As we head into the New Year I want to wish everyone the absolute best in 2012. Let’s all have a safe and healthy 2012.
My 2012 Resolution: “Whenever you find yourself on the side of the majority, it is time to pause and reflect.” – Mark Twain
In my earlier days (Late 70’s) as a government OHS Officer, I worked with a fine woman, Eleanor Raub (she was the first female OH&S Officer in the Province of Alberta – a true pioneer in a difficult time). Eleanor described the “most important cause” (it goes by many other names, “immediate” is a popular one) as the one thing that could be changed just seconds before the “incident” happened to create the damage/injury (energy released into someone or something beyond the capacity to withstand the force). In Eleanor’s view all other events and/or conditions were secondary to that one “cause”.
Being there in the early times of Canadian OH&S law and the developing safety management systems positions me to have developed the following opinions based on my observations and experiences.
These secondary “causes” that we struggled with (today some call them events, acts, conditions, basic, root, whys, etc.) all basically supported the events/conditions that allowed the energy to release at that time, in that space. The problem then was explaining how this almost infinite list of nested conditions and events all came together at exactly the correct time for the harmful energy to create a damage or injury. Many at the time wanted to throw up their hands and play the “act of god” card. Others took the position that this was silly and could go all the way back to “in the beginning”. Even others focused on creating causation charts, trees, theories, lists, what-if tests, codes, human factors and complex pictures of cheese.
The concept of multiple events/conditions/causes was hard to comprehend for most since the variables are almost infinite. It’s like contemplating the size of the expanding Universe…you’ll soon tire of it. Even for the simplest of energy releases (example: fatal fall from a poorly maintained ladder) an analysis of the circumstances and potentially inter-related factors create a MORT analysis chart (with and/or gates) that quickly grows into wall sized diagrams. This flew in the face of the new OHS legislation that needed a set of specific violations to “blame” for the injury (usually a fatality in most prosecutions). The legislation is written in a specific way to place blame/causation. Any well written regulation names a responsible party and states the condition that needs to happen or NOT happen. “No worker shall climb a damaged ladder.” “Employers will provide ladders that are in a manufacturer’s recommended condition.” “Employers will ensure ladders are inspected before put into use” are simple examples.
The Crown wanted and needed an easily explained “open and shut” case to show that they were “enforcing the new laws”. Causation needed to be reduced to a charge (or charges) under the OH&S Act. The cause/blame then transformed into a legal concept of causation that historically was much different that this complex thinking safety was creating with our charts, theories, lists, science and associated factors. The elected politicians also needed to be seen as reacting to the human tragedy (even more laws). The pressure was great on the new OH&S legal system to get results. I can assure you that no one in OH&S enforcement was bringing any pictures of cheese into court in the early days. The K.I.S.S. principle was our only approach.
The complex then turned simple…easily explained to the judge, the media and the grieving family. The employer supplied an unsafe ladder, the supervisor failed to ensure inspection and the worker climbed it! We can’t charge the dead worker…so the supervisor and the employer are to blame and are the cause of the fatality. The violation of the legislation was proof enough. Period! Next CASE! It was unfortunate for the organization that had the incident because to create a situation where those factors didn’t repeat themselves causing a repeat energy release (another worker climbing another unsafe, uninspected ladder) usually had nothing to do with the simplistic cause in the “charge”. “Good thing for prevention we had all those pictures of cheese and wall sized MORT charts.” some thought!
The political and legal influences on our thinking about causation, safety, prevention and the way we manage cannot be underestimated or ignored. None of which have anything to do with any of the pure sciences where the test for cause & effect relationships is much different. The physics of gravity seldom needs to be discussed in court because the issue presented and argued (the charge) is based on the legislation not the science. This has, in no small way, driven our profession into much debate (this discussion included).
Having been in the rooms where decisions to prosecute were made I can assure you that multiple causation and the associated logic and science have very little to do with the decisions and fact finding efforts put into prosecutions. Of course my first-hand experience is limited to Alberta…but my career long involvement in teaching OH&S legislation and Incident Investigation courses allows me to assure you that there is overwhelming evidence that this is alive and well in a large variety of jurisdictions. The debate continues…
Order “How to Hold GREAT Safety Meetings – These meetings don’t suck anymore!©” Just arrived from the printers and is Available Now!
Chances are good that your last safety meeting wasn’t outstanding, awesome or fabulous. There’s a very good chance that you would NOT describe it as the “best meeting you’ve ever attended”. Well, you’re not alone.
The overwhelming majority of people when asked say that their safety meetings fall very short of these descriptions. In fact, some describe their safety meetings as some of the absolute worst they have had to attend.
These “bad meetings” are all too common. They are a function of well-meaning people, wanting to make it safe where they work, but just not knowing how to hold a GREAT safety meeting.
There are ways to have Great Safety Meetings. Meetings that people want to go to. Meetings that get things accomplished and have the participants feel good because these meetings were a good use of their time and effort. It’s going to take some reflection; a bit of hard work and some trial and error but your organization can start having GREAT safety meetings.
If you think we don’t need help with our meetings…then why are these quotes so painfully funny?
“If you had to identify, in one word, the reason why the human race has not achieved, and never will achieve, its full potential, that word would be “meetings” – Dave Barry
“I am prepared to meet anyone, but whether anyone is prepared for the great ordeal of meeting me is another matter.” – Mark Twain
“People who enjoy meetings should not be in charge of anything.” – Thomas Sowell
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When designing and implementing safety management systems it’s often difficult to calculate the real results achieved from our efforts.
Just this morning I receive a note from a client noting their significant success in their safety outcomes…I just had to share their impressive results!
“Al thanks for your support over the last year. 2011 was indeed a performance “step level” change for HSE results in our Delivery Unit and I appreciate your training program to introduce an important part of our Behavior programs. It really works, both you and I know that but when I review the results this year, it once again hits home how effective our program is. Thought you might like some “data” (as you know I am a data guy!).
We introduced, formally, our safety management system (the what) and our BBS program (the how) c/w coaches and training support for the drilling leaders and drilling front line workers and this is what THEY did.
“We introduced, formally, our safety management system (the what) and our BBS program (the how) c/w coaches and training support for the drilling leaders and drilling front line workers and this is what THEY did.
Lost time incident frequency improved 86% in one year, moved from 4th Quartile to industry leading 1st Quartile (compared to Oil & Gas Producers, which is a tough peer group).
Total Recordable incident frequency improved 61% from last year we are now seeing months where we only have one minor! When I arrived here we were averaging 10/month and on several months were as high as 14 (hurting someone every other day!).
Our frequency for High Profile Incidents (the bad ones!) improved by 53% and most important none involved personal injury.
Regulatory inspections improved from an average of only 45% satisfactory in 2010 (I have never seen such low numbers!) to an exit of 90% satisfactory inspections (close to 400 inspections so no small feat!).
All of this while increasing the capital spend and bringing in numerous new staff and unfortunately changing out those who did not fit our culture.
Pretty dammed impressive Al Quilley. We are a team and I want you to know how effective this has worked across all areas where we have work together!
I look forward to doing it all over again in 2012, lots to do but now we are rolling!”
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A terrible tragedy that really gets to the point of how many factors come together to create these situations. Easy to blame the “unsafe act” however there is much more going on with the culture, process, management and physical work environment.
Eliminate any or all of these details and these fatally injured employees could be reading this instead of being written about.
Great job of communicating the details on Worksafe BC’s part…following in the excellent footsteps of the CSB.
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