Ok
so
it's a catchy title. But, can you imagine hearing them down at
the maternity ward: "Push, come on push
and one more
here
it comes
and
now, one more big push
and
it's
a
it's a
well - I'll be darned - it's a worker!"
Or, down at the police
station: "Hey Fred, you were the lead investigator for that
big pile-up on the freeway just outside of town - what happened?"
"Well, what can I say - every single one of the cars involved
was being driven by a worker
you know, they should pass a
law so that workers aren't allowed to drive."
Of course, these scenarios
are ludicrous. So is the idea of separating workers out as if
they were a different animal (distinguishable at birth) or a different
type of person (distinguishable through motor vehicle incident/injury
statistics). Workers are people. People get hurt - everywhere
- on a fairly regular basis. And we've been doing it all our lives.
Young children get
hurt 15 to 25 times per week. That's 5,000 injuries you can barely
remember. Many of them will be minimal. Unfortunately, some will
be a little higher up on the old risk pyramid, where a kiss and
a Band-Aid won't be enough.
Older children, from
age 5 to 12 don't get hurt quite as often, maybe only 2 to 4 times
per week. That's still another 1,000 injuries or so. Then we go
to high school. Then we go to work where, in some cases, we'll
be expected to work injury free. Perhaps the company or corporate
office with this expectation is relying on what we learned in
high school to keep us injury free. If so, they must have gone
to a different high school than the rest of us.1
So, before high school
is over, most people have already experienced 6,000-7,000
unintentional injuries. But it's not over yet because after you've
been doing something for a while, it's easy enough to start getting
complacent (just think about driving). So, while you're not getting
hurt quite as often as you did when you were a child or at high
school, it's not as if you're going injury free. Maybe you've
gotten yourself down to one injury per week or maybe even down
to only one per month. But how many people do you know who never
have a bruise or cut for a whole year?
1A
total recordable injury rate (TRIR) of two means that 50% of the
workforce will not have any recordable injuries in 25 years while
the rest of the workforce will only have one recordable injury
in 25 years (Two recordable injuries per 100 workers per year
= two recordable injuries for one worker every 100 years, one
recordable injury for one worker for 50 years or one recordable
injury between two workers for 25 years).
And again, not all
of these injuries will be minimal. Some will be minor (sprains,
stitches, second degree burns, mild concussions, etc.), some will
be major (fractures, dislocations, torn or severed ligaments,
dismemberment, etc.) and some will be fatal. Some will happen
on the road. Some will happen at home and, of course, some will
happen at work. However, when people get hurt at work, it's because
of a "dumb worker"???
How did the whole "dumb
worker" thing get started anyway? Perhaps it started out
with "human error," which then became synonymous with
"worker error" which - since only dummies make mistakes,
became "dumb worker."
Now, it's fairly well
established that less than 10 percent of all injuries and incidents
everywhere - at work, at home or on the highway - are caused by
equipment failure or malfunction. What's left, in terms of unexpected
or unplanned occurrences, will be the people component. Most people
are surprised that "the other guy" doing something unexpectedly
- causing an injury - is also very low. During the last 16 years
around 40,000 people in 300 different companies have been asked
how many of their injuries were caused by the equipment or car
doing something unexpectedly. The normal response has been about
2 to 5 percent. Then they were asked how many times the "other
guy" doing something unexpectedly was a factor. The normal
response has been about 5 to 15 percent - but for both of these
questions, most people only had one example. What's left is the
"self area" (see Figure 2 below).
In other words, if
it wasn't the equipment or "the other guy" doing something
unexpectedly to trigger the chain of events that lead to your
injury - the unexpected source was you (or, in my case - me, in
his case - him, etc.).
Did we intend to hurt
ourselves? Not likely! So it must have been an error, miscalculation,
misjudgment, etc. that triggered the chain of events. Or, as it
might have originally started out - it was human error (our own)
that triggered the chain of events. Not that this is new to any
parent of small children. After all, when your child comes up
the stairs crying - most parents ask, "Did you hurt yourself?"
Quite often you don't even have to ask because the child is already
volunteering it. "[Sob, sob]
I hurt myself
[wail,
wail]." Sometimes, as mentioned before, a kiss or a Band-Aid
will suffice - sometimes it won't. Stitches or plaster might be
needed.
But imagine asking
a tradesman with 20 years' experience coming into the first aid
room, "Did you hurt yourself?" (Personally, I wouldn't
recommend it.) Yet how many times would the circumstances or the
source of the unexpected really be all that much different from
the child's injury or the teenager's injury or from those of another
adult driving a car? How many times do you think you would hear:
"I didn't see it" or "I wasn't thinking about it"
or "I got hit by something" (being in or moving into
the line-of-fire) or "I lost my balance, traction or grip"?
These four errors (or a combination of them) are contributing
factors in over 90 percent of all recordable injuries of an acute
nature. If you go down a level on the pyramid to include bumps,
bruises, scrapes and cuts, they are contributing factors in over
99% of all acute injuries.
Obviously then, if
over 90% of all acute injuries are self-inflicted (caused by our
own mistakes), reducing human error or minimizing its negative
effects is the name of the game. Unfortunately, both of these
strategies have not been given equal "air time."
Advances in engineering
controls, machine guarding, personal protective equipment and
procedure design have had most of the limelight. And for good
reason - these controls are very efficient. But can all hazards
really be eliminated? Of course not! Yet there has been a reluctance,
and in some cases a great reluctance, to look at reducing the
unintentional mistakes we all make that can get us hurt. It's
much more popular to try to "fix" something. While "blaming"
someone is useless (or worse), and doing nothing means you "accept"
that the injury was not preventable - fixing something that didn't
contribute to the injury isn't going to get you anywhere either.
Of all the examples
that come to mind, the most extreme - in terms of fixing something
that didn't contribute to an injury - was of a hydro worker who
was walking backwards in the parking lot telling a few of his
co-workers a joke. He tripped on a concrete parking divider, fell
down and broke a bone in his wrist. The utility company decided
to paint all of the concrete parking dividers yellow. Even the
most devoted union supporters recognized the ridiculousness. "What
good would painting the dividers fluorescent pink have done? Unless
the worker had eyes in the back of his head, he's not going to
see it, no matter what color it is. . . "
Can you minimize human
error? Yes. The traditional behavior based safety approaches can
reduce human error - but primarily through rote observation and
repetition. It does work, even if it takes a fair bit of time
and expense. However, an easier and faster way would be to simply
look at what causes all types of error - and work on those human
factors or states. In other words, go down even one level further
on the pyramid and add error (see Figure 3).
What causes people
to make mistakes? Well, lots of things. But if you asked those
40,000 people mentioned above, the number one cause you'd hear
would be "rushing." Not that this kind of news will
knock your grandmother off her rocking chair. After all, "haste
makes waste" isn't exactly a new expression. Another cause
or state you would hear - although not quite as often as rushing
- would be fatigue. You'd also hear about frustration and complacency.
You might also hear
about other states as well. But can you think of a time or of
an injury that you've had that was in the "self area"
( not the equipment or "the other guy") where you weren't
rushing, you weren't frustrated, you weren't overly tired or you
hadn't become so complacent with the hazards that you weren't
even thinking about the risk anymore? Now, can you think of a
time or of an injury that you've had that was in the self area,
where you were actually looking at what you were doing, thinking
about what you were doing, aware of the line-of-fire and conscious
of losing your balance, traction or grip? If you can, you'll be
the first in 40,000. In other words, one (or more) of these 4
states caused or contributed to one (or more) of these 4 errors.
(See Figure 4).
Once you see these
state to error patterns (and you see them everywhere), all you've
got to do now is teach people to recognize when they're in one
of these states before they make a mistake, or a mistake that
can get them hurt. Not only will this reduce injuries, it will
also reduce quality problems, efficiency problems and needless
equipment or vehicle damage.
While you're teaching
people how to make fewer mistakes, don't slack off on your other
efforts to minimize the negative effects if people do make mistakes
- because they still will - (hopefully fewer after you've finished
your training) - but they will still make some never-the-less.
In other words, you need to do both. It may be imperative that
you do not slack off in your efforts to make your workplace more
"error tolerant" in order to avoid creating the impression
that you're throwing it all on the backs of the "workers."
Besides it's far more efficient to eliminate or minimize the hazard
itself whenever you can.
Again, the most extreme
example of this that comes to mind was a graphics/film company.
They preferred to use tape dispensers with a heavy metal bottom
so they could "one-hand" the tape to stick the film
on the light tables. The serrated edge used to tear the tape broke
off. What they did to fix the problem was to replace the serrated
edge with a razor blade. Realizing that they put an additional
source of danger (hazard) into the task, they put a warning sign
on the tape dispenser (see Figure 5).
Everyone, including
the owner and manager, sliced their finger or hand on the razor
blade during the next few months following the "modification."
Apparently, the razor blade could not tell the difference between
worker fingers and owner fingers - dumb fingers or intelligent
fingers. Finally, after the owner had gone for stitches the second
time, he contemplated hiring a safety consultant to come in and
talk to the workers about improving their awareness, habits, behaviors,
etc.
When he heard about
it, the consultant said, "You've got to be kidding?"
The owner
said,
"Well
we all know the razor is there - but every one
of us has sliced our hand or finger
." The consultant
told the owner to "just buy a new one - that way you don't
have to worry if people aren't looking or they aren't thinking
for a second." However, the consultant told the owner he
would be happy to come in and talk to his employees about advanced
awareness techniques because they drive on the QEW and 401- where
you can't just buy a new one. (Highway 401 in Toronto is the second
busiest freeway in the world - 16 lanes).
And the same advice
would apply to everyone else. Minimize or eliminate whatever hazards
you can. When you've come to the end of the line
then you
can start looking at behavior.
But, don't back off
or run away from human error because you think it might be construed
as blaming the "dumb worker." You can teach people how
to make fewer mistakes and fewer injury-causing mistakes. Hundreds
of companies have already done so and are enjoying significant
reductions in recordable injuries. They're also enjoying fewer
off-the-job injuries and fewer motor vehicle related injuries
and incidents. And morale didn't go down. It went up. People aren't
stupid - they know how they've been hurt (it's not as if we don't
have any data or experience - we've all been hurt thousands of
times). When you give them something useful, that will actually
help them on the job, off-the-job and especially while driving
- they appreciate it. Some even take the concepts home to their
families.
About the Author
Larry Wilson is a frequent speaker at health &
safety conferences across Canada, the United States and
Internationally.
His entertaining anecdotes and stories
come from nearly 20 years of assisting over 1,000 companies with
Observation and Feedback Processes and Advanced Safety Awareness
Training. His presentations include Keynote sessions with some
of the largest Health & Safety Conferences in North America.
On the road 150 to 200 days per year, he has more
practical experience (more companies, more places, more industries)
than anyone else in the field. Perhaps what is most significant
is that he has made over 2,000 plant and field observations in
nearly every industry.
In Larry's "spare" time he manages the
Health & Safety Team at Electrolab
and contributes articles to Health & Safety publications like
Occupational Health & Safety, OHS Canada and Industrial Safety
& Hygiene News.
As the Author of SafeStart:
An Advanced Safety Awareness Training Program, Larry has compiled
all his years of experiences into a common sense approach to working
safely on and off the job which has benefited more than 1,000,000
employees to date.