“Men occasionally stumble over the truth, but most of us manage to pick ourselves up and hurry along as if nothing ever happened.” -Winston Churchill
Churchill definitely had a lot of good quotes (unless you were Lady Astor) but this is certainly my favourite, and in terms of the title: Slips, Trips and Falls – Paradigm Shift, so very appropriate, because when you’re done reading this, hopefully you won’t just hurry along as if nothing ever happened. And hopefully this will be because of some significant paradigm shifts, which will give you a different perspective – and hence, a different set of tools to help prevent slips, trips and falls – significantly (like 50-60%).
So, here’s the first one, or the first question, which also relates (at least loosely) to the quote. When it comes to slips, trips and falls, what is really more important: what you stumble on or the hurrying? How many times have you slipped, tripped or fallen because you were rushing, which is one of the four states (or human factors) we’ll be discussing: hundreds of times? Thousands? Can you even begin to count?
If an employee fell and was injured because he or she tripped on something that shouldn’t have been there or slipped on something – usually liquid – that shouldn’t have been there, it would be incredibly rare to see anything in the incident/ injury report about the employee rushing, not seeing the hazard and thus avoiding the fall. It would be much more likely (worth betting on, in fact) that the focus – probably the entire focus – of the investigation, interview and actions taken to prevent recurrence would all be focused on the hazard that shouldn’t have been there. And the nice thing about all that – it’s easy! There is, however, an almost comical problem when presented with the situation that there wasn’t in fact a hazard that wasn’t supposed to be there, but rather the employee. Or we could just think of ourselves, simply tripping over our own feet. We’ve all done it – lost our balance and fallen on a perfectly good stairway, hallway or pavement. Sometimes we blame our shoes, but in reality, that is a very small percentage of the total problem.
What truly is comical is when you look through incident reports for industrial workplaces; and I’d know – as a behaviour-based safety consultant in the process of building critical behaviour checklists based on the actual injuries at that site – I’ve looked at thousands. What you find is that 20-30% of them are slips, trips and falls, or about 25% of their recordable injuries. But only so many of them had a “culprit hazard”. Lots and lots (and lots) of people fell on perfectly good stairways or on the plant floor with no liquid present. So, what do you say or do for “Action taken to prevent recurrence”? More training? How absurd, and yet “re-instructed worker”, “recommended worker to pay more attention in future” and “reviewed policies for stairways and handrails with employee” are exactly what you see in that last column or section entitled “Action taken to prevent recurrence”.
So, you’re going through report after report, file drawer after file drawer, and you’ve seen, by now, hundreds and hundreds of incidents of these totally flimsy “actions taken to prevent recurrence.” You might in this scenario, especially if you’re tired, say something to the client – like I did – along the lines of: “why do you even bother writing anything here? You wouldn’t bet a pound, let alone 1,000 pounds that this would ever prevent recurrence.
“under normal working conditions people can see the hazards, think about and negotiate them with relatively few problems”
To which the safety person – who was of course equally tired because he’d been going through all the reports with me – responded with: “Because… You know full well that if I hand this in without that last column filled in they’ll just throw it back at me – so I just picked something”. “Did you actually reinstruct him?” I asked. He just shook his head as if to say, “Are you nuts? Of course not.”
So, this being the case, what can you do that actually will work?
Before launching in to all that, however, it should be made clear that wherever possible the hazards should be removed, and all employees should have good footwear. That said, it’s not always possible or practical to remove all hazards (just think of a construction site). Sometimes you have to walk around them or over them. Under normal working conditions people can see the hazards, think about them and negotiate them with relatively few problems – just think about how many “hazards” you negotiate everyday driving to work. If the hazard (cable to trip on, oil to slip on) wasn’t there then I wouldn’t have to deal with it, negotiate it or bother with it; nor would anyone else. So, it’s easy to see how “entitlement” can start to creep in, which is unfortunate: because if anyone starts thinking that their safety is not their responsibility – that it’s somebody else’s responsibility – they are in for a pile of hurt. Can you imagine saying something like that to your children? “Don’t worry about your own safety – it’s not your responsibility; it’s somebody else’s.” (Hopefully a guardian angel, because that’s what you’d really need).
Cause versus outcome
Slips, trips and falls are the outcome or the result. The cause is a problem with “balance, traction or grip”. So, while someone might very well think that hazard removal is the responsibility of the employer, very few people think it’s the company’s responsibility to keep their balance for them or maintain their grip or test it before they commit their weight. Furthermore, getting employees to focus on the cause (loss of balance), over which they have a lot of control, will be a start in terms of helping them to prevent making errors or mistakes with balance, traction or grip. However, that won’t be enough.
Although it’s possible to lose your balance or grip without making another critical error, it’s rare.
Almost all balance, traction or grip errors are predicated or set up by one or both of the first two critical errors, which are:
- Eyes not on task
- Mind not on task
In other words, you didn’t see the cable you tripped on, or you didn’t think about the grass being slippery after the rain, or worse – the sharp corner on the road being slippery after it has just started raining. Eyes not on task and/or mind not on task usually set up the errors with balance, traction or grip. However, it’s not like we are making these mistakes all the time. Most people don’t even notice unless they actually fall or drop their phone and it breaks. Do you know how many times a day or a week you lose your balance now? If you were actually getting better or worse would you know it? And if you did know you were getting worse, would you know what to do about it? So, how do you prevent eyes not on task and mind not on task (the first two critical errors)?
Human factors cause critical errors
There are four states, or human factors, that cause four critical errors. This state to error risk pattern is involved in over 95% of all accidental acute injuries, whether they’re at work, at home, in the community or on the road. (See Figure 1)
If you’re questioning the 95% just look at a reliable database: your own experience. Can you think of even one time in your life (not including sport) where you got hurt and you weren’t rushing, you weren’t frustrated or tired, and you hadn’t become so complacent about the hazards and hazardous energy that you just weren’t thinking about it? If you’re like most people you can’t, or if you can it’s only one of two exceptions – for your whole life.
Now, can you think of a time (other than sports) when you got hurt when you had your eyes on task, you had your mind on task, you were aware of the line of fire and thinking about not losing your balance, traction or grip? Maybe – if a tree branch broke while you were climbing it, but again, that wouldn’t happen if you took the time to test it before committing your weight. But if your brother said, “Mum’s coming, you better get down before she sees you” then – because you’re rushing, you might not have tested that branch or made sure your foot didn’t slip. And those are just two of the problems rushing causes. Other problems like not seeing the hazards because you’re moving quickly, or not thinking about the risk because you’re thinking about why you’re rushing, are potentially even bigger problems. Rushing can also cause you to take a shortcut like not bothering with fall arrest when it’s a small job and it’s only three or four metres high. Although, in order to be willing to do that – despite whatever pressure you were under – you’d still have to be comfortable enough or complacent enough to be willing to do it in the first place. So, it’s usually a combination of states like rushing and complacency or rushing and frustration (road rage) that really affects our judgement.
Critical error reduction techniques
If you look at the pattern again in Figure 1, you see that the states come before the errors. What this means is that we are in the state before we make the error. Once we make an error with balance, traction or grip the outcome or the result will likely be a slip, trip or fall, unless you regain your balance without falling, catch your phone before it hits the ground or recover from the skid without going off the road or into a big truck. In other words, just another close call or near-miss… But, if you didn’t regain your balance, catch your phone, etc. then it’s not a near miss, it’s an incident or injury. And how serious that will be will usually just be a matter of luck, combined with the overall amount of hazardous energy (a one metre fall is usually better than a five metre fall, and landing on your feet is usually better than landing on your head). So, once you lose your balance or make another critical error like moving into the line-of-fire, it’s too late.
We need something to trigger on before we make the error. And since there are only four states that predicate over 95% of these errors, that means we can use the active states: rushing, frustration and fatigue as the triggers. So as soon as you realise you’re rushing, that is, going faster than you normally go, and instead of thinking about why you’re rushing or what can happen if you’re late, you need to be thinking about keeping your eyes on task, your mind on task (including the risk of what you’re doing, which might be driving over the speed limit so you’re not lake for work or running down the stairs so you don’t miss a start of the meeting). That is very counterintuitive, however, so it takes a fair bit of training and practice to learn how to self-trigger quickly enough to prevent the error.
Learning how to self-trigger on the state is the first Critical Error Reduction Technique (there are three more, see figure 2). And as mentioned, this technique works really well for rushing, frustration and fatigue because you can tell when you’re in a rush or when you’re frustrated, and you can certainly feel when you’re fatigued.
So back to the reliable database: what’s the percentage of times you’ve lost your balance, traction or grip when you were in a rush? What percentage was caused or at least partially caused by frustration? And what percentage of your bad falls were fatigue induced? The reason I asked for bad falls on the last one is that fatigue slows down your reflexes. So, what might have been a close call or minimal injury can sometimes be a lot worse because you didn’t get all the benefit of your reflexes.
If you’re like most people, well over 60% of the falls you can remember involved rushing, frustration, or fatigue. You may even be as high as 75 – 80%, which means that if we learn how to self-trigger quickly enough to prevent making an error, we can reduce the loss of balance by 60 – 70% which will reduce the number of slips, trips and falls by the same amount.
Self-triggering is a two-step process. As soon as you realise you’re rushing or frustrated or tired your first option (let me repeat) your first option is to reduce the state: slow down, calm Slips, Trips, Falls and Safety Flooring | Article down, or get some rest. Full stop. But that’s not always possible. So, if you can’t slow down, calm down, etc. then the next step is to make sure you keep your eyes on task and your mind on task. In other words, look for and/ or think about what could cause you to lose your balance, traction or grip. Chances are, if you’re looking for things that could cause you to lose your balance, traction or grip and you’re thinking about it – you won’t have any problems. But in the very rare instances when you do still lose your balance – even when you were thinking about it – your reflex speed will be unimpaired. You will definitely still get the benefit – the full benefit – of your reflexes if you have your eyes on task and your mind on task.
So, the first step (provided you’ve removed the slipping/tripping hazards and they’ve got good footwear) is to teach your employees how to self-trigger. That will be a big help for the rushing, frustration and fatigue. But what about complacency? Obviously, that state isn’t going to be so easy to self-trigger. You can’t feel complacency within yourself. You can see it in other people – quite easily sometimes – but not in yourself.
Complacency leads to mind not on task
Complacency happens gradually over time. When you first started driving it took almost 100% of your concentration just to operate the pedals, steering wheel and indicators. Now, you can drive home without even thinking about it, let alone worrying about the risk of a collision. Complacency causes lots of problems, but probably the biggest problem is that complacency leads to mind not on task. If you’re not thinking about what you’re doing, however, your behaviour will be what you do normally, automatically or habitually. Which means we are going to have to get people to put a bit of effort into improving their safety-related habits. Especially those habits like testing your footing or grip before committing your weight or looking for things that could cause you to lose your balance, traction or grip, or – the big one – getting everyone into the habit of moving their eyes before moving their feet (or hands, body or car).
Getting employees to put some effort – real effort – into improving their safety related habits isn’t going to happen just by telling them what they need to work on (some might, but not very many). Something like this will require in-depth training and motivation. Leadership also needs to be on board and helping with this. Working on habits – especially those related to balance, traction or grip – will be a big help in terms of compensating for complacency leading to mind not on task. But it’s always better if you’re thinking about what you’re doing vs. relying on your habits or reflexes. You see, unfortunately your habits and reflexes don’t give you the ability to anticipate a dangerous situation that might not be visible or easily visible, like wet grass after it rains or condensation on a handle that makes it slippery. Anticipating potential problems is something you need your mind for, so it would be nice if we also had a way to help people bring their mind back to the moment.
That’s what the third critical error reduction technique is for: whenever you see a state-to-error risk pattern, like someone rushing around a corner and almost losing their balance, or looking at their phone running down the stairs, it will make you think about risk. And almost automatically, you’ll think about what you are doing.
The last technique, “Analysing Close Calls and Small Errors (to prevent agonising over big ones)”, is designed for continuous improvement. Every time you catch your foot on something or lose your balance – even if just for a second – ask yourself why.
Was it a state like rushing, frustration or fatigue that I didn’t self-trigger on? Or, if it was mostly complacency then it’s probably a safety-related habit that still needs more work. Or, you’ll have to put a little more effort into watching other people for state-to-error risk patterns. So the idea is to give everybody the tools and skills they need to learn from the little ones: those momentary losses of balance that happen daily, instead of learning from a broken leg or fractured wrist. Everybody learns from the big ones, but if we could learn as much from the small ones – if we didn’t just “hurry along as if nothing ever happened”.
So, the next time someone in your facility or company is injured due to a slip, trip or fall and there’s no obvious “culprit hazard” to blame or remove, you’ll have a choice. You can write down “re-instructed worker” or some other useless piece of advice in that last column, or you can do something that actually works – that really will help to prevent the next one.