Leadership and Change Q&A

The quest for an absolute fail-safe -– when none exists -– can make leaders more vulnerable to being sold a bill of goods, with wild promises followed by crashing disappointments.

I'm always interested in messages I receive, some of which ask for my take on a vexing problem. While I regrettably can-t respond to all questions –- and many are so unique that I'd need much more information before attempting a response -- I recently got one I'd like to share because it could be useful to many leaders. I've changed some of the identifying information to protect the innocent.


I have been reading your articles for a few years, and I need some insight if you have time.

The scenario: Lock-Out-Tag-Out (LOTO) is a very ingrained concept at our plant. We perform it numerous times during the day, preach it over and over in safety meetings, and I personally whole-heartedly believe in the process. I have written slide presentations on the subject and teach LOTO to new employees.

Here is what I hear when things go wrong: "I locked out the wrong disconnect because another employee already had their lock on the wrong disconnect." "Yes, I got suspended and have since beaten myself up daily over this 'human error.'" "I now have to figure out what went wrong not only to change a broken system, but for my own sanity." "Complacency was the reason, but not following the six step procedure of LOTO is what really caused this error. I did not follow it. No one at our plant 'really' follows it to the letter. People in maintenance and operators also have to lock out their machines all the time, so the six steps are not all followed because we have done it so many times in the past."

WHY?? We are a very technological mill utilizing computers to control everything. With all the interlocks in the controller, starting and stopping motors with the normal push buttons can give you false verification. Windowed disconnects get hard to see into and verification lights are not always 100% either, and these would not matter in the case that the wrong disconnect was verified anyway.

Could you give me some of your wisdom as to how we get back to utilizing the process correctly and what you may have seen that works time after time with no exceptions to keep people aware and alert about their safety and the Lockout process?

My response:

Thanks for writing.

1. First off, it's essential to set realistic expectations. I haven't found that any "time after time with no exceptions" proposed fix is realistic. Nothing works with all people all of the time. Even the best machines wear or break down (and people usually aren't as "reliable" as the best machinery.) I never think of Safe procedures or actions as "fail-safe" guarantees, but as putting the odds much more in favor of people not getting hurt or, at very least, of minimizing injury from "unavoidable" incidents.

While this may sound like splitting hairs, this shift in approach can make a world of difference in a culture that is past-focused, head-hunts/assigns blame to those who become injured and another higher-level culture that is forward-thinking and emphasizes continuous improvement (as in, "you can't change what already happened, only what might otherwise occur in the future.")

Further, the quest for an absolute fail-safe -– when none exists -– can make leaders more vulnerable to being sold a bill of goods, with wild promises followed by crashing disappointments.

I generally make the assumption that any time a "solution" to a longstanding problem seems "easy," it likely means I don't fully understand that problem.

2. Determining the roots leads to the treatment. In my experience, many LOTO-related and other safety problems are associated with:

  • Complacency, variation 1 (as you've identified), where people default toward taking safety for granted, followed by prevention efforts hyper-ramping up after an incident ("locking the barn door...").
  • Complacency, variation 2, an "external locus of control." That is, an over-reliance on machinery and procedures (that people may not even follow) to keep them safe. If/when something goes wrong, this can lead to anger toward management or to the safety function (professionals, safety committee members, etc.) with these attributed blame for the accident (as in, "It's their job to keep me safe.").
  • Workers not seeing return benefits for effort expended. Persuading prevention is difficult because it tends to be accepted mostly by those already forward-thinking or wanting control over their lives. By far the majority of people aren't so geared toward prevention; you have to get their buy-in in other ways.
  • The inability to direct/control their own attention. These are skills that can be learned, not merely just expecting or communicating the need for "will" or "Try hard" or "Just pay attention!", all of which are very limited. People tend to become distracted, are mentally pulled away by worries of all sorts, have a habitually flitting focus, etc.
  • Mixed pressures, concerns that LOTO takes too much time or slows down work -– and more.

3. Some potential approaches (and no 100 percent "easy fix"):

  • Move toward employee-driven LOTO and many other safety interventions (vs. safety professional- or safety committee-driven). Determine the range of reasons workers don't fully follow LOTO procedures. Do this in a no-blame atmosphere to elicit honest, dispassionate responses.
  • Elevate near-miss/close-call LOTO reporting through interview and report-back (without embarrassing anyone, or you'd likely "win the battle and lose the war").
  • Improve their autopilot "program" by providing tangible skills for directing attention that they find useful and of interest. These skills have to be simple to use and show them immediate benefits to what they do. The key is they value these skills, rather than drilling them with more procedures (that only work to a point and can result in pushback).
  • Enlist the home connection. Bring in applications of LOTO off work. (Where does LOTO apply where they live? How can they use this to protect their family? How can they show/demonstrate LOTO to family members? etc.)

Obviously, anything you do has to fit with your specific culture, workforce, what you've tried. But I do know that trying to force compliance will always be extremely limited and often backfires, especially with an experienced or a younger workforce.

Best wishes,
Robert Pater

This article originally appeared in the December 2012 issue of Occupational Health & Safety.

About the Author

Robert Pater is Managing Director of Strategic Safety Associates and MoveSMART®. To contact him, email rpater@movesmart.com.

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