Dear Subscriber,

Many of you have read Jim Collins' best-seller, "Good to Great" and applied the lessons to making a leap forward with your safety and health program. One of the tenets of "Good to Great": great leaders and great companies do not hesitate to confront brutal facts.

"Why have we sucked for 100 years?" asked one CEO, kicking off his company's transformation. Tough-minded people must examine hard facts, ask disciplined questions, and debate what the facts mean, says Collins. It's not about winning the debate, but arriving at the best answers.

"Autopsies without blame," Collins calls the process.

Safety pros investigating accidents can relate to that. There's only one problem: This kind of courage is rare. Many companies are "tempted to remain as ignorant as they can," writes risk communication expert Peter Sandman in an essay posted on his Web site. "Because they have decided that knowing is too dangerous."

In this edition of ISHN's e-newsletter, we look at how to raise safety issues in a culture where managers are afraid of getting stuck with the answers.


It's impossible for a company to take environment, health and safety seriously unless the company consciously looks for possible environment, health and safety problems it hasn't yet addressed, writes Sandman.

But we see stories like these all the time:

  • "It is obviously a very tragic event, but under the circumstances we don't feel OSHA's treatment is appropriate," says a spokesman for a Maine tugboat operator fined $1,500 following the death of a deckhand. OSHA says the company needs to improve how it trains employees. The company says its training is good enough.

  • Welders working on a bridge span in the San Francisco-Oakland bay area were exposed for nearly a year to excessive levels of dangerous fumes, and the project's contractors apparently knew about it yet failed to either notify workers or correct the problem, reports the Alameda Times-Star.

  • "Employees have to accept responsibility for their own health," says the CEO of a Virginia hospital where a nurse worked for six months after contracting tuberculosis, potentially exposing hundreds of people, before she died. Hospital officials don't know how the nurse caught TB.

  • The collapse of a ten-story Atlantic City casino parking garage last October that killed four workers and injured 20 was blamed in part on contractors and inspectors who ignored warnings about cracking concrete, according to OSHA. "There are no simple answers here," said the general contractor, vowing to fight the citations.

    Sandman cites three reasons why companies will duck, dispute, or deflect safety issues. Fear — don't give attorneys any ammo. Ego — "We're not bad guys." Self-deception — You see what you want to see.

    Bottom line: Companies have the mind set that mistakes equal culpability, as in "Who's the culprit?" In a punitive world, someone's going to have to pay. So duck.


    This pessimism leads to the typical knee-jerk reaction to a safety incident — "What went wrong?"

    Then the dominos start falling. "How do we manage this?" "This can't happen again." "Find a fix." Manage the problem and move on.

    Like the man who flies off the handle one night and beats his wife. Referred to a psychiatrist, he says, "Doc, this can't happen again. Give me a pill." "But maybe it means something," says the doc. "I don't have time. Just give me something."

    A magic pill.

    Of course some companies opt to follow Collins' maxim and confront the hard facts head on. BP, the British-owned energy giant, recently posted on its Web site 11 EHS challenges that it confronted in 2003. Among them: Fatalities increased among BP employees in 2003, the company reported, with most relating to vehicle crashes. In response, BP has developed a new, more rigorous group-wide driving standard, to be implemented in 2004.

    Another issue: BP's voluntary People Assurance Survey, a perception survey, was completed by about 70 percent of all eligible employees. Results showed a decline in two areas — a diminishing perception of BP’s loyalty toward employees and less willingness to recommend BP as a place to work compared with 2002. BP says it is committed to identifying and addressing underlying concerns during 2004.

    Taking yellow flags (such as perception survey results) seriously, in public, earns you a reputation for caution, writes Sandman. "This is a bankable reputation."

    It can also earn you a new identity, one that most companies don't have. It's being proactive, rather than reactive. Committed to learning, not covering up. Not defensive, but open-minded — about your processes, ways of operating, and organizational attitudes driving priorities and decision-making.

    There's fiscal value to this identity — you'll improve financially by rooting out processes that are inefficient and attitudes that are ineffective. The result: fewer defects, errors, incidents, and accidents.

    There's also political value — you'll have freedom to operate as you like (with regulators, watchdog groups, etc.) because you've proven you can manage efficiently and safely.


    The safety field is strewn with yellow flags — near misses, employee perceptions and complaints, incidents without injuries, rising comp costs. And red flags — OSHA fines, explosions, fatalities. Yellow flags are opportunities, red flags practically mandates, to learn and improve.

    Diminish their importance and you set the stage for repeating the same mistakes, the same behavior, and the same outcomes again.

    Explore their significance to lock onto solutions that work and you can be on your way from good to great. A lot depends on how "great" your management wants to be. That decision shapes the culture for investigating things gone wrong.

    Some tips to help you "confront the brutal facts":

  • Don't cry wolf — not all yellow flags are created equal. Prioritize action items for management. Make sure you know the difference between a yellow and red flag.

  • Assess your culture. What is your organization's capacity (budget and expertise) to make corrections? What's management's commitment (how good do they want to be)? What kind of pressure (compliance, etc.) exists to compel improvements? These three factors come from a model for predicting an organization's response to environmental regulation by Mayer Zald at the University of Michigan, Calvin Morrill at the University of California at Irvine, and Hayagreeva Rao at Emory University.

  • Use positive examples of companies that don't duck bad news, such as BP's Web site and Jim Collins' "Good to Great." BP's EHS challenges — Jim Collins' article "Good to Great" (a good introduction to the concepts in the book, "Good to Great") —

  • Get an understanding of how organizations behave in the face of adversity. Peter Sandman's excellent article, "Yellow Flags: The Acid Test of Transparency," can be downloaded at:

  • Research how the medical community responds to sentinel events — adverse unexpected occurrences ranging from surgery on the wrong patient to infant abductions. Protocol set by the Joint Commission on Accreditation of Healthcare Organization states that the search for the underlying reasons focuses on systems and processes, not individuals.

  • Repeatedly asking "Why" as part of a root cause analysis is not a process of elimination that leads to a single ultimate cause, says Dr. E. Scott Geller. You'll identify more than one change that needs to be made to reduce the risk of reoccurrence.

    Dave Johnson is the ISHN E-News editor. He can be reached at, (610) 666-0261; fax (610) 666-1906.

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      Books from ASSE

      You can order these titles and more from the American Society of Safety Engineers Bookstore on ISHN's Web site. Visit —

      Among the books you'll find:

      • "Refresher Guide for the Safety Fundamentals Exam"
      • "The Participation Factor," by Dr. E. Scott Geller
      • "Safety Training That Delivers"
      • "Building a Better Safety and Health Committee"
      • "Safety Management - A Human Approach," and "Techniques of Safety Management - A Systems Approach," both by Dan Petersen.


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        WE NEED YOU!

        Are you a safety and health pro or a manufacturer or provider of occupational safety and health products or services who enjoys writing?

        Shakespeare need not apply, but ISHN is looking for authors to publish short articles (1,000 words) in our monthly issues.

        Topics include: safety success stories, close calls and personal experiences, training tips, use of software, engineering controls (machine guards, lockout-tagout), gas detection and air monitoring, confined space safety, personal protective equipment, and OSHA compliance issues.

        If any of these topics interest you — or if you have other ideas — e-mail editor Dave Johnson at

        We will also consider articles you’ve already written but not submitted to any safety magazine.