Why admin controls will get you hurt!

The problem with administration controls is they rely on your working memory to implement. Typically a risk assessment is completed and the hazards is noted on the JHA/JSA and if it cant be removed, reduced or engineered out (which is many) beware of the hazard is listed in the controls. We load this control up into our working memory and there we hope it will stay for when we need it. Thats where the problem lies.

I was involved in a crane incident where its counterweights contacted a fixed structure. The crane could only be positioned where a slew anticlockwise meant collision. So a risk assessment was completed and everyone agreed the structure couldn’t be removed so the control was to slew clockwise and operate in the 2 o’clock to 4 o’clock arc.

During the cranes set up a wind speed measurement device needed to be fitted to the boom. This meant the boom had to be slewed to the 8 o’clock position and lowered to near ground so it could be fitted. Well the operator had a lot on his mind that morning and what had been discussed, agree, reinforced and put into the operators working memory went straight out again once he started using his working memory for other thing, like crane setup. He basically forgot what had just been discussed. Ever have that happen to you?

Well working memory is limited. Most people can only remember 5-7 things at a time, so once you attempt to use working memory for more than that something has to be dropped off. In this incidents case it was the control of “not slewing anticlockwise”. He hit the structure!

So whenever you see controls that rely on remembering a newly written down admin control, be wary. Our memory is prone to forgetting and that can get someone hurt.

How rushing and frustration leads to inattention

When we rush or get frustrated, our ability to process the number of things in the cognitive part of our brain diminishes. Our brain reduces its focus to what it thinks is important. Unfortunately that may not be the hazard that unexpectedly pops up in front of you.

Let me give you an example. Today I investigated an incident involving an experienced driver that struck a small white pole about 600mm high. The driver noticed the pole when he parked the car about 2 minutes before hand but when he went to move off he didn’t see it or remember that it was there, hence contacting it.

We had been discussing the incident for a couple of minutes I asked “What were you thinking at the time you starting moving the vehicle?”

He said “Well, I had just been called back to the workshop where I’d already been, awaiting for this guy to turn up”. He continued but his voice raised “Now, he calls me to tell me he’s there and ready for me and tells to me come now!”. He quickly calmed down and reflected on his thoughts and said “I suppose I was frustrated that I had to go back there and I’ve got a lot to do. This bloke has already wasted half an hour of my time!”.

So I asked “do you think you were rushing?” He said “Shit yeah and pissed off too!”. I could see his emotional state.

When we are in this state, our body pumps out adrenaline. This causes your focus to narrow to the task that is occupying your emotional centres in the brain. In this case, having to repeat a process that has already wasted valuable time for an individual. Time he perceives he doesn’t have lots of.

This is a common lead up to safety incidents. When an event occurs that takes us out of the logic and rational part of our brain, into the emotional part and with a narrow focus. This is a dangerous phase. If something unexpected pops up that requires cognitive resources to sort out……then you better hope that there isn’t a lot of hazardous energy involved.

So what can you do? Well basically there are two options available. One is to recognise that you are rushing and/or frustrated and try to calm yourself. Typically this requires cognitive resources to do, which we have just said are limited.

The second option is build a routine into your brain that triggers when you are in the emotive state. A ‘look for hazards” or “eyes on path” type of automatic routine (habit). This routine will run automatically without you having to think about. Therefore cognitive resources are not required. I call these keystone habits.

So be wary of people that are rushing and/or frustrated. They are likely to not be paying attention to you!!!!

What is the one thing you should say to the workforce?

A friend asked me, if you could say one thing to the workforce as they walked through the gate what would you say? Hmmmmmm what a great question. What came to mind quickly is what I wouldn’t say. Stay safe or be safe. To me these are end points and don’t help. Follow the rules or procedures? That might be a good one but that tends to be workplace focused and I want to provide tools and skills that work everywhere.

I guess I would tell people to do an action. An action that would keep them away from a hazard. An action that would lead to a new habit after repetition. Maybe something like look for hazards. But telling someone to do something isn’t as powerful as asking a question or a call to action.

So i think if I was standing at the gate, greeting people as the started for the day I would say “Morning, do you have eyes on the path and mind on the job today?”.

I will try it and see what happens and let you know.

The problem with inattention and golden rules

I was reviewing two incident reports which involved potential breaches of golden rules (under a load). Now the reports had statements saying the breach occurred and the other saying it didn’t. Overall there was no independent corroborating evidence one way and in both of these cases, punitive action was unwarranted due to the lack of evidence. The interesting part for me though was inattention was marked on the incident report. Now I had conducted my own investigation and talked to those involved and a form of inattention was involved. Inattention to the hazard. I continued reading the report to the corrective actions and this is what I found:

  • Reinforce the golden rules to the people involved,
  • Amend the SWM/JHA to state at no time to go near a load,
  • Walking under loads as the next toolbox topic.

I thought for a moment. If the actions by the individuals was due to inattention of the hazard, by definition they were thinking of something else at the time they moved under or near the load. How does restating the golden rule and work method statement (knowledge and information) to them, deal with inattention or get them to think of the hazard before or when they are moving? Here was the classic safety persons response. I’m generalising I know but most think, like the rest of society, that once a rule has been set it will drive behaviour. If we create a rule it almost magically gets into our brain and the behaviour is sorted. Unfortunately thats not how it works. Our behaviours are influenced by a range of factors and probably least of all a rule that someone else came up with. The ironic part of this thinking is the rule we should be implementing (assuming it worked) is “pay attention” and not “don’t go under a load”. My logic here is if these guys were paying attention (as the root cause was inattention) they would see the obvious hazard in front of them and our primitive defence mechanisms would have kicked in. Remember people don’t intentionally go out to hurt themselves.

The problem with this thinking and corrective action is “inattention of the hazard” is not a conscious decision made by you, rather it comes from our brains need to switch into low energy mode at every opportunity it can find. It is called autopilot and the research shows we are in autopilot for most of the day. In autopilot we are running routines in our brains that have been developed from repeating a task over and over. We do this so the cognitive function (the highest energy user part of the brain) is pretty much on idle and not really doing much apart from saving energy or in this case, definitely not thinking about rules.

Both of these incidents occurred in situations where the individuals where in autopilot and thinking about something other than the load whilst they were moving. So to fix this we need to write a routine into autopilot to look for the hazard before moving. Reprogram in a way that makes this action a habit. An action that is completed without having to use the conscious part of the brain. Like what they did in the first place but with a small addition. Look for hazards, like a load overhead or the tripping hazard on the floor! Easier said then done but if we are looking to equip people with the tools to be safe, then writing a small routine into the autopilot to be scanning or looking for hazards whilst you are moving, is one way to do that.

There is solid science behind how we can write those new routines into the autopilot and I have seen it first hand. Not for this blog but this is the future for safety and providing tools for people. We will continue to remove hazards to the best of our abilities but it is true that we cannot make a hazard free world. Providing the tools, especially the brain and how we can use its full capacity, to keep us away from things that can hurt us.

 

 

 

Safety – Invest in programs based on causation

I was reading about Ray Dalio, arguably one of the most successful and influential financial people in the world (Bloomberg top 50 most influential people and Time top 100). One could fill this blog just with his achievements alone but what started my neurons firing was one of the key reasons he gave why his fund has been so successful ($160 Billion in assets under management and the biggest in the world). He spends his time looking for causation not correlation. In fact, when the rest of the investment community observes the correlations of markets going up and down, he has worked out what causes markets to go and down and based his investment strategy for Bridgewater Hedge Fund on these causes. Knowing the causes equips Ray to structure his strategy regardless of future events. Causation is king in predicting future outcomes.

Now lets look at safety. The Universal Law of Personal Injury tells us for a person to get hurt, 3 things must be true.

1. A person is present,

2. Hazardous energy is present, and

3. The person and the hazard must come together

Remove one of these and the injury won’t occur. A direct relationship that if you affect one element the outcome will change, consistently and repeatedly. This is causation.

If in life,  you find causation (as Ray Dalio has found), use it as much as you can. It is rare to find these direct relationships as most of what we think are direct relationships are actually correlations (and loose ones at that!) and our brain uses these correlations to create what we call, confirmation biases. Once the bias is in our mind, it is the truth and we will make all data fit this truth.

In safety, this is a problem. Too many well intended programs and initiatives, by well meaning and passionate safety people, are full of correlations and biases. Some argue, this blog suffers this effect. Which is precisely the reason I use the Universal law as my framework for all things safety. Start from here and you remove all the biases and unfounded perceptions. It is like starting with E=mc2 when studying light and energy.

Why is this important? Too many programs are based on the bias that the “hazard” is the issue and all hazards must be removed. Safety people are drilled with these correlations, ignoring the fundamentals. Hazards are only half the equation but they seem to get all the attention.

So, if you are not spending at least 50% of your safety effort on the person side (either spend, resources or both), your investment is skewed and probably towards the hazards. Take a look at your safety program and ask yourself “What are the key focus areas?” I’ll bet you have lots of people and money being spent of identifying, removing, reducing or managing hazards. Any investigation talks about removing the hazards and not much about the person.

Then ask yourself “Do my programs identify the person moving into the hazard or vice versa as a root cause?”. If not then it might be time to refocus where you are making your investments.

Again, the Universal Law gives us the causation that is so rare to find. It will reliably predict what happened in any incident if we start our investigations there. It can also form the basis for our safety strategy.

Like Ray Dalio, invest based on causation not correlations. Anything else is probably wasting money.

Safety Revolution – Lets get started

Greetings,

A revolution needs a start point. Here it is. In my last blog I mentioned that I have spent the last 4 years researching how people get hurt. Spoken to hundreds of workers about how they and others have been injured at work, on the roads and at home. I’ve reviewed the many systems and processes that try to keep people safe. Been involved in early engineering designs, concept risk workshops and the like. Developed and implemented hazard identification programs that improved people hazard identification abilities.

I’ve been involved in a broad range of safety initiatives and reviews looking for commonality. Looking for that “theory of everything”  if you like.  Something that described personal injury consistently every time. Something that made sense that I could use time and again to understand incidents.

Surrounded by complexity I was also searching for the complex. It seemed like I needed to go through the multiple layers of management systems, process, procedures, designs, organisation structures, cultural and then leadership knowledge before the simple appeared. It wasn’t until a chance meeting with an old friend (and safety guru), did the light come on and its beam shine on what was so simple but yet so powerful, I couldn’t believe I missed. I’ve coined it the “Universal Law of Personal Injury” and it goes like this:

For a person to be injured, three things must be true.

1. A person is present,

2. Hazardous energy is present, and

3. The person and the hazard must come together

I can show the law with the following diagram:

universal law

This law is so simple that most people don’t recognise it nor its power (and I hope you don’t either). For me it is like E=mc2. A fundamental tenet of the universe. A law that shows us how to solve the problem of personal injury. Maybe it was my engineering background but once I could show the problem in this way, the solution became clear. Work on eliminating hazards AND those human interactions that put people in harms way. It was like a bolt of lighting.

It was then that I realised the biggest mistake that we all make (including me for a very long time) and that is we focus our energies on one part of the equation, the hazard. It seems all of our systems, processes even legislation is all about eliminating the hazard. Reducing the hazard to zero meaning the overall equation goes to zero. It permeates everything we do in safety. A noble pursuit but as many of us know, we are surround by hazards and you can’t remove them all. Therefore if a hazard exists then the equation can never be zero unless you remove the person. And this is where it got interesting for me. When you can’t reduce hazards to zero, what’s next? What do we do with the person part of the equation?

So, I have focussed all of my efforts on what we can do with the people part of the equation. I choose to look at behaviours but from earlier work that I had done, I knew any behavioural studies needed to focus on what we do unconscious not the conscious. This is where our habits play the most important role in keeping us safe. I love the old saying “habits beat intentions every time”. You may intended to eat healthy this week but find yourself dipping into the cookie jar at 3pm or I going to start running next week and don’t. The research shows that we spend over 80% of our day doing what we do habitually. From the moment we wake up to the moment we go back to bed and almost everything in-between, our habits drive most of our actions. The unconscious part of the brain (lets use Khaneman’s describe as System 1) , that requires a low amount of energy to run, is primarily responsible.

It is this field of human behaviour and actions that I have explored in an effort to come up with solutions for the person part of the equation. There is a richness of information, knowledge and solutions that I found and more to be had as research continues find breakthroughs in our understanding of why we do what we do.

So if the person side of the Universal Law interests you, then lets get started.

David

ps

I recently heard Tony Robbins in an interview with Tim Ferris say “knowledge doesn’t mean shit. It is all about what you do!”……..so Lets get started.

 

Safety leaders – Let’s start a safety revolution

Friends,

Are people getting hurt in your business? Are you legally responsible for the safety of these people? Have you created the management system, identified and manage risks, developed key procedures and trained everyone……and your people still get hurt? I know how you feel.

Not happy with the explanations from safety professional, I decided to go on a search. A 4 year search it turns out.

Working with and talking to over a thousand of frontline workers and supervisors, reviewing and investigating over 100 incidents in manufacturing, construction and transport. I even interviewed some of the leading safety practitioners in industry.

But it was worth it. I now know why people getting hurt. And it’s simpler than you think or all of these management systems try to make it.

So, armed with this discovery I want to start a revolution. I want to revolutionise how we go about safety in industry, on the roads and at home. An approach to being safe that is not suffocated by paperwork. It recognises why we do what we do. Not simplify the complexity if the human condition. Rather, an approach which acknowledges the human condition.  Leveraging our knowledge to create powerful, robust and extraordinary safety results everywhere, all of the time!

Interested? then stay with me for a while. I promise a stimulating, thought-provoking, solutions driven journey…….lets start a safety revolution!