I’ve worked around big machines my whole life. Machines don’t kill people, but people die from making mistakes while working with them. Machines are totally unforgiving of human error, which is unfortunate because quite honestly, most of us are likely to err each day.

In the snow and ice we had in Atlanta a few weeks back I took this picture of icicles on my roof. Most of the icicles formed exactly as you might expect. Built by the pull of gravity, narrow at the low end with a broad base holding them to the gutter. Most were straight, and they were of varying lengths. But what about the one in the picture? Why the odd forked formation? Was it the result of an air pattern from the nearby bathroom vent that caused two streams to form? Or maybe it was the way the tree branches shaded some of them in parts of the day but not others.

If I had a goal to have no icicles form, I lost control. I would have had to put some heating wires on the roof or the gutters to assure that anything that melted didn’t re-form as ice.

If I had a goal to have identical, perfect vertical icicles, then there, too, I lost control. I may not have been able to prevent this formation, but I could have stopped it before it grew to two distinct legs.

And in safety, we try to control those things, which we have learned through experience, could result in injury or property loss. We see something that looks a little out of control, and we try to adjust it back to normal. When we are well trained, we don’t look for the failure, but we look for the potential for failure. We see things developing that could take us out of control and try to restore order.

When a person is injured or killed in a mahinery related accident, people will frequently say it was a random event. I worked with someone who received a bad hand injury reaching into a machine. He thought that he could do it safely, and had done it without incident hundreds of times. But this one time, there was a factor that was different. Not a major factor, but enough to cause a different outcome. You might say it was a random event, but what wasn’t random was his action. It was planned and reapeated time and again, just without consequence.

Do you see someone do something around machinery that makes you uncomfortable? Are you afraid to challenge them because of their experience doing the job? What if the unexpected happens? Will they walk away or is there a possibility that they could be seriously or fatally injured?

Random events. The definition is clear – you don’t know what and you don’t know when. Something is going to happen. We can’t control that, but we can control how prepared we are for possible events, and what precautions we take to stay out of Harm’s way. And to stay out of the way of his cousin, Potential Harm.

Watch out for random. Thanks, and let’s be careful out there.

Peace-bound or not, it was odd to see people in all kinds of costumes walking around the convention and participating in the annual parade. As football fans from Virginia Tech and Alabama began their tailgating experience Saturday morning, soldiers, orcs, storm troopers, wizards and characters of all shapes and sizes walked down Peachtree Street in Atlanta. College football fans and avid Star Trek fans all gathered in the same place.

Walking through the vendor areas I heard expressions I quite possibly have never heard before.
“Why, that is a fine sword indeed.”
“But an elf would never wear a vest like that.”
“These Wolverine claws can be used as a dicer in the kitchen.”
“Are you interested in upgrading your armor?”

An armor upgrade. Why yes, the perfect solution.
How many times do we propose solutions that we believe protect an employee, but instead we weigh them down with unneccesary burden. Things that don’t help them do their job better, but reduce performance.

In safety, that comes in the expectation to don more PPE – Personal Protective Equipment. In grievance resolution, we create a process to prevent future grievances of this type, but the process consumes organizational energy and resources that could be better placed improving the real processes of the organization. You know, the ones that make money and that should be better than what the competition does.

Do your employees think of protection and policies as armor, because contact is inevitable? Or do they recognize PPE as a seatbelt – you hope you never need it, but when it comes into play you are glad you have it on. More armor is just more cumbersome. That’s fine if you enjoy a role play and dress up a couple of times a year. But it is not the best solution for day to day.

Could you imagine a safety or policy improvement effort aimed at reducing cost by totally eliminating the need for a certain type of PPE? How about eliminating the need for knives as a tool, and coincidentally eliminating the need for cut-proof gloves? Or replace that eight page absentee policy with one page. If you can’t say it simply, you are managing the wrong thing.

It’s a dream, a fantasy perhaps. But sometimes a good dream leads to a real world solution.

Let’s be careful out there.

I have submitted lists before of employee answers and supervisor answers to investigations questions. This last list in the series are the answers that management gives in companies do not manage safety well. These FGA’s are not from my current company, but I have used them as examples in training others to do investigations, to help contrast effective resolution from rationalization.

1. Our record is consistently strong.
2. We have trained employees to not do what the injured employee did. He made a bad decision.
3. That machine is guarded correctly. The employee made a bad choice.
4. The supervisor usually stops people when they are doing what the injured employee did.
5. That equipment meets OSHA guidelines.
6. We are committed to the safety of our employees.
7. The employee should have shut the machine down.
8. No one has been hurt that way before. It must have been a fluke.

There is one last set of FGAs to look at. What good management does. We’ll see that list soon.

As always, let’s be careful out there.

Anna at abdpbt is responsible for the effort to Fight Listless Mondays. Find other list links on her blog. Her lists are more clever. Lots.

This makes sense, especially given the level of automation that exists today. When things are running well, employees are monitoring the process and making sure there are adequate materials coming in and product is taken away. When the process starts to fail in some way, stress goes up, as does the interaction with the process. This presents an opportunity for mistakes or accidents.

I spent a good part of Thursday traveling, and saw a lot of frustrated people and unusual procedures that only added to peoples’ frustrations. The flight was a Delta flight, a Canadair jet that requires planeside check-in of a typical carry on bag. The smaller Canadair jets seat 48 people, and are boarded from the tarmac. You leave your bag on the cart next to the steps, and when you get to the destination you retrieve it the same way. This was a larger jet that used the jetway to board. So here in Atlanta, when you get off, people line the jetway until the bags are brought up to the jetway 2 or 3 at a time.

Atlanta was my destination, but people with connections were not happy. This is when the behavior got bad. A hot jetway full of people (August in Atlanta, remember) and they start crowding the little doorway to look down the stairs and see when their bag is coming up. If your bag did come up, and you weren’t crowding the front, you wouldn’t know. So people were upset with the process, now they are upset with each other.

Then there is the train you take from the terminal to baggage claim and the airport exit. There are three long escalators, and when the train doors open it looks like the post at the Kentucky Derby! Where are these people running to? Seriously, I timed the difference between the guy who sprinted up the escalator and my passive ride, and it was about 30 seconds. What will he do with that time? Can’t save it, time doesn’t work that way.

If he was headed to a family emergency, I hope he got there safely and in time for what he needed to do. But the hurry, the rushing, the dodging around people will, at some point, cost a person more time than they saved. And may cost more than just time.

So, the next time you feel hurried or catch yourself trying to somehow make up for lost time, don’t forget to breathe. Ask yourself if it will really make a difference. Time is a great equalizer, no one gets more minutes in an hour than anyone else, and no one gets less.

Do you rush through things, or work yourself into a rushing pattern when you don’t really need to? It might be a habit worth changing.

Let’s be careful out there.

The fact is, he can’t do it alone. He needs help.

One of the people who can provide help is the Explorer. You see, every advance in safety just creates a doorway to new possibilities. But if we wait for the next accident or injury before we explore – through investigations of what went wrong – it will be too late.

The safety explorer is looking beyond today and beyond the current solutions to see what else is possible. She brings ideas that others could not see because they are busy in the “now”. And that’s good, because someone has to take care of “now” as well. We can’t all be driving to the next destination.

Do you see yourself as the explorer? Are you looking to the horizon at what we haven’t yet learned and trying to figure it out, or are you busy commissioning the design for the safety tee shirt you want to give away to promote safety? (Not that there’s anything wrong with that!)

It takes a diverse set of talents to make real progress. In the next few weeks I’ll introduce some to complement the warrior and the explorer.

Let’s be careful out there!

In my industrial experience, that is a clear near miss, and should be documented for the learning. History has shown us that if the population of near miss incidents grows, then eventually you have a serious injury or property damage. This incident was significant to me because it foreshadows something more serious if I don’t correct the root cause. My estimation is that the root cause is that I have fallen into more of an automatic mode in driving my car. I am willing to divert my focus for moments at a time because everything looks fine.

The corrective action is clear. In this case, set up the GPS before you leave. It’s easy to do and is correct the majority of the time. Fooling with it while driving is a potential problem. The other corrective action is to let the passenger work on non-driving tasks, and dedicate my energy and focus to the task of operating the motor vehicle within the rules of the road.

Have you had a near miss recently? Did you make a note of the root cause and think about a permanent fix? It will greatly reduce your likelihood of injury and may even save your life!

As always, and I need to heed my own advice here, let’s be careful out there.

1. It wasn’t the employee’s fault
2. It was the employee’s fault
3. I never told him to do that
4. I had instructed him the right way to do that
5. He never pays attention in safety meetings
6. It was his fault
7. I told the mechanic (electrician, pipefitter, etc.) to fix that problem yesterday
8. It wasn’t my fault
9. I’ve never seen the machine do that before
10. We were trying to get production out
11. We’ve all done what he did hundreds of times without getting hurt
12. I told him if he was going to reach in like that he had to be quicker
13. It’s not my fault

In a few weeks, we’ll take a look at how management eventually summarizes this kind of input in the final list on this topic.

Let’s be careful out there.

Lists on Monday are influenced by Anna at abdpbt. Her lists are more clever. Lots.

Does someone have to be blamed for every accident? Isn’t it OK, at least once and a while, to conclude that “shit happens” at the end of an accident investigation? As long as we avoid ever making this mistake in the future?

For many people, closure seems to require that someone is blamed. Whether you are talking about a workplace accident, a traffic mishap, a forgotten birthday, or a lost dog, it must be someone’s fault.

But I think sometime there is no fault. Or that the only fault that could be found is that someone neglected to predict the future. They considered possible outcome, just not this one. And the truth is, there is a universe of outcomes for every action we take.

Finding or placing blame, especially for people in the workplace or in a traffic accident, is a way of bringing absolution. It means that my insurance won’t go up because of your mistake. It means that management, who may feel accountable for any injury, will still get their bonus. Someone else messed up, not them.

We make mistakes. Sometimes they hurt us, sometimes they don’t . Sometimes others suffer from our choices. We didn’t try and cause and accident, we didn’t mean for someone to get hurt, but it still happened. Life is random. We are sometimes in the right place at the right time, and other times we are in the wrong place at the wrong time. And although that doesn’t read well on an investigation report, it is sometimes the only truth you can declare.

Have you been involved in an accident where there was no one to blame?

Let’s be careful out there.

The good investigator gets to root cause, so that a permanent fix can be put in place. Along the way, she hears many answers, sometimes to questions that weren’t asked. I won’t include the questions in the list, they are somewhat implied. (For equal time, I promise to include management’s FGAs in a future Monday list.)

1. It wasn’t my fault.
2. I told the supervisor about this problem last week.
3. I never saw the machine do that before.
4. I see the electrician do that all the time.
5. It wasn’t my fault.
6. I asked the mechanic to fix that last week.
7. The blade on the knife was too dull.
8. The blade on the knife was too sharp.
9. Joe was using the ladder, and we always use that stool to get up there.
10. It wasn’t my fault.
11. I was trying to save time and save the company’s money.
12. I’ve done it that way hundreds of times and didn’t get hurt before.
13. It wasn’t my fault.

In home safety, I know of no one who has formal incident investigations like those that exist in the workplace, but most people learn to do things differently when they experience a negative outcome. The next time they take on the same chore, they may at least stop and think about how they could avoid the consequences of the last time at that task. If we were to document incidents in the home, I would guess that a frequent cause would be improper use of tools or equipment, like standing on a chair instead of a proper ladder.

Did you have a personal accident or near-accident in the last several weeks? What did you do to eliminate the possibility of future loss from a similar incident? In what area of your life have you made a conscious effort to improve the safe outcome? Your driving? Household projects? Let others know and maybe they will be safer too!

Thanks, and let’s be careful out there.