Are there Gaps in your Safety Systems?
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I must admit that was captivated, like many fans of the Shawshank Redemption, with the escape and ultimate recapture of prisoners at the Clinton Correctional Facility in upper New York State. The methodical nature of prisoner David Sweat, incarcerated for the murder of a deputy sheriff, toiling in secret to escape has to be a cautionary tale to those of us working to keep injury at bay.
It took months for Mr. Sweat to saw through the back of his cell and ultimately into an outbound pipe in the depths of the prison to escape. He hid his progress by working at night through a camouflaged hole in the back of his cell. His accomplice lied to other prisoners about the noise made while sawing (he was “stretching canvases”). Mr. Sweat would walk quietly behind the cell walls on catwalks hunting for paths to underground service pipes that would lead under the prison walls to freedom. Both would change into dirty work clothes at night then hide them before changing back into their prison jumpsuits for normal daily activities.
We can easily make the analogy between a prisoner trying to escape and the hazards and risks related to injuries.
The obvious ways prisoners try to escape are identified and blocked. Likewise, the obvious hazards and risks in our workplaces are identified and mitigated through many of our safety systems including audits, observations, and discussions.
But what about the hidden attempts to escape? What about the latent hazards and risks that our safety systems may be unequipped to identify? It may be instructive to consider those hazards and risks trying to hide from view while actively working to break through our protections.
It’s also instructive to understand how the prison system allowed Mr. Sweat to succeed in his escape. To quote the New York Times report on the incident, the escape was “…a story of neglect by those who were supposed to keep Mr. Sweat behind bars; of rules and procedures ignored; and of a culture of complacency among some prison guards, employees and their supervisors, whose laziness and apparent inaction — and, in at least one instance, complicity — made the escape possible.”
Are our safety systems designed to keep risk and hazards at bay, but have their own story of neglect, rules and procedures ignored, complacency and complicity?
Mr. Sweat did not have to worry about getting caught out of his cell because he knew the guards would be sleeping during the night shift. This failure to do bed checks probably was shaped over time because, night after night, week after week, everything was fine with prisoners in their bed. As a result patrolling behavior was extinguished. So much so that a prisoner joked “the only thing walking the cellblocks on the overnight shift were the cockroaches.”
Behavioral extinction, a basic behavioral science principle, is often called complacency in the safety world (see Dr. Ludwig’s articles on When Complacency Creeps in: Identify & Discuss Drifts in Performance and Complacency comes when Reinforcement goes, so Reinforce More). How many tasks processes, reviews, preventative maintenance, inspections, and, yes, process safety inspections reveal nothing of substance time after time. The workers and managers learn that, most likely, they will find nothing. They don’t get reinforced for their effort and their participation in your safety processes get extinguished. When complacency happens your safety processes lose their integrity in preventing loss?
Consider also that the prisoners were deep in a large building surrounded by over 10 foot of concrete, 25 foot walls and dozens of guards. Where could the prisoners possibly go? So, what good is a small little night patrol? Similarly, this is a common perception associated with all the PPE, overly abundant training, observations, meetings, audits, inspections, work orders, engineering, safety professionals, investigations, S.O.P.s, policies, etc. that “all these things we are doing for safety means my small part isn’t worth the effort.”
Because of these sources of complacency, us safety professionals may find ourselves believing safety processes are being done when, in reality, these processes are skipped, done half-assed or pencil whipped. In Mr. Sweat’s case he used a hole in the back of his cell to get to a catwalk behind the wall giving him access to the prison’s inner passages. Guards were supposed to walk the catwalk three times a month… none had done so in years. Prisoner cells were supposed to be routinely inspected but the person-sized hole in the back of Mr. Sweat’s cell remained undetected.
If Complacency is a problem then Complicity is another layer entirely. Mr. Sweat got access to tools left by contractors by breaking into their tool boxes and getting the tools back before they were found missing. Further, there are guards and employees in the prison who granted special favors such as a guided tour of the catwalk. At least one prison employee admitted to providing heavier tools like hacksaws and chisels packaged in frozen ground beef to the inmates.
Yes, the very systems you put in place such as tools, equipment, processes, policies, supervision, can, at times, actually be complicit in increasing the hazards and risks you are trying to keep at bay. This can be the tool or piece of equipment that imperceptibly deteriorates to the point of failure. This can be the existing process that didn’t get updated with a vendor’s new product specifications. This can, unfortunately, be the supervisor driven by production bonuses who encourages short cuts (or at least looks the other way).
Certainly after the Clinton Correctional Facility escape, prisons throughout the country are asking how they can prevent these types of escapes. This may be a good time for us to ask the same type of question:
Are there “Gaps” in our safety systems?
Many of our safety processes do a very good job of finding and acting on recognizable hazards. Those who engage in behavior-based safety know this well. But when we use the same behavioral categories on our observation cards (e.g., PPE, Slip/Trip, body position, safety belts, etc.) and have the same employees observe each other in their craft, we may be missing something. When near-miss or incident investigations look to find a root cause but attribute the incident to “human error” we may be missing something. Even the trained eye of the safety professional can miss something creating gaps in our safety systems.
Safety processes should be designed (or re-designed) to better consider Latent Hazards; those hazards that are not obvious and often at the boundaries of established processes (e.g., chemical disposal, deploying engineering designs, maintenance). Similarly, behavioral safety processes should be designed (or re-designed) to go beyond what a passing observer can see (e.g., PPE, using handrails) to better consider Complacent Risks; those behaviors that increase the potential of injury from less obvious but very real risks engaged during tasks where complacency, novelty and short cuts may conceal the risks from the worker, group leaders, and the casual observers.
It may be time to build some elegant safety processes that look behind the wall and walk the catwalk and reinforce these inspection behaviors when they happen. I’ve seen some good examples of companies making headway.
Consider building a process where a cross-functional group goes out and observes high risk tasks. An employee team can choose the task based on their experience or the task can be chosen from data trends. A task specific checklist can be built that directs attention to the non-obvious behaviors that have to occur in the midst of possible latent hazards to keep the worker safe. There is a lot of asking what-if, what’s-missing, what-could-be, and what don’t we know?
Behavioral Safety checklists should be converted from static lists that never change into dynamic targeted lists, created by employees considering the hidden complacency and latent risks. Metrics could be enhanced to provide feedback and celebrate quality observations that identify new latent hazards and complacent risks. Then the information should be analyzed to dig below the obvious. We should then evaluate the actual, not assumed, fix of the problem with continued observations of safe behaviors until you can claim victory.
Finally, we also need to resist the urge to over-engineer the solution – like when the layers of PPE, extra rules, and cumbersome processes required after identifying a problem actually don’t solve the problem. Mr. Sweat is currently in a prison cell with concrete 5 inches thick…while someone else is certainly sawing away at a wall behind complacent guards and complicit enablers. Knowing this, Mr. Sweat is currently trying to convince his guards let him be a consultant to the prison warden to teach how prisoners are working actively to escape their captivity. Of course, he wants some “favors” in return.
Slides for "Lessons from Shawshank: Are their Gaps in your Safety Management Systems" available at:
safety-doc.com/keynote-speeches
Dr. Ludwig was interviewed by Dan Clark after his speech, “Are their Gaps in your Safety Systems: Lessons from Shawshank.” Below you’ll find the rebroadcast of that 30-minute interview by permission from Safety Experts Talk.
After listening to “Are the GAPS in your Safety System,” dive into the interview for more conversation on the topic of latent hazards and complacent risks.