MANAGING SAFETY PERFORMANCE NEWS

Look Out!

To acquire wisdom, one must observe.  
 
     ~Marilyn vos Savant
 

Here’s the latest in those hazard recognition gone wrong news headlines: “Man electrocuted when pole he was carrying touched wires.”  Before writing that one off, thinking “That can’t happen here” bear in mind you have a nearly unlimited supply of hazards – electricity being but one – that can go wrong. And have.
 
Besides, there’s a huge difference between something that bad happening – and something happening that could have been that bad. Otherwise known in the business as a near-miss, near-hit, close call, and even in some quarters, a “good catch.” 
 
Those non-event events come in two types: ones you find out happened, and ones “that never happened.” Surely you know the potential existence of the latter type.  Would you be better off knowing all about them? 
 
Of course you would. 
 
Of course, if you did, you’d have to manage more problems. But you may well have a lot fewer injuries to have to manage.
 
That is the point of this, isn’t it.

Root Cause Analysis
 
In this particular case, the electrocution was reported to the police; paramedics transported the injured man to a trauma center for treatment of life-threatening injuries; reportedly, “The Ministry of Labour has been called in to investigate.” As well they should: if you want to stop something bad from happening again, somebody needs to understand what went wrong. 
 
What do you think that will be?
 
The obvious. There were high voltage wires overhead. A pole made of a conducting material was being carried by a person. The pole made contact with the cables. There was an electrocution. 
 
Perhaps the not quite so obvious. The person might not have been trained. The activity might have been common practice. There might have been a rule or procedure not followed.  
 
As to the question in need of a darn good answer – “How was that hazard not recognized and managed?” – I wouldn’t bet on the investigation report providing that.  I’ve seen too many reports that slapped on a label or checked a box on list of cause categories, like rule known but not followed, management system deficiency, pilot error, normalization of deviation – and failing to recognize the hazard.
 
That done, the investigation is officially completed. But, really now, how much light do any of those so-called explanations shed on what really went wrong?
 
Darn little. Not that it stops people – including some very smart leaders – from buying that explanation or even ticking that box themselves. 
 
Perhaps the Ministry of Labour will provide an upside surprise and tell us something useful to prevention of a reoccurrence. There’s bound to have been a reason why this happened; knowing what that was is bound to help prevent something like this from happening again.
 
That is the point of it, isn’t it?
 
Understanding the Hazard Recognition Process
 
Whether or not the authorities discharge that function, a real life example like this can serve as a thought exercise to help create an understanding of the process of recognizing and managing hazards.  All that’s needed is a few basic assumptions, and the application of some practical, real world experience.
 
Let’s do this, starting with the word process. I love that word! Process: means, manner, method; the steps to be taken; procedure. Take your pick: all answer the question, “How?”
 
Process is all about the how.  Picture a task roughly the equivalent of this one being done in your outfit. What’s your process to identify potential hazards? 
 
I’m sure you have one. More than one, depending on the specifics of the work performed. Confined Space Entry, Lock out/Tag out, lifting over process equipment. Work Permit, Job Safety Analysis. 
 
Great, if that’s the work to be done. But, suppose the work being done is routine, basic, simple? Taking a reading, performing a measurement, checking on a job, pulling a sample, making a round.
 
Or, delivering parts to the job.
 
In practice, the process used to identify hazards depends on the task to be performed. High voltage electrical work demands a hazard recognition process entirely different than the delivery of parts to a work site.
 
It all makes perfect sense – until you stop and really think about the nature of hazards: many of them exist regardless of the work being performed. Case in point: those wires overhead. That hazard’s there, no matter who’s there to do the work, or what work they’re doing.
 
That’s the point about hazards and hazard recognition that needs to be understood. It’s simple, but not always understood that simply. You do.
 
An Alternative Process
 
Now you’re beginning to appreciate the usefulness of this thought experiment about hazard recognition. It demonstrates the value of detachment and objectivity to good thinking: sitting in the waiting room at the trauma center, with a good follower’s life hanging in the balance is the worst possible time to think clearly and come up with a real solution to a problem.
 
Which argues powerfully for knowing about those events “that didn’t happen” doesn’t it. No consequences to muddle your thinking.
 
But back to our thought experiment: what’s the best way to recognize hazards? 
 
The natural tendency by supervisors and managers (not to mention subject matter experts) is to focus on answering the question, “What can hurt you?” Following that approach leads to asking, “In this situation, is this a hazard? Is that a hazard? What about…?” 
 
In a word, that’s a list. 
 
When it comes to the process of identifying hazards, often there’s a list of possibilities. The list is based on experience, and not good experience. “Somebody got hurt this way. Somebody else got hurt that way. Then there was the time this happened.” Over time the list grows. Not a thing wrong with that approach, but it is a list, and lists don’t list everything possible.
 
Case in point: In my old chemical company, we added a hazard identification process specifically targeting lifts over process equipment. Why? A big crane tipped over while making a lift over process equipment.  When it did, the load crashed into a storage tank, releasing its contents: hydrogen fluoride. 
 
The only good part of this story was that that crane tipped over at a neighboring plant down the street.  It happened in the Fall, on a Friday night, in a small town in Texas. With a high school football game being played downwind from the release. You can’t make this stuff up. 
 
Naturally, we didn’t want something like that happening in our plant, so we added that hazard to our list. You can bet that company employing the electrocuted worker will add overhead lines to theirs.
 
That’s their business. Yours is using their experience to get better at the collective process of hazard recognition. 
 
I suppose you could add “overhead power lines” to your list of possibilities. You’d be better off adding one simple word to every conversation about hazards.
 
Where.
 
Asking Where?
 
Work always gets done in a three dimensional space. Meaning there’s things that can hurt people in front and back. On the left and the right. Above and below. Like those wires overhead, those hazards are there, whether or not they are recognized and managed.
 
Asking “Where?” gets people looking for hazards in all three dimensions. For the things people already know are there. Looking for things that people might not know are there. Even checking for things that people are surprised to find are there.
 
Case in point. That crane that tipped over during Friday night lights. Unbeknownst to those involved and planning and doing the work, there was an underground sewer line sitting beneath the ground where one of the crane’s outriggers was positioned. When the weight of the load shifted during the lift, the outrigger punched right though that line. That’s when all heck broke loose.
 
Afterwards, it’s likely underground sewer lines was added to their list of potential hazards. Asking “Where?” before the event might have caused someone to have wondered what lies beneath, and checked out one more possibility.
 
Reminder: not every hazard is on every list.
 
The Last Word
 
Make asking where a regular part of the conversation about recognizing hazards. When it comes to sending everyone home, alive and well at the end of every day, it can make a big difference!
 
Paul Balmert
August 2020

Spread the Word

Share on facebook
Share on Facebook
Share on linkedin
Share on Linkdin