Scaffold or gallows?

A time for reflection:

Three years ago this month, I wrote this blog. Today, despite the immediacy of the COVID-19 situation, I am re-publishing as I believe it is worthy of review. Many of us are studying and practicing human performance. This article reflects the value of human performance principles:

We all make mistakes. Behavior is a symptom not a cause.	People are not the problem, they are the solution
Major and minor incidents are preventable. We can predict, prevent and manage error-likely situations.	The path and process to high performance is also predictable, and can be led and managed
The organization, its leaders and our peers have the greatest influence on our work and the potential for incident-free performance	Sustained high performance is achieved by whole-hearted engagement, commitment to improvement, and demonstrated encouragement, reinforcement and empowerment of our people and teams.

March 22, 2017

Recently a worker fell from a 4.8-meter-high scaffold located just outside a process plant. He and two colleagues equipped with harnesses and prepped with a Tool Box Talk (TBT) set out to dismantle the scaffolding in fair weather. Despite being tied off, one man fell to the ground and suffered serious injuries. Fortunately, he did not die.

The investigation was thorough and turned-up a number of shortcomings, including:

• The direct cause of the fall was that the worker tied off to and leaned against a horizontal support which he had already loosened. The requirement clearly states to tie off to a vertical support bar.
• The worker had attended a refresher scaffolding training just two weeks prior to the incident. He clearly did not implement the training information.
• A number of management shortcomings were noted, including conflicting directions regarding permitting the work on that particular day and at that height.

Given the findings, senior management is recommending negative consequences for some managers and supervisors, including loss of performance bonuses. These will clearly be perceived as blame and punishment by many people throughout the organization.

However, some managers recognize that “blame stops learning”. To their credit, they are at work behind closed doors trying to convince their colleagues to forego the “punishment” in service of organizational learning. Those managers, and many of us reading this blog, understand that punishing people for honest mistakes at work doesn’t make sense. People don’t set out to get hurt, they want to get the job done. The outcome of those closed-door conversations is unclear.

The findings also point to improvements to be made. I believe the organization will do a good job correcting the conflicting directions for the workers and revising the procedure mentioned above, but I don’t think those steps will make a fundamental difference in the safety of scaffolding activity in the future.

Scaffolding may be one of the most prevalent of all construction activities. Outside of manufacturing-type environments, scaffolding is manually erected and dismantled almost 100% of the time. Work at heights is one of the most frequent killers among hazardous activities – why aren’t we using our brains to tame this hazard?

Said differently, worker attention, PPE and compliance with procedures are the weakest protections against injury. But these were the ONLY safeguards available to those three men. And to literally hundreds of thousands of workers like them erecting and taking down scaffolding on construction work sites every day.

For a fatal risk, shouldn’t more significant safeguards be in place, such as removal of the hazard or a firm physical barrier? In this particular case, existing motorized or rolling lifts could not get to the outdoor location. But that is true of the vast majority of scaffolding done on the site and it is true of most of the sites I work on and visit. Relying on workers to overcome a fatal risk, then blaming them and their supervisors is a failure of management and leadership.

It has been proven again and again that higher levels of safeguards cost an organization LESS not more. But who pays the bill upfront for these safeguards? For a small sub-contractor, as in this case, engineered approaches are usually too expensive.

But you know what? This site operator spends many hundreds of thousands of dollars every year on scaffolding activities performed by multiple contractors. In the last few years, this company took many thousands of dollars of cost-savings out of their sub-contracts. And it is proud of that. Are short term cost-savings the right perspective? What are accidents costing this operation? Many good managers say the right thing, “Good safety makes for good business”, but how are we actually implementing and leading that cause?

JMJ suggested that perhaps there was a bigger opportunity here. Rather than just reinforcing the rules, what might provide a better overall outcome?

Safety leadership can be boiled down to:

• People: Engaging people in the work of the organization. Not just training them in rules and procedures, rather engaging them to look out for each other, building trust, improving the work process and more. People are not the problem; they are the key. (The scaffolding crew did not look out for each other, speak-up, or review the fatal hazard together prior to starting work. Sure, they did a Tool Box Talk that day, but clearly it was not effective.)

• Perspective: Recognizing that “what we accept” may not be “acceptable”. Putting workers at risk without meaningful engagement is not acceptable. Companies routinely accept rote TBT’s; boring classroom training that is not site-and task-specific; not done by their own company and often not in their native language. Inside the same company’s perimeter fence and not far from the scaffold is their “top quartile” process plant operating at 100% reliability and for several years without significant incidents or injuries. The top notch safeguards employed in that plant might as well be a million kilometers away from the scaffolding incident, not a few meters. Certainly the razor-sharp focus on process safety inside the plant is warranted and to be applauded. However, that perspective did not help the injured scaffolding worker or his family. Accepting different standards for fatal risks in construction as distinct from production is not reasonable. When will we recognize a fatal risk that we have come to accept – like scaffolding – is a necessary but still unsafe evil?

• Catalyst: Leaders cause positive change. A leader does more than improve procedures. A leader doesn’t settle for what is currently acceptable. A leader is someone who can “get up on the balcony” and then ask, “Where do we have fatal risks not matched by appropriate safeguards? Where do we have old construction methods that we’ve not reviewed because they are outside the walls of the process plant or outside our strict contractual responsibility? Maybe it’s time for leaders across this site and many other sites to say, “Ok people, I am challenging all of us to apply the standards of excellence in our process plant to the day-to-day work of construction and maintenance.”

What brings life to safety in a catalytic way is innovation, inspiration, direction-setting. These are actions and practices a leader can take. These are practices that transcend and in fact preclude the need to punish mistakes or provide positive incentives for behaviors. They catalyze people’s best efforts.

Safety is not the absence of harm and mistakes. It is the addition of safeguards, practices and intangible elements that cause excellence in operations.

For just a few moments, imagine that scaffold. Shift your personal perspective for a few moments. Think of your son or daughter five meters up in the air doing thousands of hours, hundreds of days per year of repetitive tasks, and relying only on their own efforts to prevent a fall.

Maybe it’s time for some creative thinking, engaging scaffolders, their supervisors and engineers for their ideas, and perhaps applying investment enterprise-wide that will pay off for them and for your operation for many years to come.

A scaffold or gallows?