Tim Ludwig Safety Blog

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Are there Gaps in your Safety System?

It may be time to build some elegant safety processes that look behind the wall and walk the catwalk.   


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.  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.

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 jokedthe 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 “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?

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.  You knew he had great tools… look at the opening he fashioned in this pipe (note the note he left too!).  Further, there are guards and employees in the prison who granted special favors to the scheming inmates (for art), 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.  This can be the existing process that didn’t consider a new vendor’s product specifications.   This can, unfortunately, be the supervisor driven by production bonuses who encourages short cuts (or at least looks the other way). 

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.

Safety processes should be designed (or re-designed) to better consider Latent Hazards; those 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 injury escape.  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 – like when the layers of PPE, extra rules, and cumbersome processes required after identifying a problem actually don’t solve the problem.   Mr. Sweat is currently in a prison cell with concrete 5 inches thick…while someone else is certainly sawing away at a wall behind complacent guards and complicit enablers.


Timothy Ludwig’s website is Safety-Doc.com where you can read more safety culture stories and contribute your own.  Dr. Ludwig consults and serves as a commissioner for Behavioral Safety Accreditation at the non-profit Cambridge Center for Behavioral Studies (CCBS: behavior.org) and teaches behavioral psychology at Appalachian State University, in Boone, NC.  If you want Tim to share his stories at your next safety event you can contact him at TimLudwig@Safety-Doc.com.


Labeling is Easy: Dig Deeper to Change Behavior

 Folks, dig deeper. The labels are artificial. The labels are an illusion.  There’s always a reason for the behavior that we get.   We can all overcome our Labels!

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It’s quite easy to give ourselves a label, isn’t it?  We look at our behavior, and we look at how it affects others, and we give ourselves a label.  I live up in the mountains of North Carolina and drive back roads all the time.  Last summer I was driving in a city, was looking around at the unfamiliar surroundings, and drove right under the traffic light into an intersection.  Just in case I wasn’t aware of my error, a guy in a big Bronco SUV blasted his horn and pulled beside me staring angrily.  I looked at him and pointed to my head and mouthed “Stupid”.  He seemed to agree and the confrontation was over. I had interpreted my own behavior with a label, “Stupid”, and that simple adjective seemed appropriate.

In fact, labeling is quite popular in modern business where management training often involves some personality test like the MBTI where we learn everyone’s label in hopes of better collaboration.   “I’m an Introvert which explains my discomfort working in big teams.”  “I’m a Judger which explains why I’m so critical.”  Somehow these labels seem to be the magic elixir that make business work better.  But they don’t.  Everyone goes back to the same environment and acts the same way, nothing changes.

Don’t we overuse labels when dealing with the safety of our work crews and managers?  The implication is: if workers can’t follow rules and procedures that are clearly in the manuals and training, and then they get hurt, they’re “Stupid”, “Noncompliant”, or “Lazy” or “___________” (you can fill in the blank – please keep it rated “PG”).  


The problem is that you can’t fix a label.  All the exhortations in the world emphasizing “Don’t BE this” won’t work.  But we do that in our training, in our incident investigation summaries shared with workers, and in our personal conversations.  But nothing changes.  And you get frustrated.  You can’t fix it. You’re left with nothing, except getting more and more upset.

Instead, consider what behavioral science tells us.  Instead of asking a person to BE something, focus on how you can help them DO what is required to be safe.  Don’t pretend your God and try to change someone. Leave that arrogance behind.  Instead, be a servant.  Recognize that EVERYONE wants to be safe and act safe.  It is your job to remove the barriers that put them in the position to, knowingly or unknowingly, take that risk.  When you get away from the label, you’ll be much more likely to see what those barriers are.

My Job as a Labeler

Earlier in my career I worked with a severely mentally disabled individual named Violet.  I was working my way through school learning behavioral science.  Our reach in behavioral science goes far beyond its impact on the safety world making a difference in schools, health care, public policy, sustainability, and with human services such as our work with autistic and mentally disabled individuals. (Get on Behavior.org and learn all these areas that may touch your life and see what we’re trying to do sharing behavioral science.)

I was working with a group of about 15 folks with severe mental disabilities and other challenges, so much so they couldn’t live life on their own.  As such, they were wards of the state.  They lived together in their residence where the professional staff fed them, cleaned them, groomed them and provided what training and social life they could.

They had me come in and create programs to try to shape basic life and social behaviors. They had a psychiatrist who administered medications for the mental disorders experienced by this population. They had a social worker as a director, a new guy named Bob. He was kind of a funny, goofy guy.  But Bob was one of the wisest people I’ve ever met.

Back then we used the label “Mentally Retarded” and Violet fell squarely into that category.  I conducted a special intelligence test on her and her IQ was below 15 (the average IQ is 100).  Her verbal abilities were strikingly limited, typically reduced to sounds resembling simple words.

Violet was also a scary woman. We called her “Violent” because of her volatile behavior.  It came to a point where she slammed her fist through a sheet rock wall.  We knew this incident was coming because she would slap her right arm against her left shoulder when she’d start getting more and more agitated. We knew something had to be done.

So we had a team meeting. We had the psychiatrist there, me as a psychologist, the staff and Bob. The psychiatrist was treating her for hallucinations. The staff said she often hallucinated that there was an evil pony on her left shoulder. She was hitting herself on the shoulder in an attempt to get rid of the pony.  Her left shoulder had deep bruises from the abuse.

For these hallucinations, Violet was on Haldol, a drug given to schizophrenics. It’s a strong tranquilizer. If you take it, believe me, you’ll reduce everything, not just your daydreams.  Violet was on a pretty good dose of it.  In the wake of the incident the psychiatrist was recommending to triple the dose during our team meeting.  That’s a lot of chemicals impacting the brain.   The psychiatrist had labeled her “Schizophrenic”.

For my part of the meeting, I had all these behavioral programs worked out trying to shape behaviors to counter her violent behavior. I had labeled her “Self Injurious”.  We had a long discussion about the precursors to her behavior and the behavioral steps the staff should take to reduce the likelihood of violent behaviors.  The staff had even more suggestions in what I thought was a fruitful team discussion.

Bob was quiet and after listening to all our input he said: “Hold on... Before we do chemical or behavioral interventions, let’s consider physical solutions first”.  He wanted to find out what’s going with Violet as a person... not some label.


Bob took her to get a physical, the first in many years, and found that she had a metal screw in her ankle.  Violet was probably 40 at the time.  Her body was deformed with a humpback and other contortions.  So the big bulge around her ankle must have been considered just another deformity.

In reality, Violet had broken her ankle pretty badly in her youth and surgeons put in this metal screw for healing.  Her caregivers forgot to have it taken out.  Violet wasn’t verbal, she couldn’t tell anybody. In fact, she probably had no idea of it being there.   All she experienced was pain in her left side due to the calcification and swelling around the screw remaining in the ankle. 

Violet was in pain.  She couldn’t understand what was happening, she couldn’t tell anyone about how she felt, and her self-injurious behavior was in reaction to it.  Not because she was “Schizophrenic” or “Angry” or “Violent”…. all labels. It was because she was in pain and she couldn’t tell us.

Bob sent Violet to surgery where the screw was removed and the calcium deposits shaved away.  She then spent a couple months in physical therapy.   

When Violet came back she was a different woman.  She no longer was hitting the left side of her body.  She no longer fit the label “Self-Injurious”.  She wasn’t in pain anymore.  Soon thereafter, Violet went off the Haldol completely.  She no longer fit the label “Schizophrenic”.  

Much to my amazement Violet started using words!  My previous intelligence test assigned her a clinical label of “Severely Mentally Retarded.”  Now, with the pain gone, she started using the words she had always been capable of.  Moreover, she started grooming herself and interacting with other residents and staff persons.  I did a new intelligence test and her IQ (a measure that is supposed to stay stable over your lifetime) jumped more than 15 points with this seemingly new verbal and self-management behavior.  

All those skills were always there, we had failed to remove the barriers to her performance.

Bob (the-Wise) wasn’t done yet.  He found out that Violet had cataracts. She couldn’t see.  After cataract surgery she came back smiling, an interactive, shall I say “affectionate” person.   I left the job soon thereafter but I still remember my last day vividly.  Violet, yes “Violent,” came up and hugged me.  She used a full sentence with my name at the end, something that I thought she was too “Retarded” to do.   It was evident that even my new IQ Label was inaccurate and too low.  I was in tears.

I was there to help her. I was being paid to help here. I’d been trained to help her. I had a PhD. The doctor had an MD. The social worker, Bob, didn’t.  Who among the “Smart” people was the one that really viewed Violet as a person, not a label?  It was the person who was with her every day. The person who said, we’re not going to label.  Instead, we’re going to look at her world and understand why she exhibits this behavior.

Labeling is Counterproductive

The lesson learned here for us is that labeling is counterproductive for our safe work environments.  Instead, we need to be wise like Bob and understand what is going on in our workers’ world and do something about that… instead of trying to do something about them. We then change the environment, and by changing the environment, we change behavior.  


Do workers need different, more available tools to work safe?  Better, more behavioral training?  Procedures that lessen fatigue?  Supervision that doesn’t encourage short cuts?  Etcetera… Etcetera…. It’s your job, “Bob,” to do the analysis to find the environmental causes of the behaviors so your workers don’t have to find themselves in a position to take those risks any longer. We don’t need to label.

Folks, dig deeper. Labels are artificial. Labels are an illusion.  There’s always a reason for the behavior that we get.   We can all overcome our labels!

A Celebration is in Order!   

When I was teaching the junior youth Sunday School class at my church I had in my class a young lady who was born with Downs Syndrome.  An IQ test would have labeled her as mentally disabled because of this.  Miranda was also one of the sweetest kids I got to interact with but I knew she had a limited future, probably performing at a 6th grade level the rest of her life.

About 5 years ago I got word that my University was extending its disability services to include mental disabilities including mental retardation.   Most Universities require professors to make accommodations for students with disabilities in much the same way as they provide ramps and the like for students and staff with physical disabilities.  Typically, I have students with learning disabilities like dyslexia or attention deficits (ADD) who get extra time on exams and other accommodations so they can perform up to their intellectual abilities less encumbered by their disability.

But I was skeptical about allowing mentally retarded individuals into the University system because their intellectual capabilities would not allow for the learning to take place to begin with.  We would be setting them up to fail to live up to the academic standards of our courses regardless of any accommodations we provide.

In two weeks Miranda will graduate from Appalachian State University.

I’ll be at Miranda’s graduation, in my learned doctoral robes, once again humbled by the potential of human performance.

 Timothy Ludwig’s website is Safety-Doc.com where you can read more safety culture stories and contribute your own.  Dr. Ludwig serves as a commissioner for Behavioral Safety Accreditation at the non-profit Cambridge Center for Behavioral Studies (CCBS: behavior.org) and teaches behavioral psychology at Appalachian State University, in Boone, NC.  If you want Tim to share his stories at your next safety event you can contact him at TimLudwig@Safety-Doc.com


Satwant Singh

Tim thanks for sharing. I am very touched by Violets story. We expect employees to follow and toe the line and when they are unable to, we blame them and start labeling (as you pointed out). As safety professionals we need ensure our systems of work are sound and it can help and guide employees do what is required and at the same time remain safe. We cannot change the person but we can change the conditions in which they work.

Its Not My Car


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I get asked to visit companies and diagnose why their behavioral safety program has “lost steam” or never got off the ground to begin with.  Inevitably, I find the whole program is run by the safety department and few anointed safety enthusiasts who do the observations or supervisors, who have observations cards to complete on top of mounds of other paperwork. Employee involvement is nonexistent.   This may seem the most reliable way to do behavioral safety, but it’s creating an undesirable effect inside of the operation. 

I got a story for you that will make this point. 

I was in a rush.  My flight was an hour late arriving in Chicago and I had a 40-minute drive to get to a safety speech I was giving that was an hour away. And, I still had to pick up my rental car - so I was stressing as I got off the huge rental car company shuttle bus.  With rental papers in hand I found the car on the lot, put on my safety belt and headed for the exit. 

This was no easy task.  The massive labyrinth of a parking lot was segmented with roads and I had to trust that the “exit à” signs would get me out to civilization.  After a number of turns I finally drove up to a “T” intersection. The exit booth was to the right of me and beyond that was freedom.  I eased into the right lane to yield and turn right.  But I had to stop because one of those huge airport shuttle buses (scientific name TryceraBus) covered with the rental car company’s logo had the right of way as it passed ahead of me toward the exit.

While I was waiting for this TryceraBus to pass, another identical  TryceraBus drove right up beside me… and I mean right beside my driver’s window.  I literally could have rolled down the window and pat the axel of the 4’ diameter wheel of this thing.  It was unnerving.  I remember thinking to myself “I hope he sees me… he does this all the time”.

The first bus passed and the way was now open to proceed. I was taking my foot off of the brake when I heard the low belching of the bus next to me.  Out of the side of my eye I notice TryceraBus’ big wheel turn toward me and start turning.  The tire began crushing into the car I was in! It first destroyed the side mirror in an impressive explosion of glass.  The tire’s next destination was the body of the car, which started crushing just as easily.

I honked and waved my arms at the oblivious driver who I could see through the glass door panels.  He looked at me with wide eyes and stopped in time to prevent further damage.

Now… do you think I was pissed off?


No, It was not my car!

Startled, yes; a bit shaken, yes; but I wasn’t in any real danger.


The fact is that it was their car,

in their parking lot,

being crushed by their bus. 

To be honest with you… I thought it was kinda cool.  How many times do you get to sit in a car being slowly crushed?  I then looked at the despondent driver and thought “this is going to suck for you” and finally smiled at the realization that I may get an upgrade to a luxury rental for the inconvenience (I did!).


When employees are not active participants in the safety program, involved in its design, ongoing implementation, and evaluation in some way, well, frankly… it’s not their car.  When an employee gets hurt or disciplined you often hear employees say:

It was THEIR car equipment,

Involving THEIR parking lot process,

being managed by THEIR bus people. 

No “WE” in sight.

So when a management-led safety program starts to derail, through lack of budget, disappearing leadership support, or just plain complacency, employees may think its kinda cool (yes, the same people the program was designed to help!).  Rumors fly, observation cards get sabotaged (see the Anatomy of Pencil Whipping blog post) and become a platform for personal gripes, jokes and ribbing will be heard… “told ya so”… “flavor of the month.”  In the end, employees (supervisors and leaders too) may actually enjoy seeing it get crushed.

Back to the rental car lot… what if I was in my car and a bus started crushing the side of MY car? Would I be pissed!  Darn toot’n I would be.

I often think about what I would have done if I were in my own car that day on the rental car lot and a bus pulled up that close to me.  I imagine that instead of simply assuming that the driver of the bus had seen me, I would have perhaps honked and tried to get his attention.  We do that kind of action to protect the things we value.

It’s the same with safety programs and its based on a straightforward psychological principle that Gordon Allport (1937) talked about 70 years ago; what Deci and Ryan (1985) famously called “Self Determination” in the social psychology literature.  It’s a concept that Scott Geller (2002) wrote about in his epic book, The Participation Factor, and a concept I’ve researched for two decades and discussed in my own book (Ludwig & Geller, 2000). Modern Management Psychology research cites data on “Engagement” that has been shown to correlate highly with safety outcomes (Harter, Schmidt, & Hayes, 2002; Ludwig & Frazier, 2012). 

Sun Tzu talked about the same principle in his epic book, Art of War, written over 2000 years ago.  In it, he tells his readers the way to defeat your enemy most effectively is not by force of arms -  instead, it is through inviting them to take part in your conquests.  They will not destroy what they helped build (see The Rule Mill blog posting)

Consider the pride of ownership an employee-owned safety program.  First, lets note something important.  This does not mean turning over your entire safety programming over to employees.  There is always a need for professional safety competencies and management coordination.  I own my car but I didn’t engineer it (I’m not that smart), I didn’t build it (I’m not that resourceful) and I don’t repair it (I’m not that skilled).  But I did pick the make and model along with the color and accessories, I maintain it, and I choose how to use it.

Employees don’t have to engineer, build, and keep track of your safety systems.  They just need to do things like name it, develop the content (e.g., the behaviors that go on observation cards), customize the process so it make sense “on the ground”, review the data for risks and share the trends, and suggest interventions to reduce risk and hazards.

Employees are right people to involve in this way because they know firsthand where hazards exist, where at-risk behaviors occur, and where attitudes affect safe work practices. 

Case in point: Marathon Petroleum Company LP, Michigan Refining Division, invited a colleague and I to their Detroit site to understand why they have one of the best-in-practice behavioral safety programs according to the Cambridge Center for Behavioral Studies (you can read about them at www.behavior.org).  We were met at the gate by Radwan Dagher, an hourly employee.  Once there we interviewed members of their Circle of Safety (COS) team… all employees.  We saw how they managed their program, how they led a large number of contractor safety representatives, how they used their data to shape training, and how they interacted with site leadership to direct attention and resources.  It was there I saw true ownership.

This was a Teamsters Union workforce.  While some unions advise against Behavioral Safety to their members, this outpost of the Teamsters were not only advocates, they were OWNING it. 

It was their car and if anything threatens it they get pissed.  The evidence was there. When anything threatened the program or the safety of the workforce (like new construction that brought hundreds of contractors on-site) the COS teamed with management to bring to bear resources and hundreds of hours of effort to protect and succeed together.  It was their car so they proactively made it work, they worked with leaders to grow it, and they waxed it up real well because they were proud.

Just like a fine Detroit-made Mustang!

Timothy Ludwig’s website is Safety-Doc.com where you can read more safety culture stories and contribute your own.  Dr. Ludwig is a partner in Praxis2 and serves as a commissioner for Behavioral Safety Accreditation at the non-profit Cambridge Center for Behavioral Studies (CCBS: behavior.org) and teaches behavioral psychology at Appalachian State University, in Boone, NC.  If you want Tim to share his stories at your next safety event you can contact him at TimLudwig@Safety-Doc.com.



References cited:

Allport, G. W. (1937). The functional autonomy of motives. American Journal of Psychology, 50, 141–156.

Deci, E. L., & Ryan, R.M. (1985). Intrinsic motivation and self determination in human behavior. New York, NY: Plenum.

Geller, E. S. (2002). The participation factor: How to increase involvement in occupational safety. Des Plaines, IL: American Society of Safety Engineers.

Ludwig, T.D., & Geller, E.S. (2000). Intervening to Improve the Safety of Delivery Drivers: A Systematic Behavioral Approach.  Monograph.  Journal of Organizational Behavior Management, 19, 1-124.

Ludwig, T.D., & Frazier, C.B. (2012).  Employee Engagement and Organizational Behavior Management.  Journal of Organizational Behavior Management, 32 (1), 75-82.

Harter, J. K., Schmidt, F. L., & Hayes, T. L. (2002). Business-unit level relationship between employee satisfaction, employee engagement, and business outcomes: A meta-analysis. Journal of Applied Psychology, 87, 268–279.


Frank Fox

Absolutely loved the analogies, and it was pure reality. Yes we will need safety professionals, but the behavior I always dreamed of was the employees having the passion to own and grow safety. Who better to take care of a house but the owners, certainly not a baby sitter or renters. 
I think the union owning safety was excellent, because many of them do have a great deal of pride. Some unions are broken, but there are still some good examples. 
Many times I have seen the "it's not my car" attitude from hourly and salary. They grow weary of being hammered in audits, and asking people to do more than what they are used to. They don't like participating in safety meetings, they could have finished that hunting story or fishing story in the break room. It's a victory to many if safety folks get egg on their face. They must trust and respect you, or it will always be an uphill battle, all the way. 

Of all of the links we get asked to read, this was worth my time. Thanks, encore, encore.


Jonathan Tavill

I enjoyed reading this article enormously and the analogy pretty accurate. I have been in the same position watching my own car slowly being bent and buckled by a HGV while sat inside (although honking was the last thing on my mind I have to say;-) ). Ownership is the greatest and most important hurdle (also for environmental awareness). With ownership it is possible to evoke culture change.


Paul Shapiro

Definitely very intetesting. I too have seen the train wreck coming a few times and it is not fun. Mine worked because I did have good relations with my field folks, it was upper management that was way out of touch and set unrealistic goals across broad spectrums. It was impossible to meet the goals within the desired time frame without significant expense which is where the wheels started to come off. Great article, it would be nice to see more like it.


stanley babila

You must make it your car if your striving for excellence



Hi Tim totally agree -to get the car started you need a driver, a route , and an idea of the mechanics or know where to get it fixed -sadly some companies today will give you the car and say get on with it and there is lots to do -its about people , place , process and management leadership and culture -that need to be changed my strap line is GOING FORWARD -else the blame culture kicks in which is like the wrong fuel best John


Steve Delp

It's been my experience that the Safety Department is often times most resistant to an employee driven/owned safety process. Probably because they can't envision a role for themselves in this sort of environment - even though a most productive and rewarding role awaits them. Either that or they are happy with the Fireman/Superman role they now play.


Douglas Dennis

BBS when implemented is like a shiny new diamond everyone wants one! Once the newness has worn and the shine turns into a light twinkle the interest in BBS goes to the way side. This is why you make BBS a nugget that everyone wants and you feed your employees at a slow rate to keep interest up and that want in the forefront.


Kenneth Rogus

Tim - Love your story.....I hope you don't mind if I share it with co-workers. Here is a shared experience for you to build on your story. When I work with others (or I'm in the interview mode for hiring) it's always interesting to ask that person to drive me to the site or lunch or back to the office. You can find-out a lot by OBSERVING how people keep their vehicle. Interesting side bar - you probably keep & treat your rental car (your habits) the same way you treat your own personal vehicle. These habits transfer to company machinery, equipment, and instrumentation owned by the company.Thanks for sharing a great story.


Martin Hippsley

Tim I would go further if management is not driving the thing forward at the outset it won't start, No matter what you do to change a workers mind or attitude to health and safety and the risks within his work and or workplace. 
It cant be changed until management show they are in agreement with and actually want the change most workers work they way they do because that is how management have told them or implied that the way they want it done, 
to get meaningful change management have to show they (a) want this change and (b) fully support it, at the end of the day it may not be the managements car but it is their ball and its a case of play our way or don't play, this means the onus is or should be on the management to play the safe way


John C Brown

Exceptionally well done bringing real life to the classroom. All of us can relate and find inspiration in your style. Crisp, Clear and Real. Kudos!


Erik Ingersoll

Well written Tim! As a safety professional who actually works in the car rental industry, I found your conclusions to be spot on and your analogies seemed a little more like "reality" to me! I've shared your link with some of my industry peers and leadership and I'm keeping my fingers crossed that your accident did NOT happen at one of our brands. Again, well done.


Dean Lailey MSO

Buy in has always been key, how to achieve it has always been elusive. There is no simple answer because everyone is different. The safety guy or gal has to connect - be supremely patient and find not only the key individual but the key to THAT individual which is different in every case ( and lots of keys are needed) in my humble opinion


Lisa Milne

This is very good. In coming from a background where I created and implemented a safety program/s from the ground up I often found some of my best results came from starting from the bottom up rather than the top down. When you get collective understanding and employees asking for nothing less from their Management teams, it really makes it hard for managers to say no.


Dennis Hoaglin

The site leader has to be enthusiastic about the program and lead by sharing his enthusiasm. The three killers of behavior based safety: 1) Withdrawal of leader support; 2) Disciplinary actions arising from behavioral observations; and 3) Perception on the shop floor that nothing of value comes from observations. We have to keep asking observers to dig deeper to find value in their observations. Don't walk away until you feel that you've been helpful either by finding something to fix, a way to make safe choices more convenient or simply reinforcing safe behaviors with sincere praise. The perception of value is paramount and, as you point out, Tim, you'll never get it if owner ship of the program is vested solely in the safety department.


Alan Langstone

Great article Tim.

Many of the answers to our problems, not just safety, lay with the job experts (the employees), the skills we need are the ones to extract the information and the knowledge to know how to guide them into using it.

Below Zero Injuries

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Good, better, best. Never let it rest. Until your good is better and your better is best.” 

raised-hands volunteer

Your annual injury rate is a static number.  It can define your safety program performance but injury rates can seem random.  It’s frustrating working so hard to reduce that rate only to have it bounce around arbitrarily. 

That Zero Harm goal on all the posters may seem insurmountable. A more fruitful path is to get to the numbers behind the number… a path to get you below zero.  Let’s learn how some companies achieve Below Zero…

Best-in-practice Behavioral Safety Programs

One of the cool things I get to do is work with the Cambridge Center for Behavioral Studies (CCBS).  CCBS is a not-for-profit organization whose mission it is to reduce human suffering through the application of behavioral science.  Applications of behavioral science have impact on people (and animals) through work in autism and human services, in schools and prisons, attacking violence and encouraging volunteering, and, of course, increasing safe behaviors in the workplace.  Check us out (behavior.org).

CCBS accredits the best-in-practice behavioral safety programs around the world.  This means these behavioral safety programs use the principles of behavior science associated with significant reduction in injuries.   Currently we have 23 accredited programs empirically showing behavioral safety can indeed reduce injuries significantly.  Better yet, we all get to learn from these programs.

It’s cool to visit these programs, meet amazing people, and learn what makes them great.  It’s a beautiful thing to review data where injury rates are near zero and have been for many years.  See for yourself - check out the injury recordable data from Eastman Chemicals Acetate Fiber Division (AFD) and Marathon Petroleum Company Illinois Refining Division (IRD) below.  Feel free to go to behavior.org and check out other companies whose applications show their data and describe their behavioral safety programs in detail.

Eastman Chemical AFD

Marathon Petroleum IRD

Most of these companies experienced the two S-Curves. The first drop in injuries was achieved grabbing the low-hanging fruit by implementing sound safety management systems like processes and rules, guarding and LOTO, discipline and reward programs, training, safety meetings and the like.   They then experienced a “plateau” and needed to involve their employees to start the next S-Curve.  They studied, learned, and ultimately adopted behavioral safety.  The second S-Curve got them substantially below industry standards and near zero.

Good, better, best. Never let it rest. Until your good is better and your better is best.” 

I learned this poem in grade school.  The author is unknown but many literary folks think it stems from the 1800’s.  It seems to be the motto of the folks at these accredited sites. They are always looking for further improvement to get closer to zero. 

Yet statistically, the closer you get to zero the harder it gets. 

It’s like asking your friend to stretch a rubber band in front of you.  Pretend the stretched rubber band is your industry’s average for injuries.  You work hard to pull that injury rate down.  Much like grabbing the middle of that rubber band and pulling… easy at first but then it gets increasingly harder.  What does that rubber band want to do?  Bounce back up. 

Consider all the forces trying to increase injuries: aging equipment, aging workforces and new workers, cost cutting and production pressures, new leadership, etc The further you pull toward zero injuries the more pressure you’ll feel trying to force that number back up. 

So staying near zero is an achievement by itself.  But its not very satisfying or reassuring.  Lets discuss how to get Below Zero – even if you’re not near zero, this may be a path to consider.

Reporting – Measuring Communication

I’ve suggested in previous blogs that a good definition for “safety culture” is people talking to one another.  Communication is the key to a positive safety culture: Peers giving feedback about risk to peers, supervisors sharing safety tips with their team, managers looking at data and asking questions.  The more everyone talks about safety the better.

One type of communication that is critical to reducing injuries is when employees communicate where hazards are, what risks are being taken, and when they have a close call or minor injuries.

Reporting is a behavior we can promote among our employees. Reporting helps us discover where injuries lurk. Reporting allows us to intervene proactively to make the workplace safer before injuries happen.  Reporting is a measure of communication and a really good one. 

Every CCBS accredited site measures reporting.  It’s easy to see the relationship between increases in reporting and decreases in injuries.

Marathon Petroleum’s Illinois Refining Division’s reporting increased in the number of behavioral safety observations turned in by their staff and contractor workforce.

Eastman Chemical’s Acetate Fiber Division’s reporting increased two ways.  The number of at-risk behaviors reported by their workforce in their behavioral safety program increased as did their near-miss reports in the same time period.

Flip it

To better understand the relationship between reporting and injuries, let’s take these same graphs and turn the reporting data upside down so that increases in reporting instead trend downward from zero.

Notice that injuries tend to decrease as if pulled down by reporting.  But this time instead of your hand struggling to pull down the rubber band you’ve got all those employees pulling it down together.

Injuries cannot go below zero and its rare and improbable to achieve zero injuries.  But you can achieve Below Zero with a strong reporting culture helping you fight the forces trying to increase your injury rate.  More reporting allows you to proactively mitigate hazards and risks catching these forces in the act…before they injure.  Its as if all of your employees are helping you hold that rubber band down!

Look to your improvement in reporting as your beacon of success (or area for improvement).  Your focus should be on increasing reporting and getting more sophisticated on how you use reporting to create a safer workplace.

Here is how you get BELOW ZERO

Costain, Ltd., a large CCBS accredited construction company in England has a sustained reduction in injury rate over the past 14 years corresponding to various manifestations of successful behavioral safety programs.  They have many innovations in behavioral safety that we could talk about.   However, their Reporting system and scorecard are exceptional.


Costain’s reporting system is a simple card designed to be easily used on construction sites and can be easily customized for each project, business segment or joint venture.  Typically supervisors write cards for employees.  These cards offer the opportunity to report hazards, behavioral risks, and close class on an anonymous, no-name/no blame basis.

What makes their system work is that reporting turns into actions. Reporting data is reviewed and analyzed, using ABC Analysis, for environmental and behavioral causes.  Then interventions are designed to make the workplace safer.  But they don’t stop there… they make sure the employees know their reporting resulted in these actions.  For example, some of their projects have adopted a “You Said, We Did” program where Costain managers take reports, act on them, and then advertise improvements back to the workforce citing the original observation.  Most reports are responded to even if they cannot be acted upon immediately.

This is a critical component.  If reporting results in nothing then reporting dies out (we call this “extinction”).  When reporting results in overt actions for a safer workforce then reporting will increase (we call this “reinforcement”).

Costain has a corporate scorecard containing many categories of important types of reporting such as high-potential near misses, close calls, hazards identified, safety observations that are tracked in time series across business segments and individual projects for trends.

They create an overall ratio based on the “Safety Triangle”. Numerical goals are set based on the theory that incidents should be a low percentage of close calls, which should be a low percentage of hazards, which is a still lower percentage of behavioral observations.  Goals specific to each project man-hours are set based on these percentages.   The ratios are defined so that any ratio over 100 is meeting the goal.  On one spreadsheet you can tell which projects of this large complex organization need improvement and which ones are “Below Zero”.  Costain’s “Engagement” ratio is to be put on the top-level executives’ corporate dashboard as one of their 7 key performance indicators.  How about that?? A leading indicator of safety performance has become a corporate KPI.

As a result Costain’s reporting has risen 75% in the past three years to over 30,000 close call/hazard reporting & observations in 2014.

Would you like to hold down that rubber band by yourself or have 30,000 others helping?

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Timothy Ludwig’s website is Safety-Doc.com where you can read more safety culture stories and contribute your own.  Dr. Ludwig is a partner in Praxis2 and serves as a commissioner for Behavioral Safety Accreditation at the non-profit Cambridge Center for Behavioral Studies (CCBS: behavior.org) and teaches behavioral psychology at Appalachian State University, in Boone, NC.  If you want Tim to share his stories at your next safety event you can contact him at TimLudwig@Safety-Doc.com.



Greg Gottschalk

Electrical Engineering Manager

There's a good general solution at work here. There are stable statistical relationships between levels of mishap. For every fatality, there are many serious injuries. For every serious injury, there are many minor injuries. For every minor injury, there are many mishaps which did not result in injury and for every minor mishap, there are many risky behaviors. Shrinking the base of the pyramid can be the most powerful way to eliminate the top. But how can you shrink the behaviors at the base it if you don't know about them?
Increasing the rate of hazard reporting is a powerful tool because it makes every employee a safety inspector. The base of the pyramid is never allowed to grow. Incentive and recognition programs that reinforce safe behaviors can also be coopted to drive hazard reporting.
In general, a similar approach could be used to mitigate non-safety-related undesirable outcomes. If you can find precursors to those outcomes and the circumstances that generate the precursors then getting people to report those circumstances can help put an end to those outcomes.
On a related note, Goldratt's Theory of Constraints offers a number of cause-effect mapping tools that may be useful in connecting the dots between circumstances, precursors and outcomes. Bill Dettmer’s “The Logical Thinking Process: A Systems Approach to Complex Problem Solving” is a useful guide to some of these tools.
The process could also be reversed to drive desirable outcomes.


Tom Reeves 

Tim, I've seen very similar patterns with Injury / Illness rates. As near-miss reporting and/or observation participation percentage goes up, injury rates tend to go down. Safety is a focus intensive activity and an organization must manage any distractions that may take focus off of executing safety. Voluntary participation can be a great leading indicator and we found that when our organization experienced a disruption, such as a major schedule change or an economic dip or increase, voluntary participation would dip -- maybe 5-10 percentage points. Based on that drop, we'd move as a leadership team to re-establish focus.


Joseph Mathew

It sounds good, a factual approach to real incidents and its reporting make things realistic.

Randy Creek

Senior Consultant, Environmental, Health and Safety at Chualar-Creek and Associates, LLC

Good subject. This is one of those dilemmas that is hard to explain.......how can you have less that "zero" incident rate. If you are at this point you are experiencing a few things worth noting; - employees are definitely seeing the results of the program, - management is seeing improved employee satisfaction in the workplace, - realization that numbers going down is always a good thing for goal achievement which is a good indicator for management. These points can be measured. 

If your processes have been showing below zero incidents for the current period of goals, you may want to discuss this with the management team. Could be a good idea to take a step back and take a serious look at the work community. Is there anything going on that could be driving the numbers "underground"? Example, if third party satisfaction surveys and audits are positive, then you may want to redefine your measurement parameters to include a strategy for "Near misses or Close Calls" 

Make sure that you are doing whatever it takes to be proactive. Can be very difficult to explain to employees and management why the trend is now going the wrong way and what is being done to address the issue. 

Is your root cause analysis approach as good as it can be? All of you are doing formal benchmarking. If not I suggest you get on board. Your root cause analysis process could be totally ineffective. Benchmark with the best companies in your business to see what they are using then investigate the posibiity of makin a change or getting re-training for effectiveness. 

I am not a sales-person but I can tell you that more and more businesses worldwide are using a product called Tap Root which, from my point of view, is the most effective root cause analysis tool available. 

Feel free to contact me if you have questions, but continue to be focused and diligent with the "below zero" results.

Nicchia Schutt-Toleman

Incident Investigation Lead

I always believe that what worries the workers should scare the heck out of management. This is a great example of a reporting system where everyone is listening. Communication and paying attention to the workforce is the most important step towards a healthy safety culture.

Luke Sullivan

Safety, Environment, Risk & Sustainability

Very interesting article. I'm pleased there is some honest discussion about how you can make your stats work for you in a more practical way. The challenge will always be the human condition – that which makes us self-aware sentient beings, introspective, searching for meaning to our lives and propelling our analysis of the existential...and the capacity to be complete idiots. We have been hardwired for random acts of stupidity. People get it wrong, make mistakes - that's what makes us human. Zero harm is a myth, but making people believe it's possible defines our profession.


Safety Management Consultant at James Loud Consulting


Nice post but I do wish we wouldn't define our profession based on a myth and instead help define it as a management priority similar to other importasnt organizational priorities. Safety is much more than a worker behavior issue and our focus on the zero myth has a number of well documented negative (unintended) consequences.


Top Contributor

Thanks for the discussion. I agree with the notion of Zero Harm being a myth. It is statistically improbable for more than a short period of time. And measuring toward that goal can be demotivating. Instead, lets choose other numbers that can consistently improve as well as make a difference.

Complacency shouldn’t be your Exit Strategy

Taken as a whole it seems like complacency is pervasive – the #1 cause of injury.

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Yeah, I guess I got complacent”. Jack had been working the extruder for years now but this time he failed to recognize a common hazard when he was clearing a blockage.  He got lucky injuring only the sleeves of his shirt as the blades regained their motion.  When asked Jack, and many others who experience a near miss, use “complacency” as an explanation for their action. Likewise, frustrated managers blame employees for being complacent.  Taken as a whole it seems like complacency is pervasive – the #1 cause of injury.

Common wisdom suggests complacency is built up over time working a process over and over.  As the worker comes in contact with the hazards of the job frequently a process called “Habituation” may take over. 

                                HABIT (your Habits take over) UATION (the Situation)

This means that you go on Autopilot and your ability to notice changes in the hazard, or perhaps your own behavior, fades.

Just like we habituate to loud noises over time to the point we barely notice them.  We can come habituated to the hazards around us and barely notice them as well.  When this happens our behavior drifts toward risk – because the hazards are not as salient to us.  Since we notice them less, these hazards no longer influence us to take extra precautions for safety. 

In fact, we probably don’t see the hazards as hazardous any more.  With the completion of World Trade 1 recently I’m reminded of how fascinated I always was with pictures of workers finishing the Empire State Building.  What would have you and I “puckered in our pants” because of the extreme heights of the construction instead seems to be experienced by these 1930’s workers as commonplace.  No doubt they habituated to that environment above the NYC skyline.

Yet habituation is a very normal animal conditioning (humans are animals by-the-way).  In fact, it is a useful biological tool that frees up our brains instead of being overwhelmed by stimuli.  We do it all the time.  We do it automatically.  There is nothing wrong with it.

Yet, we blame those, including ourselves, who habituate to hazards; that become complacent in their tasks.  In fact, we often accept “complacency” as a root cause in our incident investigations or descriptions of risk in our behavioral safety processes. 

Unfortunately, the term “complacency” does not lead us to a solution to reduce the risks taken.  Often the complacent individual is told to “pay more attention.” But we are exhorting them to go against human nature…to stop being an animal.  And they can’t.  Complacency shouldn’t be an exit strategy… the end of your analysis.

So lets consider another approach to complacency from a behavioral science perspective. 

Acquisition – Behavior seeks out reinforcement

Remember when you first learned a complex task, perhaps one that put you in the presence of hazards and you needed to follow a process pretty closely to avoid risk and do the task correctly?  You were not very good and hopefully you had someone coaching you as you practiced and shaped up your skill.

This beginning phase when you acquired the skill was full of variance.  You varied the way you did the task in big and small ways until you eventually started doing it the same way every time.  You got better because you reduced your variance.  You got safer because you reduced your variance. 

This process of shaping occurs because you got reinforced for the correct actions.

Perhaps you had a coach who first corrected you and then said “yep, you got it” when you did it right.  Maybe you initially struggled using a tool but when you used it correctly it made things easier.  Or you finally got the harness to fit better so it wasn’t as cumbersome. 

There are a number of reinforcers that shaped your behavior.  The process probably made you feel safer around the scary hazards so you did them more.  Regardless, you systematically started doing things right, you got reinforced along the way. You mastered it and did the task the same way every time.

At this point you were doing the task safely and probably doing a high quality job helping your production.  This is the fluency zone… where you want to be, where you want everyone to be.


Extinction – Behavior stops being reinforced and seeks out new reinforcers.

So how do we lose that fluency and get complacent?  Our fluency gets extinguished, slowly burnt out by a lack of reinforcement. 

Complacency is a lack of reinforcement. 

When a set of behaviors are no longer reinforced they go seeking reinforcement just like they did when you acquired the skill. 

It is now that you start seeing small variations in the way you the task is done.  You begin to glance away from your work, allow for a bit more slack in the line, pencil whip the checklist a bit, not do that extra inspection, any one of a plethora of varying actions in search of reinforcement.

And behaviors find reinforcement, often resulting in undesirable results.   Perhaps its that small bit of social interaction, escape from bordom, a quicker procedure, one that’s more confortable or convenient.  Behaviors will find the reinforcers and then the new variance sticks.   It starts small at first but then gets bigger and bigger… unbeknownst, sometimes, to the performer. 

One only needs to look into the research surrounding Normalization of Deviance to see this phenomenon in action.

The process of acquisition, fluency, extinction is kind of like going down a funnel.  You begin with a wide range of behaviors that get funneled down, through reinforcement and practice, to a narrow range.  If these fluent practices are no longer reinforced then you exit the funnel.  Although initially well directed, you hit your target but then, bounce a bit off the target.  You begin to go a bit off target again and again.  If the behavioral variants are reinforced then that becomes your norm.

Now pair extinction, which causes more variance, with habituation.  What do you get? 

     More risk

               happening in the midst of hazards

                         that no longer feel so hazardous.

                                                                                 Bad news.

SO… how do you fight complacency?

If complacency is a lack of reinforcement… then Reinforce more. 

This is what your behavioral programs are designed to do.  Prioritize your high hazard/high potential loss tasks.  Create checklists to guide observations in those areas.  Do observations (peer, self, or supervisory) and reinforce safe acts thereby locking them in place a little longer.  You’ll also find opportunities to discuss the drift you see and reintroduce the funnel.

We are in a constant fight against complacency.  Fortunately we have a very strong tool in reinforcement.

Extinction = to exit reinforcement’s influence.                                                                                                     Don’t let complacency be your exit strategy. 


Timothy Ludwig’s website is Safety-Doc.com where you can read more safety culture stories and contribute your own.  Dr. Ludwig is a partner in Praxis2 and serves as a commissioner for Behavioral Safety Accreditation at the non-profit Cambridge Center for Behavioral Studies (CCBS: behavior.org) and teaches behavioral psychology at Appalachian State University, in Boone, NC.  If you want Tim to share his stories at your next safety event you can contact him at TimLudwig@Safety-Doc.com.


Excellent article.

When I was working (now retired) we started to measure our safety and health performance using the Luck Factor, which was a take-off of Dan Petersen’s. We started encouraging and rewarding near miss (Complacent) incident reporting. We started to get a real feel for what was happening. We then began really analyzing every near miss as if the worst had happened. We assigned number 1-5 for what might have happened. We then created a multiplying factor % for the probability of the worst case actually happening. Multiplying the two numbers gave us the real safety and health performance of our facilities. That number became the Luck Factor and the real way to judge our S&H performance as opposed to incident and severity rates.

Our incidents were then analyzed according to the luck factor when previously they were analyzed based on actual severity. This really opened everyone’s eyes. No longer were plants celebrating only because they had on lost time injuries. They were celebrating a luck factor less than three (by our definition a 3 would be first aid required).

We had to work really hard to keep “Management” out of the process. When they saw that we weren’t really as good as the OSHA recordables showed, they first response was punitive. Because I was a successful Plant GM with an outstanding S&H record, I was asked to change the Corporate Safety and Health Culture. Because of my past performance record I was able to convince them that discipline would destroy the program. Only deliberate unsafe acts were subject to discipline and that involved neutral analysis. There was a lot more involved, but I think you get the picture.

Ultimately, when our CEO started referring to the Luck Factor, we knew we had made the culture change from top to bottom that everyone agreed was a game changer in our S&H program.

Great pertinent information and direct, real world feedback to the front line workers goes a long way toward ending Complacency.

Dan Lambert


Good, powerful article on how to fight habituation...just look at the president's security guards!


Jim Corns

Safety Consultant at Havtech

Tim I think you are spot on. I have been in a safety position for may years and when things become routine some one is going to get hurt. I have preached cross training for years and still feel if I could rotate personal accidents would be reduced. Again, I like your article.


Trish McBee

EHS Coordinator at D-J Enginering Inc.

Thanks for the article. I think I can learn from this.


Joseph Reilly

Director of Health and Safety at Specialized Industrial Services

Thank you Tim. Very insightful post and helpful in understanding the human behavior that leads to complacency as well as the way to avoid falling into that trap. 

I really gained additional insight from your double funnel diagram. Great post!


Carleton Emerson

Site Safety Manager, Webcor Builders

Well written article! I think safety programs that lacks acknowledgment for the workforce is missing a key component. In my years of experience it doesn't take much to keep people focused on their tasks and avoid becoming complacent. A shirt, a lunch, a tool, etc. Something that tells the workforce your work is not going unnoticed. Another way to help with complacency is rotating people off the same task. In construction that is a lot easier to do than manufacturing, but teaching people new skills, and keeping their work day interesting will help keep them engaged in their work.


Gerry Colverson

Independant health and safety consultant

a good article and the use of reinforcement is definitely the key for this problem. There have been some interesting studies on positive reinforcement as a tool to reinforce wanted behaviours. It is far better to praise the individual who is getting it right than tear a strip of the one who is getting it wrong. 
Unfortunately, this is a technique not used that often by supervisors who see any aberrant behaviour as a threat to their authority and focus on stopping that rather than looking for correct practices and praising them.


Tony Ferguson


We are our brothers keeper in that we all look after the safety of each other. We adopted this approach when we became aware that complacency was setting in following a long period without suffering any injuries. It works for us!


Mark Wootton MA MInstLM

SNCO of 71 Sqn Royal Electrical Mechanical Engineers at UK Ministry of Defence

Excellent article and a reminder to always go back to first principles especially if training others!


Azal Mohammed, PE, CSP

Process Safety Management | HSE Senior Consultant | Leadership, Knowledge, Change Management

This is a well written and thought-provoking article. The act of increasing reinforcement to sustain performance needs to include varying the frequency/type of reinforcement otherwise normalization of deviance can till creep back in.


Gerry Colverson

Independant health and safety consultant

I have read your blog and agree with the points you are making. You highlight two areas that I feel are generally not covered as well as they could be in the training given for would be safety advisers. The first is an understanding of data, its uses and misuses, and how widening the data collected can give valuable insights into the overall level of safety compliance and culture. People often fail to understand what they are measuring and what that data is telling them, either coming to conclusions that reinforce existing prejudices or hoarding the data as if it was a source of power not to be shared. 
The other area is that of managing people. Western industrial management practice is to focus on the product and the profit margins, almost to the exclusion of all else. This style of management is all about control of people and their behaviours by the use of detailed rules and penalties for failure to follow those rules. The history of management practices and the evolution of those practices is an interesting study and H&S people are also within the system and are influenced by the current management styles. 
Managing people requires the ability to understand what makes people behave as they do and demands a wide range of motivational skills as people are prone to variations in behaviour and can make mistakes. 
Thanks for the insights in your article.


Ron Richardson

Client Account Manager - Health and Safety Training

Complacency is human nature, just as we drive home from work everyday and never really think about, we just do it. Using complacency as an excuse is never acceptable, this is why it's so important to have continuous safety training to reinforce the proper actions and procedures on an ongoing basis, so we make sure everyone goes home at the end of the workday


Michael Burns CHST

Construction & Pipeline Safety Specialist

I'm still trying to absorb the whole article in my tiny brain, but it gave me many things to consider! Is it fair to say that if we see complacency creeping back in, we are not doing the things necessary or frequently enough to reinforce behavior? Do you have any suggestions on how to improve reinforcement or different variations that might help? I am now a subscriber!


Henrik Tived

Health and Safety Coordinator

Nice article, however if your conclusion on an incident investigation is "Complacency", then you need to ask yourself Why?

Why was the worker complacent?

Complacency is another silent killer in our workplaces


Michael Podgorny JP

Senior Consultant

We hear and see during many investigations the term "complacency" being used either orally or written in reports. It is a difficult and often subjective term to define and accurately diagnose. Because something does not go the way we would expect it or a person or object does not react and respond in a manner consistent with our interpretation...are they complacent?


John C. Budd, MBA

T&D Project Construction Manager

Thanks for the excellent read on human performance. A great reminder that all behavior is reinforced.


Dean Lailey MSO

Safety & Compliance Coordinator at Endurance Technologies Inc

Put another way......Incremental Justification- and throw in some Risk Homeostasis and look out!


Riaan Richards

Senior SHE Specialist at Anglo American Platinum

My view on complacency and why it is so difficult to manage is due to all the variables impacting on this. The moment you systemise it, then it becomes the new norm causing complacency to creep in. I think this requires a person with a "good feel" for what is happening on the operation and good analytical abilities to identify the slightest of trend from all the monitoring and measuring initiatives to identify complacency and respond accordingly. I also belief there are no one solution to managing this and it is changing constantly as an example seasonal, time of year etc


Hao Zhang

Project HSE manager

Habituation and complacency. 
When people stay in a work environment for long time, he will get used to everything around, which include hazard. If an office-based employee go to construction site occasionally, he will point out a lot unsafe findings; while site-based employee may just think it is overreacting. Frontline workers play with hazards all the time, their "threshold" for risk is quite high. There is always different opinion about probability from different background when we do risk assessment. So alarming bell like cross inspection, external audit, different viewpoint is very important as well as a "keep-away" stance. 
"He who fights with monsters should look to it that he himself does not become a monster... when you gaze long into the abyss the abyss also gazes into you..." -- Friedrich Nietzsche


Rajarshi Ghosh

Unit Safety Manager- INDIA at Mott MacDonald

The hazards and the near misses are pointers,fact making us more aware of unsafe acts and conditions as a precursor to an accident. I do agree that complacency is one of the topmost causes of accidents and this needs to be managed quite effectively. However, complacency is something which could be quite relative as to how we percieve risks in general. Sometimes we need to make a choice. e.g. I cycle to office regularly manouvering through the city traffic which could be seen as a bad choice in terms of safety, but at the same contributing towards carbon footprint reduction in some way.So, as far as reasonably practicable in managing risks makes it more wide ranging in terms of both probability and severity!! However, fundamentally we must appreciate and encourage hazard spotting and Near miss reporting, because it goes without saying that it is good way to learn, or rather unlearn to get out of the complacent mode.

Labor Day Musing

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It was three years ago today that I started the Safety-Doc.com blog on Labor Day.  I felt it appropriate to celebrate the unparalleled contribution laborers have made to this country, our communities and families.

So to all of you who grow your company, community, and country through your labor;  to all of you who did it in the past and have taken up the mantel of protector/safety pro; and for all of you who support our laborers -- SALUTE!

My original post three years ago… 

"In my first safety blog I’m going to reflect on Labor Day.  This Labor Day I watched Rising: Rebuilding Ground Zero about the group of workers racing to complete the September 11 Memorial by the 10-year anniversary of 9/11 (this weekend).  I’m reminded how our laborers have built (and rebuilt) our nation.  Throughout the show the featured workers repeatedly were quoted “we have to get this done in time, no alternatives.”  Indeed, the six-hour workweeks were reminiscent of the 24-hour work to fix the Pentagon after 9/11.  Beyond the focus on the victim’s families, my biggest concern was about the safety of the workers whose self-pressure could put them in harm’s way.  Shot of large iron-works and plumbing reinforced that concern.  Until I saw a shot of an ironworker breaking a forgotten weld; he was surrounded by a group of his fellow laborers coaching him on the safe execution of the hazardous situation.  It was then I celebrated Labor Day."

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The Feedback Sandwich should be a Pizza

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We’ve all heard about the “feedback sandwich” where it’s recommended that critical feedback should be sandwiched by positive feedback on both sides.  This practice has us starting with positive feedback followed by the constructive yet critical feedback that you really wanted to address in the first place.  Then the interaction is ended with another dose of positive feedback.  The notion is that we protect the ego of the receiver by making them feel good at the beginning of the conversation, then, after we have to bring them down, we build them back up at the end. 

I’ve always felt that this method was a bit contrived, transparent, and confusing putting the receiver at risk for mental whiplash and leaving them wondering what the whole point was. 

Regardless, those of us who study and teach behavioral science often are asked the best way to give feedback.  It's a good question because one of the most powerful behavioral tools is feedback.  It is also one of the most studied techniques in behavioral science as we apply it to organizations. 

Feedback is one of those unique tools that serves as both a consequence and an antecedent to behavior.  As a consequence, feedback occurs after the behavior and can reinforce and shape behavior.  As an antecedent, feedback helps direct changes in the quality or quantity of subsequent behavior because performance can be compared to a goal, standard, or prior performance.  The resulting “gap” may guide changes in behavior that are then reinforced by subsequent feedback and so forth.  In clearer terms, feedback tells you how you did and gives you the means to try and do better next time.

Feedback works, its cheap, and people are curious how it can be best applied for maximum benefit.  My own research has shown the efficacy of feedback alone, with goals of different sorts, within competition, delivered in teams or individually, given publicly or privately, or delivered normatively allowing you to compare your performance with others. 

Behavioral Safety has feedback at its heart. 

The recently retired Anne French (safety trainer extraordinare over a 20 year career with Safety Performance Solutions) used to say

            “It ain’t an observation without communication.” 

She was right, the data gathered through observations in behavioral safety don’t motivate.  It is the feedback that peers provide peers directly after the observation that has the biggest impact on behavior.  In that conversation, and it is a conversation not a lecture, the observer works through the observation card noting at-risk and safe behaviors and the co-workers discuss the work and safe alternatives.

So is there a sequence to best deliver person-to-person feedback?

Amy Henley, a student of Dr. Florence DiGennaro Reed at the Department of Applied Behavioral Science at the University of Kansas was curious.  Amy warns me to be tentative about her study because more research is needed to confirm what she found.  However, I thought our readers would like a sneak peek.

Amy and Dr. DiGennaro Reed gave participants feedback using the “feedback sandwich” of Positive, Critical, Positive (PCP) on some occasions.  On other occasions they manipulated the sequence using Critical, Positive, Positive (CPP) or Positive, Positive, Critical (PPC) feedback sequences. 

Guess which one provided the highest rate of performance?

I’ll call it “The Feedback Pizza”.  Sessions when participants got the critical feedback first, followed by positive feedback were associated with the highest level of performance. 

The Pizza beat the Sandwich! And both beat the Pie that started with positive feedback and ended with criticism (PPC).  Further, when participants were asked which type of feedback they liked the best they preferred the Pizza over the Sandwich!

So don’t beat around the bush… get to the point of your corrective feedback first.  Afterward, acknowledge the desirable behaviors being executed with positive feedback…because they are indeed abundant and need reinforcement.


Be a Pizza Deliverer  ; )





Timothy Ludwig’s website is Safety-Doc.com where you can read more safety culture stories and contribute your own.  Dr. Ludwig is a partner in Praxis2 and serves as a commissioner for Behavioral Safety Accreditation at the non-profit Cambridge Center for Behavioral Studies (CCBS: behavior.org) and teaches behavioral psychology at Appalachian State University, in Boone, NC.  If you want Tim to share his stories at your next safety event you can contact him at TimLudwig@Safety-Doc.com.



While reading your safety blog “The Feedback Sandwich should be a Pizza” it reminded me of my father giving me a spanking for misbehaving.

He would spend me to my room and before spanking me ask if I agreed that I misbehaved. After the spanking, he would leave the room and I would be left holding my rear end. However, after a few minutes he would return and tell me he finds it hard to understand why I did (want ever it was I did) because of all the good, I have done over the past few days and he would mention them.

By the time he left, I would have forgotten the spanking and just want to prove I am the good son he expected.

Keep the blogs coming? 


Vincent Smith


For the last 15 years or so my mantra has been to avoid mixed signals.  Give the feedback (positive or negative) respectfully, but directly.  My line of thinking has always been that consequences are a form of reinforcement.  Reinforcement that works best from my perspective seems to be direct and unambiguous.  

From an evolutionary standpoint of fitness (not necessarily from a social standpoint) it seems that direct consequences are the easiest to understand and have the most profound effect.  I.e., you eat that plant and get violently sick… you don’t eat that plant anymore.   You eat this critter and it tastes great, so you spend a lot of effort domesticating it and now you eat it all the time (moo).

Anyway, I really enjoyed this entry and found the research coming out of Kansas to be very interesting.

Thanks for sharing it.

Chris Goular

Pull the Domino and Build your Safety Culture

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My Mom’s family in Texas were big dominoes fans.  When I visited as a lad, Grandpa would come from the day at the ranch, grab a beer, and play dominoes with Grandma and Mom and Dad.  I remember his big hands holding all seven dominoes in one hand as they played “Texas 42”.

As kids, my brothers and I would take the dominoes and make up our own games. All kids with porcelain tiles probably shared these same games.  The first was the cascading tumble of dominoes lined up optimally an inch apart.  We would try to line up as many as possible in as many interesting patterns as we could.  But we never got as extravagant as this example

Heinrich asserted nearly 75 years ago, ““88% of worker injuries are due to the worker’s unsafe act”.   He proposed a Safety Domino Theory that suggested the worker’s ancestry and social upbringing (first domino) led to being at fault (second) which led to an unsafe act (third) which led to accident (forth) and injuries (the last domino to fall). Heinrich was an insurance investigator. He certainly didn’t understand behavior, which he blamed for injuries. 

Assumptions that the worker is to blame for an injury has led to incident investigations that list “Human Factor” or “Worker Error” to be a “root cause” of an incident.  We know this leads to bad problem solving and further injuries (See “Don’t Turn out the Lights by Playing the Blame Game”). 

This “blame the worker” message kills cultures.  Somehow Heinrich’s stat has been attributed to behavior-based safety programs (United Auto Workers). If you know behavioral science you’d know that we follow the works of B.F. Skinner; not Heinrich.  Behavioral science always looks at environmental influences on behavior and never blames the worker.  

Brad Gardner, an amazing safety speaker, tells his poignant story that led to the loss of his arm by a turning auger at a potato factory.  He admits that he left the auger running to better clean the gook that had built up in a casing.  He knew the danger but he timed his reach into the auger to avoid the slow moving blade.  He was distracted momentarily and his arm was gone.  Human Factor?  Human Error?  It was easy for even Brad to blame himself. 

But blaming the injured does not solve the problem nor does it help us avoid risk and injury in the future.  Instead, we see human behavior not as the cause of injuries; we see at-risk behavior as a result of other factors. 

A Different Domino Theory

Instead, lets consider a different Cascading Dominoes Theory to describe the real cause and effect relationship between behaviors and injuries.

See, there are other dominoes, cascading well before the behavior, setting the context for the worker, either knowingly or unknowingly, to be in the position to take the risk.  Then physics and chemistry sometimes take over and the injury occurs.

In behavioral science we recognize that your system is perfectly designed to get the results you earned.   In other words, your system is perfectly designed for the worker to take the risk.  When we fail to set up the right environment we leave the dominoes ready to fall.

What are the other dominoes?  Many are obvious when we look at hazards related to equipment and facilities.  Badly designed facilities, aging equipment, missing or broken tools create the environment that will interact with behaviors to build the setting for an injury.  Those that manage the physical environment have left a domino in place. 

But is it possible to mitigate all the hazards at a worksite?  Efforts to engineer guards, protective equipment, and barriers take a big bite out of injury rates, however, constantly changing people, processes, tools and equipment conspire with their aging counterparts to keep hazard mitigation a moving target.  In Brad’s case, the auger was designed to self-clean but the plumbing leading to the auger had busted.   This plumbing wasn’t budgeted to be fixed until the next fiscal year.  The domino remained in place.

Indeed, management decisions, especially decisions made without considering the safety implications, can fail to remove the dominoes or worse, put new dominoes in place.   Well-documented manager decisions favoring production over safety stand out when major disasters such as the Deepwater Horizon and Big Branch Mine are investigated.  However, we must realize that managers are humans too and act under the same behavioral principles as their workers do.

Brad had been asked the clean the auger because the normal person wasn’t at work that day.  He had been told to “be safe.”  All the dominoes remained ready to fall because he had not been fully trained or instructed on the safe cleaning of the auger.

To promote safe work, managers attempt to pull dominoes by putting systems in place targeting worker behavior.  These systems include training in all its forms, discipline procedures, rewards & recognition schemes, and different ways of communicating including management delivery of instructions and expectations as well as front-line reporting and suggestion systems. 

How do we help target the dominoes that need to be pulled?  Some safety culture surveys designed to measure employee perceptions of management systems can help.  One such survey that my lab helped validate asks employees and managers where potential dominoes remain because of limitations in their safety management systems.  We found that the survey targets key systems such as work pressure, incident reporting, communication, training, discipline, and rewards and recognition.  The survey could also target where behavioral programs may benefit manager and/or employee behaviors to enhance interpersonal support for safety.  Survey results then help managers know where their efforts are most needed to do their part in pulling the dominoes.  If you need to get really bored you can read the full article here or contact me for a copy.

It starts with the Culture

When I am speaking to employees about these cascading dominoes I sometimes get some animated workers start complaining how safety incidents are mostly management’s fault because they have “failed” to provide safe equipment and facilities, or push production and budget over safety, or rely on the workers to do all on the job training with folks to green to know better, or blame the workers through their discipline program, or…or…or…typically pointing at an imaginary manager named “they”.


I learned in elementary school that when you point a finger at someone you think is at fault, you have three pointing back at yourself. 

The very first domino at the beginning of the chain… the one, if pulled, could protect the worker even if the rest of the dominoes are perfectly set up for failure… that very first domino is the Safety Culture cultivated by the workers.

In the midst of all the hazards, in the midst of faulty tools or equipment, in the midst of untrained tasks… there are your fellow workers.  Fellow workers know where the hazards are.  Fellow workers know the risks being taken.  Fellow workers are aware of the changes being made around them.  Fellow workers are more likely to have influence to change behavior.  Fellow workers care.  Fellow workers are most likely to also benefit from safe behaviors.

If the culture has been built around actively caring, where fellow workers recognize risk and are willing and able to coach their peers to avoid risk, then we can pull the first domino out.  In Brad’s case the equipment, staffing, and even supervision put him in a position to take the risk he did.  What if there had been fellow workers aware of the hazardous tasks going on around them and if one of them would have checked up on Brad, telling him about the risks he was taking, instructing him in the safe alternatives, lending additional hands, helping him problem solve to reduce the hazard, or being willing to help him stop the job and speak to management?  What if that first domino was pulled?  Brad would still have his arm.

Considering the physics of cascading dominoes where a 5mm high domino can eventually topple the empire state building in a 29 domino string, we begin to see how even the smallest behavior could start (or stop) the cascade that could avert catastrophe … a lesson for those of us trying to impact process safety.

One of the things we kids did with dominoes when the adults were not playing “42” was to stack the dominoes and build fortresses.  The idea was to build a fortress strong enough to withstand the impact of a sliding domino slung at the structure by your opponent.

Perhaps that’s what a safety culture does.  It pulls the dominoes out of the cascading lineup and builds a stronger culture, one domino at a time.  The pulled dominoes now stacked as a united front representing trust and determination to withstand hazards.

Check out Union Pacific Railroads “Pull the Domino” program.  UP’s Houston Service Unit’s Total Safety Culture (TSC) team adopted a program where TSC members hand dominoes to anybody, employee, manager, or contractor to thank them for “working safe, giving a helping hand, or stopping a line.” 

"When one domino falls, they all fall," said John Hughes, TSC coordinator. "'Pulling the domino' refers to stopping that cycle; it means that we vow to remove any 'pieces' before they cause a problem."



Timothy Ludwig’s website is Safety-Doc.com where you can read more safety culture stories and contribute your own.  Dr. Ludwig is a senior consultant with Safety Performance Solutions (SPS: safetyperformance.com), serves as a commissioner for Behavioral Safety Accreditation at the non-profit Cambridge Center for Behavioral Studies (CCBS: behavior.org) and teaches behavioral psychology at Appalachian State University, in Boone, NC.  If you want Tim to share his stories at your next safety event you can contact him at TimLudwig@Safety-Doc.com.




We had Brad Gardner in Texas last year for our BNSF Railway meeting for Roadway Equipment. He and his wife did Great and we got our Safety Hardhat sticker from there speech.



Jed Harting



As usual I enjoy your articles and would like to make the following statement about injuries: We attempt changing a safety culture without taking social culture into consideration and it is impossible to change a behaviour or a culture without considering the culture within a community or country. This is what I am talking about in my concurrent session at the conference. An example of what I say is the following – in Zambia one of the effects of poverty is lack of sanitation and means of waste disposal – on site housekeeping and the washing of hands forms part of our safety systems as this may cause injury through tripping hazards or becoming ill when not washing hands before consuming food etc. We have an expectation (correctly so) that people are not able to meet because even though we provide these facilities we LACK TEACHING PEOPLE HOW TO CREATE THIS WHEN THEY HAVE NOTHING. They do not have ANY facilities when they go home, they literally just dump everything where they want to. Should we not rather focus on quipping these people to create or develop some form of system that they can apply at their homes as well rather than expecting them  to comply to ours.  There are significant cultural differences that we do not take into consideration when establishing a safety culture within a country in Africa.


Connie Engelbrecht

Safety is NOT a Verb… but it should be


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It may seem ironic that a guy (me) who speaks and writes for a living hated English classes as a lad.  My English grades would attest that I didn’t like English and it didn’t like me.  What I remember disliking the most was the task of outlining a sentence structure.  We had to take a sentence and place arrows to note the nouns and verbs and participles and adjectives and conjunctions and adverbs and other autocracies of school teachers trying to insert cognitive worms whose purpose was to root out a young kid’s freedom to split infinitives and worse, end a sentence with a pronoun!

I guess at one point I found words and sentences to be useful enough to begin to try to use them to communicate what was inside my head.  After all, what good is it being opinionated if you keep it to yourself?  And, to be honest, it took an old English major named Scott Geller to pound my sloppy, run-on sentences into a semblance of proper shape. 

With more experience traveling around in the real world seeing safety programs in action (or inaction) I realized that words matter.  They not only communicate but they can shape the very approach you take to your safety programming.  They can get you stuck or they can liberate your safety culture.

Consider the term “Safety” which is a chameleon of a word.  The word used in so many different ways.

“Safety” is most often a NOUN when we decree Safety first”.  This may seem like a great slogan that would inspire the workforce to think through the safety implications of their actions.  However, the great slogan may also just be a feel-good sign with no real benefit.  

W. Edwards Deming, the late influential quality guru, called these “exhortations”.  Exhortations Deming told us, give us the illusion that these outcomes are achievable and if employees simply tried harder, they would do better. This offends the worker - it does not inspire the worker.  Dr. Deming is quoted as saying:  "You can beat horses, they run faster for a while. Goals are like hay somebody ties in front of a horse’s snout. The horse is smart enough to discover no matter whether he canters or gallops, trots or walks or stands still, he can't catch up with the hay. Might as well stand still. Why argue about it? It will not happen except by change of the system. That's management's job, not the people's." As time passes the messages become washed out. Without real change no worker seriously pays attention.

“Safety” can also be a PROPER NOUN which is used to denote a particular person, place, or thing:  “Let’s call in Safety to take care of this.”  As a safety professional you should hate this use of the word because it creates the assumption that safety is a role that is done by one person or department (see Safety is Not your Job).  It’s too easy for individuals, work teams, supervisors, professionals, managers, and leaders to see safety as someone else’s job. They will wait for “safety” to come along to inspect, train, and authorize work.  This is not the type of proactive safety culture you are trying to build. Performing your job safely, making decisions that impact safety, and looking out for the safety of others is everyone’s job. 

“Safety” can be an ADJECTIVE that is used to describe a particular quality of another word.  Adjectives label.  Consider the sentence: “You are an unsafe employee”.  First of all, how can someone be un-something?  A un-person is dead.  Secondly, when you use adjectives you are labeling the subject of your sentence: “You are unsafe.”  We may as well say, “You are stupid.  Well friends, you can’t fix stupid (see Don’t Turn out the Lights by Playing the Blame Game).  When you use a label your under the illusion that you’ve arrived at a root cause of a problem.  But all you’ve done is exonerate yourself of the responsibility of finding the real risk and change real behaviors.  Your safety programs languish and safety culture becomes driven by labels.

“Safety” can be an ADVERB where it modifies verbs by indicating a place, time, circumstance, degree, cause, or manner such as in “I’m going to have to write you up for not climbing that ladder safely.”  Here safety is an outcome; Safety is the lack of injury. This use of the word “Safety” drives our measures and motivations to be outcome-based.  Traditional outcome-based measures are a rate of injuries over labor hours, severity indexes, or other rates reported upwards and outwards.  These lagging indicators are a mixed bag, its good to have a KPI that can be related to ROI to capture the CEO’s attention (FYI).  But lagging indicators do not show you where risks are being taken, only where they had been taken.  You can’t manage safety through lagging indicators… if you do you’ll be laying awake at night waiting for that phone call.


“OK guys, let’s be safe in everything we do today”.  The use of “safe” in this sentence is a SUBJECT COMPLEMENT ADJECTIVE.  It may sound good but be safe is not a call to action; it's a call for inaction.  Think about it, the best way to be safe is not to act at all, not to come into contact with hazards, and not work.  But in the work world we act.  And our actions are badly needed to create a safe outcome.  We need to engage the guards, wear PPE, read instructions, talk to others; we need to act.

In none of these grammatical uses is our word “Safety” actually doing anything.  For action we need it to be a verb.

“Safety” is not a verb. 

Instead, safety depends on behaviors and behaviors contain real action verbs.  Action verbs make them operational; when someone operates they are doing something.  That’s why in behavioral science we call behaviors “Operants.”

So consider the following sentence structure when instructing someone how to operate:

            • Do What?                 (Action Verb)

            • To What?                 (Subject)

            • When?                     (Context)

            • To Achieve What?   (Purpose)

For example:

Lock out and tag …

            the equipment energy source …

                        after your task briefing …

                   to remove the risk of energy being turned on while workers                                                     .                                                   are engaging the equipment.”


This sentence has all the components.  It gives you a clear operation.  It tells you the context where the operation should be done. And it suggests the consequence of the action.  In behavioral science we call this a Discriminant Stimulus because it helps the operator discriminate the course of action.  When presented correctly, your safety directions can be discriminant stimuli that exert control over behavior in predictable ways.   Otherwise, they can be ineffective exhortations.

So build a disciplined approach to using words to create action.  Use this sentence structure when you train, write instructions, give prompts, provide feedback and when you record behaviors in incident reports, JSA’s, and in BBS trend graphs. 

Don’t take short cuts… communicate the action.


Timothy Ludwig’s website is Safety-Doc.com where you can read more safety culture stories and contribute your own.  Dr. Ludwig serves as a commissioner for Behavioral Safety Accreditation at the non-profit Cambridge Center for Behavioral Studies (CCBS: behavior.org) and teaches behavioral psychology at Appalachian State University, in Boone, NC.  If you want Tim to share his stories at your next safety event you can contact him at TimLudwig@Safety-Doc.com.



Hi Tim,
Good point, clear communication is vital.
May I offer a few ideas, not necessarily new or mine.
1.Safety is a necessary investment not a cost. Labels impact on decisions.
2.Some appear to think constant re-labelling is development. I believe it is active non-standardisation and causes a reduction in standards.
3.Ensuring safety is the assigned task of all managers, isn’t it?
4.Ask if in your company/corporation a safety representative attends board level meetings? If not do they really put employee safety first?
FYI In aviation the ‘Definitions’ page is essential reading in any manual/publication.

Hi Tim - I applaud your raising this as an issue. Language frames thought, thought frames action. I'm not sure I agree with some aspects of your analysis, however I totally agree that this is an important discussion.

"Safety" is used as a noun ("in the interests of safety"), a proper noun as you say ("let's call in Safety") or as a noun adjunct (a noun that describes another noun e.g. "the patient safety movement"). But it is not an adjective (the related word is "safe") or an adverb ("safely").

You make an interesting point that there is no cognate verb directly stemming from safety or safe for "making safe" or "being safe". The closest would be "to safeguard" which has connotations of avoidance of harm and/or protection from attack. Certainly this is part of the familiar traditional view of "safe" and "safety" - however Hollnagel and others are taking the "safety" concept further, in wishing to encompass reliability concepts as well ("when things go right as well when things don't go wrong").

By Stavros

This is an interesting piece, mainly because the author (from Safety-Doc.com) fails to implement the approach he is advocating, which is encapsulated in the closing tagline:  “Don’t take short cuts… communicate the action.”  Here the author’s intended “action” is to motivate/inform people to achieve a particular (safety) outcome.  He implies that this is simply a matter of choosing the right words, without looking at the other elements of the action.  The examples cited show that it is not so simple.

In reality, the action consists of (at least):

·         Define what the objective is (what outcome is desired)

·         Determine what needs to happen for the objective to be met

·         Determine what will motivate someone to take the right actions to make those things happen (taking into account not just the desired outcome, but the complexities of human behavior)

·         Identify the best means of communicating the message that will create this motivation

·         Design and deliver the message

The tagline “words matter” applies only to the last of these elements (or perhaps the last two).  If the others are not handled properly, then the choice of words will not matter – a poor outcome will still result.

Using the example described, if it is decided that a safety outcome can be achieved by pressuring, denigrating or humiliating someone, then this can be accomplished in a variety of ways (for example, speech, facial expressions or gestures).  If, instead, the approach of describing and providing instruction on an action is chosen, it might be possible to implement this approach using gestures, pictures, video, speech or physical demonstration.  Choosing which approach to use doesn’t have anything to do with selecting words; it is a more fundamental (and non-verbal) step in the process.

Therefore, in my opinion the author has taken a “shortcut” by implying that one can achieve desired outcomes simply by choosing the right words.  This is akin to saying “cranes matter” to describe how to construct large buildings.  Yes, cranes matter, but they are not the only important element, and, in fact, some quite large edifices have been built without the use of cranes.  The right tools will fail if they are not used to implement a plan that is suited to the objective.

In any kind of communication, if the idea to be communicated is not clear and organized (or is just plain wrong), the most well-constructed message will not yield the desired effect.  I review and edit many technical documents for colleagues, and find that some can be easily touched up despite grammatical errors, awkward phrasing and other problems, because the underlying idea is being presented in a straightforward and organized way.  Other documents, with better-constructed sentences, may be much more difficult to deal with because of poor logic or organization.  In my own work, if I find myself struggling to find the right words, it is usually because I really have not thought through clearly what I wish to say, and the solution is to go back and refine the idea, not to simply seek a better mechanism for communicating the idea as it exists.

Indeed, words matter, but they matter as one part of a complex system – they are not the system itself.




I fully agree with Roger's assessment although I didn't intend the shortcut he describes.  Roger is correct in pointing out that we too often just focus on the antecedent (i.e., the "message") and short cut the motivational components of the change effort.

By suggesting the verbal components in the blog (i.e., Action Verb, Subject, Context, Purpose) I was hoping to create the context for users to analyze the three-term contingency (i.e, Antecedent, Behavior, Consequence) which are the motivational components of a behavioral system.  The consideration of that full system should suggest intervention past the simple "message delivery".

Research shows that consequence-based interventions are the strongest (e.g., performance feedback, checklists) and they are made even stronger when paired with adequate Task Clarification containing the components of the verbal messaging I describe. 

What Roger offers in addition is a link to the greater performance system by asking us to describe the objective desired and how the behaviors/actions link to that outcome.  Indeed there is an emerging set of research describing how we analyze the Behavioral Systems to include how the behaviors impact performance in ways that are important to the task, process, and ultimately, the organization.

I applaud Roger (and you) for recognizing this.  You've given me fodder for a future blog.



Thank you for forwarding Roger’s very thoughtful comments on Tim’s blog.   Roger is very astute to describe that words are part of a larger system (of contingencies) that function to alter the behavior of the listener (reader) in some actual context.   Much research shows that how we describe an event (like describing work routines in SWI’s)  can affect the way people respond to those descriptions.  A functional account of language supports his interest in designing effective communication of genuine solutions to readers who might be quite different from the author(s) of those communications. 

He is right, of course, that the solution being communicated has to be right (functional) for the situation.  To convey that optimal solution to others (e.g., the audience for standard work instructions) entails consideration of the complexities of each individual’s motivation. Roger is spot-on to highlight that.  Once the correct solution is determined, crafting messages (words, images, illustrations, etc.) to frame the communication to the intended audience is quite challenging.  There are analytic approaches to help make sense of that.

Attached are a two interesting papers that describe research into this.  These are a bit technical but convey some of the complexity of a functional account of language. Please pass these on to Roger and his team if you see fit. 

One paper (metaphors_reasoning) shows that altering just one word in a description of a problem alters the solution generated by readers.  I find it very interesting that changing one word can reframe a problem to lead to dramatically different approaches to a solution.

The second paper (RFT_IO psychology) describes rule-governed behavior and a framework for analyzing it. The meat of this paper starts on page 62 – see their analysis of why people might follow rules (or not).

Behavior science offers some very useful methodologies to inform how we frame communications with consideration of the complexity of human’s response to words.  The true test of the effectiveness of communications (verbal or non-verbal) is to observe their effect on the listener’s behavior. 

Mark Alavosius

Blow your own Horn


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One of my clients in South Africa (ZA)  instituted a People Based Safety (PBS) program about 4 years back.  As you recall this was the time the Football (soccer) World Cup was hosted by ZA in 2010.  The Vuvuzela, a plastic horn that produces a loud bellowing sound, is a common noise-making tool for football spectators in ZA and the intensity of its use in the 2010 World Cup was impossible to miss.  There were estimates that Vuvuzela use exceeded 120 dB during matches.

In one of the mine construction locations in the east of the country the PBS team were looking for ways to increase observations.  Obviously the World Cup was on everyone's mind in this football-loving country.  So the employees on the PBS team decided to use the ubiquitous horn in their campaign. 

Here's how it worked.  At random intervals during the work shift a PBS team member would blow a Vuvuzela whose high bellow you could hear throughout the site.  When the Vuvuzela was sounded, everyone who safely could stopped work and did a behavioral safety observation on themselves or someone close to them.  They were also encouraged to get a drink of fluid and adjust any PPE or guards.  Turning in the observation cards was optional.

In that year, this site had the highest reduction of injuries of any project in the company's history.

I appreciate when safety teams out there find creative ways to increase participation and don't resort to monitory incentives (see the Anatomy of Pencil Whipping and You Get What You Pay For blogs).  So send me your creative ideas and we will post them here!


Hi Tim, I like this introduction of the non routine, the blemish, the mild irritant to keep folks alert...what happened the year after? If people became habituated to the horn how long did it take? Regards John


That's a great example of the real power of behavior based safety to share with business people who may not be familiar with it. Among the key attributes are:
1) It was effective in improving safety.
2) It was low cost and easy to implement.
3) It focused on proactive measures such as proper use of PPE rather than reactive post-accident investigations and countermeasures.
4) The varible interval schedule enabled by the Vuvzela ensured a high steady rate of safe behavior between horn blasts.
5) Social reinforcment from peers was provided at no recurring cost.                       

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