SAFETY FITZ LLC

Setting the Table:

The Webster’s Dictionary defines the word pervasive as, “existing in or spreading through every part of something.” I heard this word used about fifteen (15) years ago at a lockout seminar. Prior to this seminar, I do not remember hearing this word used much. However, what surprised me the most was how well it fit, to the subject matter of the seminar. It was like that feeling you get when you tell yourself, “I should have thought of that!” The seminar leader further used the term, “unintentional pervasiveness.” He did not even have to explain what he met by the term, because it hit home with me the instant, I heard it! It seemed to fit many safety cultures I knew.

I remembered what interested me in this specific seminar. It was not my first lockout seminar. However, in the marketing email I had obtained on this one, it said the speakers would discuss the real reasons employees did not perform lockout. In going even farther I was thoroughly sold on the premise and could have left the seminar right there, although I stayed for the day.

Let me say at the beginning no one wants their employees to be unsafe. I know most modern managers want to keep their employees healthy and safe. Almost all managers have strong moral and ethical compasses. Most managers understand that injuries are expensive, and their job is to manage the resources of the organization. Everyone says things like, “Safety is #1” and “You (to employees) must perform lockout.” My purpose here is not to fix blame but to introduce awareness.

The Customer:

Soon after I retired as a site Human Resources and OHS Manager of a large industrial publicly traded corporation, I started OHS consulting with smaller manufacturing LLCs and sole proprietorships. I start all my introductory meetings at the customers’ offices, usually beginning with the person charged with Health and Safety (H&S). My first question is always something like, “What does Safety look like here are XXXXX Inc.?”

Typically, I will get platitudes on how important safety is at XXXXX. We will then continue with several questions. Since we are talking manufacturing, I always bring up the topic of lockout, since I know most amputations occur because of failure to lockout. Again, I will hear things like, “Oh yes! Our people know lockout is important. They hear about it in their training.” it is important I do not seem skeptical of answers like this.  My skepticism is confirmed when I ask for information on their Lockout Program like. “What do your periodic inspections show on the effectiveness of your Lockout Program?” Do you have current lockout training records?” The blank looks and/or fumbling around for answers tell me much about their H&S program. I have also previously researched the company on www.OSHA.gov regarding their OSHA Enforcement history. Often I am not surprised by what I hear.

Then we will go on a plant tour. I look for “Tells” on the tour, that give me clues on the existing Safety Culture in the plant. Many times, we will see employees engaged in maintenance and setup of machines. All too often in these instances the employees are not practicing lockout. Occasionally, the safety person will recognize my attention. Although they have already walked by, they sometimes approach the employees and remind them to lockout. However, all too often the safety person has kept on walking oblivious to my observation. That is a huge tell and confirms what I am starting to conclude, that this organization may have unintended pervasiveness.

How I Learned:

In 1976 I was fortunate to start my management career as a Shakeout Supervisor in a large automotive foundry. I was fortunate in my choice of jobs because my management instilled in all of us the absolute importance of our employees’ safety. Frankly, given all the dangers of a foundry we had to take safety very seriously! As evidence supervisors were required to do four (4) weekly STOP BBS Observation Cards and weekly Safety Talks with our employees. Most importantly we were required to have at least a preliminary accident report on our bosses’ desk on the shift the accident occurred. This had to be completed before we went home.  Our supervisors often said, “No excuses would be accepted or entertained!”

One night one of my employees decided to clear a jammed conveyor belt. A piece of iron sprue jammed between the chain and sprockets on the drive for the main belt. He removed the guarding and reached in and grabbed the iron and attempted to remove the hunk of iron (about the size of a softball). As he freed the sprue from the sprocket and chain, the pressure was relieved, and the sprocket rotated with the chain. The employee lost two fingers on his left hand, in the resulting pinch point. My investigation clearly showed the employee had not locked out the drive prior to removing the guard as the SOP (Standard Operating Procedure) and his training required. The accident occurred at 10:50 PM, 10 (ten) minutes before the end of our shift and third shift took over the line.

As I sat down at my desk, at about 11:30 PM on a Saturday night (on OT), I was not happy. I had to get an accident report completed but was eager to get a shower and get home. It was our first wedding anniversary, and my wife had a candlelight dinner waiting. I was mumbling to myself as my boss walked by to his desk.

When I got to the corrective action section of the report, I wrote down two things. First the guarding needed redesign and modification as it allowed a large piece of iron to fall in the drive unit, which caused the jam up. Second, the employee was trained when to perform lockout, and reinforced in my Safety Talks, as recently as two weeks before, to lockout in situations like this. Since he did not lockout as instructed, upon his return to work I would be issuing discipline to him. I thought I had done a good job and rose confidently and walked over to my bosses’ desk to put the report in his in-box. I did so and started to leave as all the rest of my shift paperwork was complete and it was already midnight.

As I walked away, “Big Johnny” my new General Foreman, spoke up and said, “Wait a few minutes, Fitz! Sit down while I look over your report. We are talking about amputation with this one. We will get questions from my boss and Personnel on this one!” John read my report. After a few minutes, he looked up at me, smiled and said, “You are not done! You missed an important point here!” I immediately started to protest, but he held up his hand to silence me.

He looked at me sternly with his immense size and girth and said, “Look kid, two points:

First, as far as the time and having to stay to do this report, I heard your grumbling when I walked past you. It my not be your fault this injury occurred, but it might be, but get one thing straight, it is always your responsibility that it did! This report is your job! Never ever forget that again or will have a very serios talk!

Second, you are saying the employee made the choice not to lockout, right?’ I nodded. “Ok, now let me ask you, whose job is it to ensure that the employee understands that he has NO CHOICE but to lockout! I am sure you know that is you and me! Have we done that? You and I both say Lockout is important. But do we reinforce what we say with our actions? When was the last time we asked an employee on the job about lockout? When was the last time we thanked an employee for lockout out? Do our words match our actions? We need to address that one further! Let’s work on that one! As I know you are in a hurry my job is to help you!”  

I had not consciously thought of Big Johnny’s words in years. As I recall forty-seven (47) years later Big John’s and my corrective actions concerning our actions as supervisors fell on deaf ears in a plant of 3,000 employees. But at this 2008 seminar these works immediately clicked with me again. I thought I had understood what Johnny had said twenty-five (25) years before but now they really struck home. I also remember Big Johnny’s favorite question, “Fitz we got the tail wagging the dog again?” It sure seemed to apply with this idea of unintended pervasiveness. 

Appling the Lesson:

To further illustrate, if anyone in your management walks past an employee not locking out when the situation requires it, you are at best telling your employees that you are not looking.  If it is important, you should be looking to confirm the correct behavior.  Worse yet, if you see it and continue to walk by your actions say you do not really care if your employees lock out or not! This equates to your condoning their decision not to lockout. That is a very bad belief to have in our plant culture. Did you as a manager intend that consequence?

I sometimes hear the employer blame the employees for an amputation because the employee did not lock out when required. When I hear this from a customer, I find myself in a slight predicament because I do not want to lose a customer. However, I have been in manufacturing management for a very long time, and just pointing a finger at an employee and blaming them for an accident does not go anywhere near enough to fix the real problem unless you ask yourself some serious questions. I diplomatically but firmly explain the concept of “unintentional pervasiveness”.  The questions I ask are:

1. Do your leaders and supervisors constantly reinforce lockout and other important safety requirements, by more than just words, but by actions and deeds? I know as a former supervisor I constantly asked my employees about their production numbers and to examine their parts, demonstrating production and quality were important. I did not do enough to show the same priority to safety! I knew my actions did not reinforce my words. I always told myself I was too busy.
2. Do your leaders and supervisors really understand the importance of lockout? How do they show it?
3. Are your leaders and supervisors Authorized Users?  If not, why not? If you expect them to reinforce lockout and manage it in their departments, how can they not be Authorized? If they are permitted to lockout an unsafe machine, they are Authorized and must be trained as such!
4. What is the ratio of Authorized Users to Affected Users of Lockout? If you have many machine operators that remove or negate guarding, you should have a large percentage of Authorized Users?

You know you have started to combat unintentional pervasiveness when you see your leaders and supervisors not just walk by someone that should be locking. Instead, they walk up and address the situation immediately. You not only see it is documented in Safety Audits, Employee Corrective Actions, and other documentation. On the flip side you have arrived when your leaders and supervisors thank people for doing lockout when they should to reinforce lockout.  

To assist to attack the problem of unintentional pervasiveness I encourage employers to get their employees, managers, and leaders involved with H&S in every way you can. One place to start is for Supervisor, Leader, Manager, and anyone on a Safety Team to perform Safety Audits and Reviews. To do this you must train these people to see H&S hazards. This includes safe behaviors, as an example locking out when an employee should be positive behavior. Not locking out when you must lockout is unsafe behavior.

Many of our employees are superbly trained and very skilled. Often these employees are on a pedestal to production workers because of their skill and training. I can tell you as a former production supervisor a good maintenance employee is worth their weight in gold! A few of these employees may think they know more than a “Safety Weenie” sitting up front in an office, and thus may take shortcuts! There is danger in that thinking. So, what I advise customers to do is recognize that skill and training and allow the employees some say in their work. By this I mean that in a lockout situation if an employee believes they do not need to be under full lockout to complete a Hazardous Work Permit, for example a testing situation. In this permit they ask management if they can take a risk and what they are going to do to stay protected (which is what the law requires) when not locked out.

Conclusion:

We all know that OSHA 1910.147 requires “periodic inspection. The reason for this inspection is clearly stated in the standard, to ensure your Lockout program is “effective.” I believe in so doing, an employer needs to ask if they have a culture of unintentional pervasiveness concerning lockout. Simply put, do your employees believe they have a choice when they find themselves in a lockout work situation? If that is the case, why has that belief prevailed? Employees need to know that they have no choice in a lockout situation but to lockout and follow your Lockout Policy. This needs to be reinforced by the entire organization in speech and actions. We want to avoid pointing fingers. Remembering what my mother, may she rest in peace, use to tell me, “Tommy do not point a finger, remember when you do you have three pointed back at you!” One of those fingers pointing back at you may be unintentional pervasiveness.

Safety Fitz can assist you with your entire safety culture, most especially with The Control of Hazardous Energy (Lockout).