Identify gaps in your systems
Lessons from the New York prison breakout
I must admit that I’ve been 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 this past June. 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”). They would walk quietly behind the 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.
An easy analogy
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, it is “…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.”
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 Safety-Doc’s blog on “Complacency Shouldn’t be your Exit Strategy”). How many tasks processes, reviews, preventative maintenance, inspections, and, yes, process safety inspections reveal nothing of substance time after time and then get extinguished where they lose their integrity in preventing loss because of complacency?
Compound this with 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 results in the attitude, “all these things we are doing for safety means my small part isn’t worth the effort.” Consider that the prisoners were deep in a large building surrounded by walls and dozens of guards. Where could they possibly go? What good is a small little patrol?
Complacency and complicity
We may find ourselves believing that 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 were guards and employees in the prison who granted special favors to the scheming inmates (for pieces of artwork), which led to a guided tour of the catwalk as well as some of the tools used in the escape. At least one prison employee reported they knowingly and actively helped by 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.
It can be the existing process that didn’t consider a new vendor’s product specifications.
It can, unfortunately, be the supervisor driven by production bonuses who encourages short cuts (or at least looks the other way).
Time to ask hard questions
Certainly after these events, 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.
Latent hazards, complacent risks
Safety processes should be designed (or re-designed) to better consider Latent Hazards -- 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 both 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. I’ve seen some good examples of companies making headway.
Consider building a process of cross-functional group observations of tasks as they are being worked. An employee team can choose the task or the task can be chosen from trends found in other safety data such as data coming out of behavioral safety. A checklist can be used that directs attention to the non-obvious, 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 evaluate the actual, not assumed, mitigation of the problem with continued observations until you can claim victory.
Finally, let’s consider what we do when we find these hidden sources that help cause injuries. Our mitigation actions need to be considerate of the job process by involving those who do the task. We need to resist the urge to punish. Indeed, in the aftermath of the prison outbreak in upstate New York, reports are coming out that prisoners have been abused with beatings and solitary confinement to find out what they knew.
We also need to resist the urge to over-engineer the solution – such as when the layers of PPE, extra rules, and cumbersome processes. Mr. Sweat is currently in a prison cell with concrete five inches thick. The Clinton Correctional Facility identified its system problems after the prisoners made their break on June 6 (Richard Matt was killed by police on June 26; Sweat was captured June 28), but has it actually solved the problem?