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Stepping up on my soap box...  Some people filling the role of safety person need to take a long look in the mirror.  If you do not believe your role in the organization is the most important then how in the hell do you expect anyone else to believe it.  Stop looking to management to prop you up and take charge of the safety movement and be a leader!!  

Many of you may have seen an email that has been circulating for a few years or read a post by Terrence O’Hanlon on the LinkedIn site of the Association of Maintenance Professionals. This is a well thought out follow up to that story and worth a few minutes of your time. We can all learn something here.

Here is the original story -

A toothpaste factory had a problem. They sometimes shipped empty boxes without the tube inside. This was caused by the way the production line was set up, and people with experience in designing production lines will tell you how difficult it is to have everything happen with timings so precise that every single unit coming out of it is perfect 100% of the time. Small variations in the environment (which can’t be controlled in a cost-effective fashion) mean you must have quality assurance checks smartly distributed across the line so customers all the way down to the supermarket don’t get angry and buy another product instead.

Understanding how important that was, the CEO of the toothpaste factory got the top people in the company together and they decided to start a new project in which they would hire an external engineering company to solve their empty boxes problem since their engineering department was already too stretched to take on any extra effort.

The project followed the usual process: budget and project sponsor allocated, RFP and third-parties selected. Six months (and $8 million) later, they had a fantastic solution - on time, on budget, high quality and everyone in the project had a great time. They solved the problem by using high-tech precision scales that would sound a bell and flash lights whenever a toothpaste box would weigh less than it should. The line would stop and someone would have to walk over and yank the defective box out of it, pressing another button when done to restart the line.

A while later, the CEO decides to have a look at the ROI of the project and sees amazing results! No empty boxes ever shipped out of the factory after the scales were put in place. There were very few customer complaints and they were gaining market share. “That’s some money well spent!,” he says, before looking closely at the other statistics in the report.

It turns out the number of defects picked up by the scales was zero after three weeks of production use. It should have been picking up at least a dozen a day, so maybe there was something wrong with the report. He filed a bug against it and after some investigation, the engineers came back saying the report was actually correct. The scales really weren’t picking up any defects because all boxes that got to that point in the conveyor belt were good.

Puzzled, the CEO travels down to the factory and walks up to the part of the line where the precision scales are installed.

A few feet before the scale was an inexpensive desk fan blowing the empty boxes out of the belt and into a bin.

“Oh, that,” says one of the workers, “one of the guys put it there ‘cause he was tired of walking over every time the bell rang.”


Many of us laughed and said, “That’s what’s wrong with industry” and “Those closest to the problem”.

The general consensus was that the CEO was in the wrong and there was no doubt the worker had done the right thing and we need more of those types of solutions. On the face of it, this appears to be true, but what happens if we take a deeper look at this story.

First of all, the worker just ignored a system that the company had paid a lot of money for - that was set up to capture information that would help measure the extent of the problem and maybe, just maybe, prompt further investigation. Or at least it might have, but the worker didn’t know or care to know.

The project took six months - this must have meant people were in and around the area - ample opportunity for the worker to give input. Why didn’t he give it? Why wasn’t he asked for it? (Isn’t that what some consultants do - come into your plant, ask the operator what the problem is and then write a report stating that?)

I’ve worked for Ma and Pa shops and Coca-Cola and I can state categorically that there was never a problem such as this - in consumer packaged goods, the biggest crime is for a faulty product getting to the marketplace as the empty boxes did - when the CEO was the only person who knew about the problem. This type of problem is the biggest stick that CEOs will use to beat those below them. So what happened to the plant manager, quality group, etc.? Did they show up and the worker ignored them too?

Next, an inexpensive fan was installed. Whenever I’ve seen such solutions, they are plain unsafe! The cord runs across the floor, or even worse, is draped about head high onto the machine. Did anyone check if the fan could fall into the conveyor? Did maintenance know they now had another strategic piece of equipment to take care of?

The engineers visited the site to ensure the scales were working correctly. Didn’t they see the fan?

So what at first seemed to be a case of a stupid CEO and a much maligned worker turns into a comedy of errors. Would you want any of those people - CEO, plant manager, quality, engineers, or even line worker - working for your company?

Before you answer that question, did you see the biggest mistake of all? The one most prevalent in North American industry? The one that most often gets missed?

They were all dealing with SYMPTOMS; the actual problem they all needed to address was WHY WERE THE BOXES EMPTY?

No one was upset that what the worker had done was just maintain waste - empty boxes that had been printed, cut and formed ending up in a bin.

There was no mention of the missing toothpaste tubes - waste also?

So many times in accident reports, downtime analysis, etc., we look at the story at the level that Terrence posted it - and never dig deeper - never get to root cause - never eliminate the defect.

So maybe when we next see a story or read an incident report, we won’t take it at face value and instead probe a little deeper.

Later on I posted a “Happy Ending” for this fairy tale - and it goes like this:

So the CEO returned to his desk very happy that at least the empty packages weren’t getting to the customers. He continued to monitor the results, and for a couple of weeks there were still no empty packages causing line stops. However, on the third week, there were 15 instances of alarms, but the CEO believed this might just be a blip.

When the next week revealed another 15 alarms, he decided to visit the shop floor again. When he got to the scales, he noticed the fan was no longer there.

“Hey Bill, what happened to your fan?”

“Don’t talk to me about that fan. Your new safety officer came down here and decided that the fan was unsafe. The cable was on the floor and the fan was held in place with electrical ties. He said until we had a conduit run and a proper mounting for the fan, we couldn’t use it. Knowing how long projects take in this place, that will be a couple of months!”

“Well, you know that safety is #1 Bill, keep up the good work.”

“Oh, one other thing before you go back to your office.”

“What’s that Bill?”

“My name is Bob!”

So the next week, the CEO saw the alarms at a rate of 15 again and took solace in the fact that it wasn’t increasing.

When he saw the following week’s report with no alarms, he was intrigued. Even he knew that the electrical group never did anything that quickly and he was afraid that they had ignored the advice of the safety officer, so he headed back down to the scales.

“Hi Bill, er Bob, I see the fan’s not ready yet, but you didn’t seem to have any empty packages last week, how come?”

“Come with me,” and Bob started off up the line. “I got so fed up with that bloody alarm that I called Joe the mechanic to see if he could do anything. Well he asked me a stupid question, ‘Why are they empty?’ When I told him I didn’t know, he said, ‘Let’s go find out,’ so we did and that’s where we’re headed now.”

Bob and the CEO finally reached the area where the toothpaste tubes were fed into the boxes and the CEO could see two pieces of plastic tie wrapped around the feeding chute.

“When we got here, Joe noticed that every now and then a tube wouldn’t enter the package and so he started to take stuff apart. He seemed happy when he told me the problem was really a simple one yet at the same time one that wouldn’t go away. He said the feeding chain for the boxes stretches as it gets used and that’s normal. The problem is when it stretches to the point of not quite lining up with the chute. The chain still has plenty of life though, so he put those pieces of plastic there so the tube wouldn’t fall over and would find its way into the box!”

The CEO just laughed and shook his head. “I guess that’s what you call getting to the root cause of the problem. Bob, can you talk with Joe and figure out when would be a good evening for me to take you both out to dinner - this is great work. Oh, and don’t forget to cancel the fan project!”

A rather well known "management consultant" back in the 70's and 80's was Forrest H. Kirkpatrick and Mr. Kirkpatrick wrote a poem about leadership that hangs on my wall in my office.  It pretty much sums up what being a safety leader is all about - even though Mr. Kirkpatrick meant for it to be a message to all managers.  Bottom line, it is one thing to "preach" safety and an entirely different approach when one "LIVES SAFETY".  

Safety Professionals MUST LEAD by EXAMPLE in ALL that we do, both at work and at play , but especially at work.  Mr. Kirkpatrick sums it up all to well in these 10 lines:

A rather well known "management consultant" back in the 70's and 80's was Forrest H. Kirkpatrick and Mr. Kirkpatrick wrote a poem about leadership that hangs on my wall in my office.  It pretty much sums up what being a safety leader is all about - even though Mr. Kirkpatrick meant for it to be a message to all managers.  Bottom line, it is one thing to "preach" safety and an entirely different approach when one "LIVES SAFETY".  

Safety Professionals MUST LEAD by EXAMPLE in ALL that we do, both at work and at play , but especially at work.  Mr. Kirkpatrick sums it up all to well in these 10 lines:

The eye’s a better teacher and more willing than the ear;
Fine counsel is confusing, but example’s always clear;
And the best of all the preachers are the ones who live their creeds.
For to see the good in action is what everybody needs.

I can soon learn how to do it if you’ll let me see it done;
I can catch your hands in action, but your tongue too fast may run;
And the lectures you deliver may be wise and true.
But I’d rather get my lesson by watching what you do.

For I may not understand you and the high advice you give.
There’s no misunderstanding how you act and how you live.

Forrest H. Kirkpatrick

One morning in 1888, Alfred Nobel, inventor of dynamite, the man who had spent his life amassing a fortune from the manufacture and sale of weapons, awoke to read his own obituary. The obituary was printed as a result of a simple journalistic error. Alfred’s brother had died, and a French reporter carelessly reported the death of the wrong brother. Any man would be disturbed under the circumstances, but to Alfred the shock was overwhelming because he saw himself as the world saw him—"the dynamite King [the weapon maker]," the great industrialist who had made an immense fortune from explosives.

As Asiana Airlines Flight 214 flew into San Francisco International Airport on Sunday July 7, the Boeing 777's 291 passengers didn't know that the man at the controls had never landed this kind of plane at this airport before.  Does it matter that the pilot at the time - aviation veteran Lee Kang-kuk - has only 43 hours of flying time in the 777?  South Korea's Asiana Airlines says Lee has flown the model nine times.  It's "highly significant," former Department of Transportation Inspector General Mary Schiavo said Monday, particularly, how he came across the water and over the seawall, she said.

If the pilot were going to avert danger, Schiavo said, he needed to take action well before the plane reached that seawall. Lee knew how to fly.  An experienced pilot for Asiana, Lee had more than 10,000 hours in other kinds of aircraft, the airline says. (Source,  This pilot was very experienced generally but was conducting a non-routine activity (landing a plane that he had very little experience with at a location for the first time, even though he landed other types of planes there before).

This is exactly the situation that experienced workers may find themselves in when one or more aspects of a particular job changes and the new risks are not adequately managed.  When the workday is going smoothly, and the work processes and tasks are being completed successfully, the hazards associated with them are somewhat predictable.  However, it is just as important to ask, “What if…?”

  • What if the process breaks down?
  • What if the job suddenly changes?
  • Have all the possible hazards been identified?

It is critical that we think pro-actively and find the hazards BEFORE they become an accident.  Predicting the outcome of all possible scenarios is impossible. However, taking the time to ask “What If…?” questions may uncover hazards that would not be identified during the routine tasks.  

Routine Work is a work activity that takes place on a regular frequency: the employee is always familiar with the job steps, work environment, PPE required, potential hazards and critical actions necessary to work safely. 

Non-Routine Work is a work activity that:

  1. Takes place infrequently: the employee has not performed the work often enough to be completely familiar with the job steps, PPE required, potential hazards or critical actions necessary to work safely.
  2. Takes place outside the employee’s normal work area or in an area to which the employee is not very familiar.
  3. Takes place while job conditions change, for example, an industrial process that includes various metal forming and cutting machines works well when all machines and systems are operating properly.

The hazards associated with the machines, including machine guarding, are fairly predictable.  But, what hazards MAY occur if the machine gets jammed, parts fail, or machine modifications are needed? Regardless of the work classifications described above all workers must ensure that all tasks are assessed and performed safely.

Methods of Controlling Hazards & Risks

A Job Safety Analysis (JSA) is a structured approach to identify and address the potential hazards of a specific job.  A JSA considers all job steps, special PPE required to safely perform each step, the potential hazards of the work and the critical actions necessary to eliminate, reduce and manage hazards to safely do the work.  

JSAs are developed for Non-Routine Work or High Risk Work. JSAs can be used immediately before performing Non-Routine Work or High Risk Work, reviewed routinely to maintain familiarization with job hazards or used as a task training aid for new and refresher training. Field JSAs may be developed on the spot to address Non-Routine Work or High Risk Work where a Formal JSA is not available.  Once the work is completed a Field JSA may be converted to a Formal JSA if it is likely that the same job will take place again.  

A Standard Operating Procedure (SOP) is a written step-by-step procedure for completing a given task, whether low or high risk.  SOPs may include instructions related to operations, maintenance or other types of work. An SOP is used to provide a consistent approach to performing a specific task.
SOPs should be referenced to identify job steps and potential job hazards when developing JSAs.  SOPs can be reviewed immediately before performing the work, reviewed routinely to maintain familiarization with job procedures or used as a task training aid for new and refresher training.

Always Think Incident-Free and Perform Self-Assessment before Task.   Evaluate all tasks before starting work by reviewing and taking action on the:

  • Planning
  • Proper Tools and Equipment
  • Training
  • State of Mind

Hazard Identification

Inspect the work area prior to the start of the work shift or prior to the start of a job assignment. These inspections focus on identifying unsafe conditions in the work area.  Personnel (typically equipment operators) perform inspections of mobile or major stationary equipment using a formal checklist to identify unsafe conditions or functional deficiencies.  Other pre-use inspections should be made on all tools and equipment with a focus on unsafe conditions or functional deficiencies.  

Mental Attitude

For some persons, safety only becomes an important consideration when they are doing a “dangerous” job or task.  They rationalize that safety procedures can be bypassed or ignored when the task is simple, small, routine and seemingly presents little risk of injury.   Unfortunately, this type of thinking is why many routine, and apparently safe tasks or jobs, end up resulting in the most serious of accidents.  

Safe work habits should not be limited to those projects or tasks that are the most difficult or “dangerous”.  

Safe work habits must be part of your everyday work routine.

If safety is not incorporated into every job or task you do, it’s really only a matter of time before an accident occurs.

Think about the job you’re on now and the tasks you and other employees do each day.

Maybe the project is just starting, or nearly finished. Both situations clearly make for less risk than at other times during the project, or do they? Or maybe it’s the size of the project.

The so-called “smaller” projects present less safety risks, or do they?

In both cases, the answer is NO. Safe work practices are required whether your project is just starting, or nearly finished.  Safety is critically important no matter the size of the project. Smaller projects should not encourage you to take safety shortcuts.  Another temptation is many times on smaller projects, often no one, including the supervisor, is around to see you.  It also doesn’t matter that you may have done a particular task a thousand times without incident.  If you’re not doing that task safely, it’s only a matter of time before an accident will occur and your number may be up.  Safety is an attitude – and that attitude should be positive with no exceptions.  

Do the right thing the right way and follow safety rules every day no matter the size or the stage of the project you’re on.

“We cannot hold a torch to light another’s path without brightening our own” Ben Sweetland

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