklists Help Your Safety Performance?

In our plants and factories, it is critical that those doing the work are fully present mentally, physically and emotionally so that the safety of themselves, their work partners and others is maximized. Two places where simple checklists could be quite helpful are in shift start meetings and doing a “Take-Two” just before a maintenance job, a repair job or in trouble-shooting. These would be simple, carefully crafted, focused checklists that could be reviewed and used in a couple of minutes to make sure that everyone on that job is fully present and ready to do the work. These are to support and remind skilled people of several critical factors that could make the difference between a smooth, skillful, successful meeting or job and a disaster if something was missed in the hurry to get into the work.

These checklists are not the usual ones we see being used to be sure the equipment is checked out, rather they are checklists to be used to be sure that people have cleared their minds and are fully present mentally, emotionally and physically ready to do the work safely and well.

Just before a shift start meeting or at the beginning of a maintenance or repair job, the leader could quickly skim the checklist to remind him/her of key issues facing the people on the shift and remember to talk about them together. As they talk together, they can check to see if everyone is physically, emotionally and mentally ready to work and develop a better understanding of the day’s challenges and tasks. They can ensure that the right equipment and PPE are available and will be used, that the right people will be involved, and that they have a backup plan if something goes wrong. They will see if they need to ask for help from other groups for the bigger or specialized tasks. There will also be reminders about not taking short cuts and stopping the job if it can’t be done safely.

The checklists can easily incorporate the sharing of information, building trust and interdependence and helping people to see the importance of their work while also focusing on the particulars of the immediate work. These would serve as tools to support the highly skilled people doing the work.

Since so many of our injuries and fatalities occur in driving accidents, a simple checklist could be used to help drivers to remember 3-4 key driving principles when they step into their vehicles before starting the equipment.

These checklists can be a very simple, easy way to significantly reduce incidents, injuries and fatalities.

Why were we at this VPPPA Conference?

At our exhibit booth, Claire and I shared our Partner-Centered Leadership approach. We handed out brochures and other literature that can help organization’s achieve safety excellence and move towards their OSHA Star designation. We were there to share important information, including the need to be able to lift up and address one’s safety elephants that are preventing organizations from being the best they can be.

We talked with a lot of people and learned of their safety journeys:

  • Those who had attained their Star status were looking for ways to sustain their performance, but there was a deep concern that complacency was undermining their safety achievements. Sustaining their work was a goal.
  • Those who were working towards their OSHA Star status were often struggling with communications problems between and among the workers, the union, and even the supervisors and managers. Getting everyone on the same page, and committed to the endeavor seems insurmountable (to some).

The Keys to Success and Sustaining Safety Performance

The keys for addressing both of these concerns in building sustainability into their programs and in achieving the OSHA Star status is for the people at all levels and parts of the organization to talk together to get clear and aligned on just what they really want to do. How sincere and authentic is the desire to have safety excellence for the long-term? (This means Communication with a Capital C—requiring Co-creation, Clarity and Coherence.) In addition, together they must take the time to co-create a set of ground rules about how they agree to work together in order to achieve their safety goals and then hold each other accountable to live up to them. (That’s Partnership and Commitment!) The process to achieve this is available to you and your organizations now.

There is no question that excellence in safety performance is good for both the people and the business. Creating and sustaining a workplace where everyone can go home injury-free, where everyone is treated respectfully, and everyone shares core safety values is what we should be doing.

In creating a workplace like this, the people are also generating benefit for the business. Eliminating OSHA Recordable Injuries and avoiding the average cost of $50,000 for each one provides real value for the business. Maintaining the production without the interruption of having had an injury and all the distraction that this causes is a also major contribution to the business. Building a reputation of being a safe, reliable supplier of quality produces another big value to the business.

Once everyone is clear and aligned that they really do want to achieve and sustain excellence, then talking together every day about doing this is critical. Toolbox meetings at shift start need to alert everyone on the challenges of working safely and a review of the day’s tasks, the looking out for the unexpected, taking two minutes before a job to be sure the right people and equipment are there, and emphasizing the importance of helping each other to stay alert and focused are also very important for these meetings.

As managers and supervisors walk around, they need to be talking respectfully with the people, listening and showing that they are really concerned for their safety. In doing this, we all learn together as better relationships develop and new ideas emerge. Talking with the people as true partners in the safety and business effort is key to moving to excellence. With everyone working together, on the same page, you are creating Partner-Centered Safety.

What are the overdue safety conversations you need to have?
And with whom?

What is it really all about?

This is all about having everyone go home in one piece and having a profitable business. Excellence in both the safety performance and business results are attainable.

When I was the plant manager at a big chemical plant, we got the total injury rates down to about 0.3, sustained this for 16 years, and had our earnings go up 300%. We have the roadmap that never fails—if you’re ready to travel that journey with us!

We can have it all if we want to do these things.

When the safety gets right, everything else gets right!

Leading Safety…Working with People because People are the Key!

Safety 2015,” the Annual ASSE Professional Development Conference and Exposition, was held in Dallas, Texas, in early June. It was a terrific conference and gathering of about 4,000 safety professionals. There was a lot of networking, excellent keynote talks, a vast array of all kinds of safety equipment, and lots of papers in concurrent sessions. About 100 people came to hear me talk about achieving sustainable and excellent levels of performance. Total Recordable Injury Rate was <0.4 for 16 years when we approached the organization as a complex adaptive system (CAS).

There was a lot of interest in this based on the attention of the audience, the quality of the questions and the excellent feedback I received at the end. This was the only paper addressing the complex adaptive systems approach to achieving safety excellence at this conference. Based on my experience, this is a much easier and more effective way to lead safety. The Safety Leadership Process©, the correct tool for use in CAS, requires the leaders to get clear and focused in their safety thinking and message, then go into their organizations listening, talking, abundantly sharing information with the people about how to get better and then helping the people to implement their improvement ideas.

While the conference and exposition presented lots of good papers and displayed a huge array of safety equipment, I got the feeling that a lot of people think that they are disempowered for making safety improvements. Many lament, if only management would listen to the safety professionals, or if we added more focused safety people, or if we could purchase more of the fancy new equipment like that on display, that maybe then our safety would get better. Is this not more of the same way we have been managing safety for years?

I think that more technical papers, more traditional training activities, and new safety equipment will only get the organization to the level of safety compliance – it does not get organizations to the level of safety excellence. I have tried this technical-based approach over the last 50 years without achieving safety excellence. And why? Because people are the key!

But, when I shifted to using the Safety Leadership Process©, described above, the shift in attitude, the willingness to improve performance, and the energy and excitement of the people, enabled the organization to reach and sustain the higher level safety excellence.

Those in leadership positions and at the top of the organization have the responsibility to engage with the people – setting the conditions where excellence can be achieved. This only requires a commitment to get clear on the safety message, go into the work places and engage with the people exploring new and better ways to having every one go home without having been injured at work. With courage, care, concern, and commitment, we can all reach and sustain the level of safety excellence!

Visualizing the Future to Avoid Fatalities

Visualize the Future to Avoid FatalitiesIn my reading, studying and talking with many people, I have found that over half of the fatal accidents are often unanticipated and missed using our traditional approaches to accident prevention. The Heinrich Accident Triangle is very useful as we look at unsafe acts at the base of the triangle. Lots of slips, trips and falls are avoided as we do this.

But, many potential, fatal accidents don’t show up in this work. Only very few of the unsafe acts at the base of the triangle ever lead to a fatality. Why does a man fall from a cell phone tower when he has his fall protection harness on properly? Why does a man rush down the ramp to quickly fix something at the end of his shift where big paper rolls are stored prior to loading, when he knows the dangers of getting caught between the rolls and getting killed? Why does a man jump onto a large baking oven conveyor belt in a hurry to enter the oven before it is cool enough to do some maintenance and gets killed? These sorts of impulsive, tragic actions aren’t picked up in our normal safety audits.

Yet many of the reports of fatal accidents indicate that the conditions and impulsive behavior surrounding these accidents were obvious in hindsight. As people think about the fatality, they often see that, while the obvious conditions and impulsive tendencies were there, they were not in people’s everyday conscious thinking.

Often, the causal details are a mystery like in the situation with some of the fatal falls from cell towers and the workers have their fall protection gear all on but somehow they didn’t have it hooked up for a fatal moment. Or the man caught between the big rolls of paper or the guy who got cooked.

One possible approach to eliminating these sorts of fatalities is built on the belief that the people closest to the actual work are in the best position to see the obvious if they open their minds. Suppose that, once a month, the various work groups take 30 minutes to think about their work with the focus on identifying the conditions and work practices possibly leading to unlikely events and potential fatalities. Think about what work the people actually have to do to get their job done. They would open their minds to unlikely possibilities and see if there is something coming out of this that would alert them to a potential fatality. Including a few people from another work group with fresh sets of eyes would be helpful.

Here are some questions to consider:

  • Are there high pressures to get the work done quickly?
  • Do people just jump in impulsively?
  • Do the people talk about both safety and production and the need to do both well?
  • Is there information that needs to be shared that would help to prevent a potential fatality?
  • In your safety culture, is it okay to stop the job to fix a safety issue?
  • Are procedures gradually being changed that might weaken the protection?
  • Do people really trust and help each other?
  • Can you reach out to an impulsive person and hold him/her back?
  • Those closest to the work know their work and their work-mates better than anyone else and can explore the unlikely possibilities. Supervisors and managers should also be included and support this effort.

Once they have discovered a potential fatality situation, they could put together a team to focus on it and develop ways to eliminate or modify the conditions, behaviors and procedures that could lead to a potential fatality.

This important work should be shared with all the other people in the organization so that everyone can learn and improve. Keeping track of these disaster prevention sessions could become a leading indicator of the safety culture.

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