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Is Your Workplace Ripe for a Serious Injury?

The absence of injuries does not denote the presence of safety. In fact, a series of near misses indicates a problem in your safety management. Here are some important safety factors that identify whether your shop is at heightened risk of a serious injury or fatality.

Posted: January 10, 2013

One cause of process variability is the lack of engineered process documentation, where employees are assigned a goal then expected to figure out how best to accomplish it. Dangerous levels of variation can develop between the methods used by two different workers doing the same task. Where variation exists, so does risk.

Unlike others in your industry, you’ve never had a fatality at your location and you’ve gone years without a recordable injury. Are you good or just lucky?

This is a serious question for manufacturers who – after a series of near misses – must confront the chilling realization that the absence of injuries does not denote the presence of safety. Serious injuries and fatalities are alerting unsuspecting companies that all is not well with their safety management systems.

While tragedies of this stripe tend to be seen as unforeseeable acts of God, they are neither impossible to predict, nor the actions of a vengeful deity. In fact, with a little investigation, manufacturers should be able to identify when they are at heightened risk of a serious injury or fatality.

Most of these factors may seem, on the surface, to be unrelated to safety, but each one correlates closely to the system flaws that cause or contribute to worker injuries. In other cases, these factors can act as catalysts and hasten the likelihood of an injury or worsen an incident’s severity:

Process variability is not only destructive to part quality and production efficiency, it also increases the probability that the employees themselves will be injured. Situations such as parts shortages, falling behind in schedule, or widespread inefficiency are key indicators of heightened risks of worker injuries.

Any good safety program should monitor these indicators as part of a balanced scorecard program. This requires the safety professional to understand the process to accurately assess the risk associated with the instability of certain workstation layouts, methods, equipment, tooling, noise, etc. The risk assessment will only be as accurate as their understanding of the process, so the safety technician should work closely with someone from operations or engineering.

Another root cause of process variability is the lack of engineered process documentation. It might surprise you to learn how many manufacturers don’t have a single, standard way of doing a job. Employees are simply assigned a goal and expected to figure out how best to accomplish it. With no formal, correct way of performing a job, dangerous levels of variation can develop between the methods used by two different workers doing the same task. And where there is variation there is risk.

The best way to protect workers is to ensure that they have completely and accurately mastered the core skills associated with their jobs. Some manufacturers try to shortcut the employee on-boarding process and prematurely assign the workers to production. These unqualified candidates on the shop floor generate a substantial increase in risk, because untrained workers typically function at substandard levels and avoid injury by sheer luck.

Gaps in formal training or an overall weak training infrastructure are clear indicators of a risk that can deceptively increase to near-threshold levels whenever a manufacturer erroneously perceives they do adequate or even good training and ignore how their actual efforts are substandard and shoddy.

A formal training process should be rooted in needs identification – that is, training should be based on the gap between the actual skills that workers possess vs. those needed to properly perform their jobs. The characteristics of an effective training program are:

The effectiveness of training is regularly evaluated. This typically involves evaluations at four levels and the data derived from these assessments are used to make the necessary improvements to the courses.

  • Fred Rubel wrote:

    Phil, you are quite right. I especially agree with your point about an “unstable process” being a slippery slope leading towards serious injury. A manufacturing facility with severe and repetitive mechanical failures will lead to people trying to do more than what they safely can do. Eventually, the result will be injury – – and perhaps a serious one. Maybe not an easy parameter to measure, but I think instability of process is a very good leading indicator of future injury.

  • Marc McClure wrote:

    Great points and a great article! We look at these type of indicators as “just practice” for the real event.

    • Phil La Duke wrote:

      I’d love to compare notes on which factors you think are important and the relative risk that they carry.

      Thanks for reading and commenting

  • James Whitlock wrote:


    Your article is excellent in identifying the tunnel vision we get with focusing on engineering and execution of getting a project completed or reaching a production goal within scheduled completion dates. And safety seems to become a buzz word of good intention.

    My world consists of getting the facility built and production lines operating. My strategy is to make sure safety is recognized as part of the work. I teach the contractors the concept “safety is a tool” that must be part of your tool box. Safety is only as good as how well you plan it in your work plan, and it must be a part of the work scope.

    As I look back at 2012 and the near misses investigated and lessons learned, your column is a sobering reminder that, for every near-miss recognized, how many events were not recognized nor reported. At the pre-bid meetings I ask the engineers, designers, and contractors: “Is safety a part of the scope of work, engineered and incorporated in the design?” “Contractors, have you included safety in your bids?” and then I name some equipment, tools, scaffolding, training and added percentage for difficulty to execute work.

    Over four years and one million man hours spent without an injury to a contractor person. I wonder, “Do they really understand safety as a tool, have they made safety an integral part of the work?” After a site safety audit, I focus on the unsafe work practices or behavior I corrected and I question whether they really get it or do they think safety is just something the Department of Labor wrote in a book, or a crazy concept some safety professional thought up.

    I question myself whether I am really giving 100 percent every day to make sure the work force returns home without an injury. Sometimes I wonder . . .

    • Phil La Duke wrote:


      When we start questioning ourselves and challenging ourselves to ignore our flawless safety records and start asking if we understand the probability of injury on our job sites and what if anything we are doing about it, we begin to grow complacent and put our organization at real risk.

      Thanks for reading and commenting

  • Fred Rubel wrote:

    Very helpful, Phil. Things like “run down time,” intermittent “reductions in production,” “number of emergency work orders issued (or executed),” are just some of the obvious metrics that could be tracked as indicators of process instability. Excellent insight (as always!).

    • Phil La Duke wrote:


      I am working on this week’s blog post and the tentative title is “everything costs money”. In it I plan to explore the many ways to quantify in hard figures things that people initially see as intrinsically intangible.

      Good suggestions for topics

  • Michael Menarry wrote:

    Good article Phil.
    I would include authority/responsibility in there as well. A common factor in many of the organizations that I see with performance problems is that no one is responsible or is seen to have authority for the failings. Its the poor sucker unlucky enough to be injured that takes on the pointy end of safety!


    • Phil La Duke wrote:


      You point out a key omission. The effectiveness of the accountability systems are directly correlative to low risk of injuries. Thanks for the addition.

      Thanks for reading and thanks for your comment.

  • Randy Klug wrote:

    I agree with all of your points except the reference linking BBS and incentives. My experience over the years is that a properly managed BBS process has no connection whatsoever to an “incentive” program. Done properly, it is the antithesis of that. Conducting observations and providing feedback on risk actions in advance of an incident and identifying system or process “barriers” to desired actions is fundamental in moving a safety system to the next level.

    • Phil La Duke wrote:


      One of my personal points of contention with BBS is that so many experts have weighed in on the topic with so many differing opinions that BBS as a descriptor has become essentially meaningless. It’s like when you tell someone you don’t like weasel anus and they respond by saying “you haven’t had it cooked right”. Can a company derive a lot of benefit from a well managed BBS? Yes, but of course that assumes that: a) we all can agree on what a BBS system is and what it is not (which is seldom the case)and b) we call all agree on what “well managed” means. I have seen BBS programs that don’t have any incentive programs associated with them, but I have also seen them with incentive programs central to the strategy. I have even seen them with pretty good incentive programs associated with them. The problem is, no matter how you cook squirrel anus, it aint for everyone.

      Thanks for reading and thanks for your comments.


  • Danny MacEachern wrote:

    Phil, I agree with you on the fact that there is no certain SOP and I use it as Safely operating Procedure, When you have variables in the way, the same work is being performed it sends up a red flag for me. Great Article.

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