Incident Prevention Magazine

For all of 2018, this column and its associated webinars have focused on human performance (HP). I have thoroughly enjoyed and learned a lot from the guest speakers who participated in the webinars, as well as the readers and webinar participants (you) who have been engaged, shared their experiences, and asked intelligent and challenging questions.

In this article, I will wrap up the HP series by reviewing key points, outlining proven strategies about HP implementation and inviting you to our next webinar – scheduled for January 16 – that I am really excited about because we will have a panel of experts gathered to explain HP implementation, address your concerns and answer your questions.

HP Review: Principles and Key Points

Principle One: People are fallible, and even the best make mistakes.
People screw up. We make mistakes, and often we are not aware of them. That is a real problem, especially with regard to safety. Rarely are our errors and their undesired consequences intentional, and most errors have no immediate negative consequences. Because of this, your safety program must acknowledge that people will make mistakes. With that acknowledgement, we can use HP tools to reduce errors and manage controls.

Frequently I am asked about the qualifications of a safety professional, what makes a good leader and what it takes to work safely. My answer to each question is the same – you must get really good at asking and understanding “why.” At a minimum, you must ask and understand why rules, procedures and work methods are in place; why performance, behavior and results are occurring; and why past events, incidents and errors happened.

If you become really good at asking and understanding “why” in those areas, you will be able to employ human performance (HP) principle five, which states that events can be avoided through an understanding of the reasons why mistakes occur and application of lessons learned from past events or errors. This principle reminds me of an adage most of us have heard before: Fool me once, shame on you, fool me twice, shame on me. It also reminds me of a definition of insanity – doing the same thing over and over and expecting different results. I like to summarize HP principle five by saying simply, “‘Why’ works.”

Not long ago, my son was trying to park a golf cart in the cart shed. He got upset because he was in a repeated cycle of turning too early, almost hitting the shed, backing up and trying again. I let him go through that cycle of repeating the same mistake a few times and then calmly said, “Try again, but do something different this time.” He tried again and still turned too early but improved. The next time he turned too late. After a few more tries, he finally got the cart in the shed without hitting anything.

He got the cart in the shed because, without knowing it, he used HP principle five. He shifted from expecting a different outcome with the same behavior to understanding why the situation was occurring and trying something different until he achieved his desired outcome. Now, he applies the lessons he learned and usually parks the cart successfully on his first try.

“That night in the city, when you thought I was the Special, and you said I was talented, and important … That was the first time anyone had ever really told me that, and it made me want do everything I could to be the guy that you were talking about.” -Emmet in “The LEGO Movie”

When Emmet made this statement to Lord Business in 2014’s “The LEGO Movie,” he nailed human performance (HP) principle four – that people influence each other – and taught viewers of the movie some valuable lessons about how safety should be led. In this installment of “Frontline Fundamentals,” I’m going to present some of those key safety leadership points, along with expected outcomes when HP principle four is properly applied.

Key Safety Leadership Points

• HP principle four: People achieve high levels of performance based on encouragement and reinforcement given to them by leaders, peers and subordinates.
• Encourage others: Believe in yourself and others; provide feedback, coach and mentor with the goal of achieving excellence; and have a positive attitude.
• Reinforce desired behaviors: Don’t assume because behavior is good that people will know it’s good and repeat it; tell them it’s good, why it’s good and how it will benefit them to repeat it.
• Minimize negative consequences: Punishment will generally get you compliance, but it’s likely that compliance will only occur when someone is watching.

What happens to a saltwater fish if we put it in fresh water? No matter what that fish does, no matter how well it can swim, no matter how strong it is and no matter how hard it tries, it cannot survive because we put it in the wrong environment.

When it comes to human performance, HP principle three states that individual behavior is influenced by organizational processes and values. It implies that incident causation goes deeper than individuals, and that to prevent incidents, organizational (systems) deficiencies must be identified and corrected. The challenge for an organization is to create an environment in which employees – the organization’s greatest asset – perform at their highest level. You do not want to create an environment in which latent organizational weaknesses set employees up for failure.

Us vs. Them
Imagine a group called Us and a group called Them. Them has a package labeled Profit that needs to get from Point A to Point B on or before a day called Standard. Them creates directions on how to get from Point A to Point B, which are contained in the Map. Them gives the Map to Us and instructs Us to go to Point A, pick up Profit and deliver it to Point B on or before Standard.

Us arrives at Point B two days late with only part of Profit because Us got lost. Them is furious and blames Us for losing part of Profit by not arriving at Point B on Standard. Us blames Them, complaining that the Map was wrong, which caused Us to get lost and be late. Two weeks later, this scenario is repeated, with more of Us losing part of Them’s Profit, so Them sends Middle Man to investigate and determine corrective action.

I have fond memories of G.I. Joe. When I was a kid, I played with the toys and watched the cartoons. I sang along with the theme song and was ready to say “knowing is half the battle” in unison with the hero at the end of each episode, after Cobra had been defeated. The Joes were smart to realize that knowledge is power, and knowledge is especially powerful when it comes to safety, and more specifically, incident prevention.

Imagine for a moment what it would be like to know the future – think about how powerful it could make you. How much money could you make if you could predict winning lottery numbers or the winner of a sporting event? Think about all the undesirable outcomes you could avoid – such as getting injured – if you knew the exact date and time they were going to happen.

It’s unlikely you will ever know exactly what the future holds, but you can use human performance (HP) to predict, manage and prevent error-likely situations that could have led to incidents. In other words, the second principle of HP – that error-likely situations are predictable, manageable and preventable – gives you a crystal ball.

Let’s define what is meant by the term “error-likely situations.” These situations occur when error precursors are present and negatively impact decision-making. Error precursors, which are grouped into four categories – task, work, individual and nature – include such things as imprecise communication, departures from routine, distractions, inaccurate risk perception, overconfidence and time pressure (see more in the TWIN Model of Error Precursors sidebar).

The first principle of human performance (HP) is that people are fallible and even the best make mistakes, or in simpler terms, people screw up. How error-prone are we? Studies vary, but for our purposes, we will use an average of five mistakes per hour. That’s a lot of mistakes, and a scary thing to think about is we often are not aware of our mistakes.

Let’s consider how this relates to safety, and more specifically, how HP Principle One needs to be incorporated into your safety and health management system. Safety programs tend to be based on the concept that if there is a rule and the rule is good, people will always follow the rule and perform perfectly, which simply is not the case.

While it would be fantastic if no one ever made another mistake – no one tripped and fell in the right-of-way, no one skipped a step in a switching procedure, no one dropped a tool from a bucket, no one forgot to look before backing – that is not realistic, and it is irresponsible to assume mistakes will not happen.

Executives, managers, supervisors and safety professionals, you need to acknowledge that mistakes will happen, and ensure safety by design and defense in depth are being utilized to protect your employees from their mistakes. Utilize these concepts, and the consequences of errors will have little impact on the safety and health of the workforce. If you are responsible for investigating incidents, don’t forget to put yourself in employees’ shoes as you examine motivation, perhaps thinking about what you might have done in a similar situation. People rarely intend to hurt themselves, and part of your job during an incident investigation is to think about employees’ decisions, which likely made sense to them at the time. Be careful about the tendency toward Monday morning quarterbacking that starts with, “Here’s how I would have done that job and that would never happen to me.” If you haven’t already, educate yourself on organizational HP tools such as benchmarking, observations and self-assessments. Being critical of people does not engender appreciation of the value of investigations and cooperation.

Please take a few moments to think about the following questions:

• Should a vice president tell his employees, “I only want new mistakes”?
• Is telling a 10-year-old baseball pitcher to throw strikes a good way to teach him how to pitch?
• When is the last time you provided positive reinforcement for safety behavior, or do you consider safe work a part of the job that shouldn’t be praised?
• How do your frontline workers feel when you say zero injuries is the goal and nothing else is acceptable?
• Do most of your post-incident corrective actions involve administrative controls such as retraining and targeted observations?
• Imagine one of your employees rear-ends another vehicle and does $100 in damage to an older-model sedan with high mileage. Another employee does the same thing but hits a new luxury SUV and does $10,000 in damage. Are both vehicle collisions investigated? Do both employees receive the same disciplinary action?
• Would you spank your child because they spilled their milk? Would that keep them from spilling it again?
• How does it help someone when you say, “Be safe,” and are you doing it for them or yourself?

Here are two additional questions you should carefully consider, as they are the ultimate test of your safety program’s effectiveness. If your answer to either one is yes, there is room for improvement and an opportunity to add human performance (HP) principles into your program.

• Do the same kinds of incidents continue to occur at your organization?
• When incidents happen, are you left in disbelief that they happened, about how they happened and about who they happened to?

Imagine this scenario: A worker seriously cuts his nose on the job. The laceration causes part of his nose, at the base of the nostril, to partially separate from his face. The worker glues his nose back together with super glue to prevent going to the doctor and having an OSHA-recordable injury. He then receives two rewards through the company’s safety incentive program. The first is an immediate reward when his supervisor recommends him for safety excellence because he prevented a recordable injury. This is followed by a financial incentive at the end of the year, when his work group is given a bonus for not having a recordable injury during the calendar year.

Here’s another scenario to consider: An employee is stopped at an intersection and gets rear-ended by another vehicle hard enough that he is taken to the emergency room and receives medical treatment. Pursuant to 29 CFR 1904, “Recording and Reporting Occupational Injuries and Illness,” this is determined to be a new, work-related case that meets the general recording criteria and therefore is a recordable injury. Because he had a recordable injury, this employee is not invited to attend the company’s annual safety awards dinner, where prizes such as televisions and all-expenses-paid vacations are raffled and given away. Note: OSHA prohibits employer retaliation for reporting an injury (see 1904.35 and 1904.36) and will not allow employers that offer financial incentive programs to participate in their Voluntary Protection Programs.

Incentivize Desired Performance
Both scenarios are unfortunate and too common in the workplace. Organizations need to be aware that the absence of injury does not necessarily indicate the presence of safety. With that in mind, they must stop programs that incentivize results and instead focus on performance, which is the combination of behaviors and results. The guiding principle behind any incentive program, coaching or feedback should be to never reward results or punish someone without understanding the behavior driving the results. Get the desired behaviors and the results will take care of themselves.

If you were in a cave and someone yelled “Watch out for that stalagmite!” would you look up or down? If you said down, you are correct. Both stalagmites and stalactites are formed in caves by mineral deposits from trickling water. Stalactites result from water dripping from the ceiling. They hang down, typically are hollow, have smaller bases and form faster than their counterparts. Stalagmites are built from the ground up when water drips on the cave floor. They have a more solid structure with a larger base that takes more time to form.

This imagery is useful when contemplating and discussing organizational culture. Does your company have a top-down (stalactite) or bottom-up (stalagmite) culture? As you think about your answer, consider how your organization handles the following occurrences.

Occurrence 1: Change
Stalactite: The company is reactive and changes only because they have to due to incidents or regulatory reasons. Management creates or revises programs and policies that are implemented during lecture-style training sessions conducted per organizational hierarchy. Employees have no or very limited opportunities to ask questions or provide feedback about the change.

Stalagmite: The company is proactive and changes because they want to. Leaders anticipate the need for change. Frontline workers are involved in creating or revising programs and policies that are implemented during training sessions, and they encourage questions and feedback from safety leaders, safety advocates and change agents.

You are responsible for your own safety and the safety of others.

Most people would say they agree with that statement, but do their actions reflect their agreement? Let’s consider that question in the context of the following incident investigation.

The Incident
Bob, who works in shipping and receiving, has just cut himself with his pocketknife while attempting to cut a zip-tie off a package. Randy, the shipping and receiving manager, is Bob’s immediate supervisor. Pam is Bob’s co-worker. Ron is the facility’s safety supervisor and is interviewing Bob, Randy and Pam as part of the investigation.

Bob’s Interview
Ron: Can you tell me what happened?

Bob: We have a specially designed box cutter we use for cutting zip-ties. It works really well, but we lost it. I told Randy we lost ours and he said he would get us another one. That was three weeks ago. What am I supposed to do, not work? I have a job to do, and I’m going to make sure it gets done.

Ron: What could we do to prevent this from happening again?

Bob: We need the right tools for our job. Someone needs to make sure we have them.

A fundamental premise of working safely is that hazards must be identified and then controlled. Too many incidents occur because hazards are not identified, or worse, they are identified but ignored or tolerated.

One of my favorite ways to introduce the concept of risk tolerance is to ask a Frontline class this simple question: “What are some things you might hear someone say before something really bad happens?” It always amazes me – and scares me – how open participants are when I ask this question. Typical responses I have heard include:
• “We’ve done this a thousand times and no one has ever gotten hurt.”
• “We’ve always done it this way.”
• “This is going to hurt.”
• “If this works, we’ll be heroes.”
• “I think it will hold.”
• “I can survive anything for two minutes.”
• “What’s the worst that could happen?”
• “Here goes nothing.”

That list could go on for a long time, and it gives us a lot of insight into how we think about hazards and risk. In fact, I want to be sure to mention one incredibly memorable response not listed above that led to some great discussion about risk tolerance: “Hold my beer and watch this.”

Take a moment to remember if you have ever made that statement or heard someone else make it. What followed? I have heard stories involving “testing” an underground dog fence, in which someone held the shock collar in his hand and ran through the fence; jumping off a roof into a swimming pool; attempting to bench-press 400 pounds; boxing a kangaroo; and a myriad of other superhuman feats fueled by alcohol. Oddly enough, sober people do not think it is cool or that it will impress someone if they, for instance, eat a spoonful of cinnamon.

“Get us a bucket truck, a rock and a hard hat. The rest of the class and I will meet you outside in 10 minutes.” Those were my instructions to a participant who, during a recent Frontline program session, challenged me as I was teaching the hierarchy of controls and explaining why PPE should be considered the last line of defense.

The participant was adamant that he had always been trained that PPE is your primary protection and that if you are wearing it, you are protected and can work as you want. The rest of the group validated that was how they understood their training. This put us at an impasse because I firmly believe safety boils down to your ability to identify and control hazards, and I am extremely passionate about using the hierarchy of controls as a decision-making tool to control hazards to the fullest extent possible. I also believe overreliance on PPE is a serious and growing problem, and that far too often, hazards are identified but tolerated or not properly controlled.

After about 10 minutes of failed examples and discussion with this Frontline group, I decided to go another route and requested the bucket truck, rock and hard hat. The participant who had challenged me gave me a quizzical look and replied, “What?” I told him that per his understanding of PPE, if there was a hazard that involved me dropping a rock from a bucket raised 30 feet in the air, he was OK standing underneath the bucket as long as he was wearing his hard hat. I then gave him three choices: eliminate the hazard (I don’t drop the rock); eliminate the risk (he doesn’t stand underneath the bucket); or I drop the rock and he relies on his hard hat for protection.

Suddenly it became obvious to the class why elimination is the first choice in hazard control and PPE is the last line of defense. We then had an amazing and exciting discussion about the hierarchy of controls and how the group was going to change their training. More importantly, the class talked about how they were going to approach hazard mitigation in the future.

In computer terms, multitasking is the concurrent operation by one central processing unit of two or more processes. Interestingly enough, this is not accomplished because computers can perform multiple processes at once. They simply give the appearance of multitasking because they can switch between processes thousands of times a second.

Look around your job site. There are hazards including suspended loads, moving equipment, heat, electricity, insects, falling objects, poison oak and traffic. Assuming you work for a company with an effective safety program, they have trained you in hazard identification and mitigation. Your mitigation plan to control some hazards includes PPE. You inspect it, store it properly and wear it as directed. In short, you protect it so it can protect you. You are covered in PPE from head to toe and ready to go to work. Or are you? Have you forgotten the most important PPE you will ever use – a mirror?

Certified. Qualified. Competent. What do these words mean and how are they interrelated? A customer of a utility contractor recently rejected an application from a safety professional who wanted to work on their project, stating he was unqualified. The safety professional had CSP certification and more than 20 years of relevant experience. He is obviously certified, and his experience arguably makes him competent, raising the question: Is it possible to be certified, competent and unqualified? During the same week, this contractor bid on another job that required a CSP on staff. So what, exactly, is the value of safety certification? The answer to that question obviously depends on who you ask, but what are the arguments?