Its time to point to the elephant in the room and acknowledge Pencil Whipping within Behavior Based Safety. Pencil Whipping is a euphemism used to describe when workers, supervisors, and, yes, safety managers fill out observation cards, sometimes in great numbers, without actually conducting the observation (much less providing the critical feedback). This white paper will seek to understand and provide solutions for the environment that causes pencil whipping by reviewing research data and case studies for clues into this potentially deadly practice.
Forms, forms, forms
I looked at a supervisor’s office at a major construction site. It was more overloaded than mine (yet much neater). The desk was full of paper, forms upon forms to fill out. These included operational forms, HR forms, quality checks, surveys from upper management, and, of course, a plethora of safety forms.
Job Safety Analysis (JSA) forms to be done every shift, first aid forms, safety audits, injury investigation reports, safety observations like STOP or BBS, safety work orders, safety suggestion forms, process safety checks… I asked the supervisor when he had time to go out into the site. “And give up my desk job?” he replied jokingly.
Employees are increasingly asked to complete forms. Permits, equipment inspections, work orders, and behavioral observations are just a few that focus on safety.
Now all these forms are designed to reduce injuries. A well designed behavioral observation card not only provides the “script” for reinforcing feedback, it also can identify risk and give the observer an opportunity to write a comment that identifies the cause of the actions and suggest fixes that the whole work team can learn from.
These forms serve an important purpose, and the more of them that are completed, research and real-world applications show, the more injuries are reduced.
This is because more observations result in more one-on-one feedback, which is the most powerful motivator of safe behavior out there (and cheapest too). As an added benefit, when the observations cards come in, they can be analyzed and trended to find the areas of risk that are most prominent on the job. When these areas are targeted for improvement, equipment is updated, protection is worn, and short cuts are no longer needed. This reduces the threat of injury as well.
That is, if the forms are actually used for this purpose. Enter the Pencil Whip.
“Pencil Whip” is a verb, which means it’s an action, something someone does, and something someone does intentionally. Yes, the term is so prolific that it made the Wikipedia dictionary: “To complete a form, record, or document without having performed the implied work or without supporting data or evidence.” In Australia’s vast mining industry they call it “Tic and Flick”. The idea is that you are filling out forms so fast, making up the data, that the end of your pencil is whipping in the air.
How do you know data are getting Pencil Whipped?
Look at your behavioral observation data for big jumps in cards in just a couple days. Look at those cards and you’ll see multiple cards turned in at the time. The same person would do these cards in just a couple days (if they are good they will use different pens and different inflections in the handwriting, but not usually). They certainly do not take the time to write in comments or suggestions.
You’ll also notice that at-risk behavior is rarely reported on the pencil whipped cards. Indeed, if your at-risk behavior percentage is below 2% on nearly all your behaviors, you’ve got a pencil whip problem.
Perhaps the easiest way to find out about pencil whipping is just to ask. Most will admit to some pencil whipping but typically you’ll hear “supervisors tell us to do observations because we need to make our numbers,” or “I do the card afterward from memory,” or “I do the cards to get in the drawing for the gift cards, I nearly forgot before the deadline.”
Or, simply ask yourself. Admit it, you already know. In fact… you may be enabling pencil whipping. Yup, you. Because having a lot of observations make you look good!
The case of the 1000 observations a month
A mining construction general contractor had the best intentions when the experts told him to monitor his company’s behavioral observation process measures. He was coached to ask about the number of observations his contracted workforce was engaging in. When I went to meet with him after the process was in place for over a year he was sure that behavioral observations did not work. I would have drawn the same conclusions.
“We are getting over 1000 observation cards turned in a month, yet we keep getting around two incidents each month.” He concluded, “It doesn’t work in construction.” He went on to describe a number of times when his safety people reviewed cards from the previous day and saw that an action was done safe 100% of the time.
“Walking under loads was a big one, it’s a real risk being taken on a construction site with cranes everywhere. Well dozens of cards were turned in indicating that no one was walking under these cranes, 100% safe.” His teeth clinched a bit, “The day these cards were turned in my safety guy went out to that work site and saw nearly all the workers walking under a crane. There were no barricades or markings. In fact that pathway was the only route between two work areas. There is no way these cards are accurate. The employees only want to make each other look good.”
It was time to ask questions. “Confidentially, tell me what’s going on.”
Employees: “I never heard of the program.” “I’ve not been observed.”
Then I started asking questions up the line.
General Contractor: “I did what I was coached. I asked to see the contractor participation numbers.”
Construction Manager (reporting to the General Contractor): “I told the contractors to get me their behavioral observation numbers.”
Contractor Manager: “The General Contractor wants the numbers, I pressed my supervisors to get those observations done so we looked good. I don’t want to be the one that loses this contract over a safety program.”
Supervisors (when presented with the dozens of cards in their handwriting): “I filled out the cards for the employees…at the end of shift.”
Translation: Pencil Whip.
Production is a numbers game, and it should be, but when “Getting the numbers” gets applied to safety, well, you get the numbers.
Going “all-in” with Incentives
Another well-intentioned tactic to encourage observations is to offer incentives. In my travels I’ve seen a number of increasingly innovative incentives. Raffles seem to be the most popular because they seem to not really be an incentive; instead it’s a game.
A contractor organization at a refinery had developed a very popular game to Texas Hold ‘Em to promote observations. It was pretty cool. At the end of the month you received a playing card for every 5 observations you turned in (up to 4 cards). You could get 2 additional cards for self-observations, 2 cards for doing observation training modules, and 2 additional for special safety programming like participating in inspections. The employee who had the best poker hand won a $50 gift card.
This game generated a lot of observations, but they came in waves, right before the end of the month. Now this company has a great behavioral safety program and their injury rate is near zero, amazing for a construction company. But if you look at cards done in the 4 days leading up to the end of the month you get the tale tell signs of pencil whipping (one person turning in multiple cards a day, all 100% safe, no comments).
You get what you pay for.
How Pencil Whipping Evolves
An excellent behavioral safety program had been developed in a company operating a fleet of ocean research vessels. It was replete with common observation cards, online observation card recording software, electronic training, local steering teams, and a second-to-none data analysis program. Mariners would retrieve a card, do their observations, give feedback, and then enter their observation data themselves on an on-board computer connected to the company intranet.
Some vessels had better safety records than others and some were getting more observations recorded than others. In an effort to increase observations on some vessels one of my students helped this company devise a shorter observation form. Their original form had 18 items to observe and score safe or at-risk. He went through their incident and first aid files to find the 8 behaviors most likely to end up in an injury. They then adapted the cards to include only those 8 behaviors and put these cards on the decks of three vessels with the word that these cards are easier and quicker to complete.
Well, it didn’t work. The observation counts did not go up. However, an interesting thing did happen: they kept reporting on the old behaviors. That’s right even though the new cards dropped 10 of the behaviors, only listing the 8. When the employees went to the computer software, which had not been changed so it still listed the 18 items, they reported on all 18 items, not just the 8.
In our interviews afterward we were told, “Well, the guys have used the cards for so long they just rely on their memory to enter the observations.” They were no longer using cards at all.
It occurred to me that this is how pencil whipping may evolve. At first, employees use the card and do a real observation of a peer. They then most likely provide that person feedback and the data they turn in is accurate.
When the cards get memorized I would imagine that the observations still take place but probably rather quickly. Feedback is less likely to happen over time. When the data are finally recorded on a card or, in this case, in the computer, accuracy goes down. With memory comes forgetting. We know that only 7 +/- 2 pieces of information can stay in short term memory at any one time and those memories only last a couple minutes, and that’s when they don’t get interfered with by other things demanding attention.
Because we are likely to forget we tend to rely on our overall impression of the person, the type of work being done, or how safe things tend to be out there. This is called the “Halo Effect,” not because we see the person as “angelic” but because we let our overall impression of the person or situation help us guess. Indeed, we end up guessing and accuracy goes away further, we miss the opportunity to identify risks.
Then, follow the trend here. The employee or supervisor now has experience not using the card yet still getting credit for turning in an observation. They figure out quickly that the only thing they really get credit for is turning in a completed card or, in this case, entering data. This can be done, they find out, without even doing an observation, much less by giving feedback.
So the pencil whip is shaped up nicely and the safety observation program is in jeopardy, worse, people’s lives are more in danger.
Pencil whipping occurs because it is the path of least resistance. Don’t blame the whipper. In fact, your observation form process is perfectly designed to produce pencil whipping. Redesign it to reinforce the conversations it is designed to facilitate.
How to stop pencil whipping
a) Name the Demon.
In the bible, Jesus gets rid of demons by calling out their name. There are parallels in every religion and tribal custom. The wisdom rings true here. Bring pencil whipping out of the closed offices or workstations and into the light. Admit it is a problem by name. Don’t accuse, instead inquire – “How can we change this?”
b) Drop Incentives and Quotas… go to rewards.
Incentives are planned and advertised as a positive consequence of action. Rewards, on the other hand, are seemingly spontaneous acts of gratitude. They don’t have to be big, they have to be fair, and they have to be based on the outcomes of the behaviors the employees can control. They should specify the behaviors that happened and offer a genuine “thank you” or recognition.
In the case of behavioral observations, rewards should be given for the identification of at-risk behaviors and comments, especially those that lead to fixes.
c) Provide group feedback abundantly. Make visible changes.
Reinforce the notion that doing an accurate observation, giving feedback, and reporting all make a difference. You show that life is better because of their actions…the workplace is safer and things are changing. Provide the group feedback of their success: rising observation counts, higher participation, injury reduction, and most of all, at-risk behaviors identified.
A contractor fitting insulation at a refinery has an excellent behavioral observation program effective at identifying risk. One of the risk behaviors that kept showing up was working outside in hazardous weather (see the graph). The work team was thanked for providing the data to show that this was an unnecessary risk that workers felt they had to take. Management then instituted a clear policy statement on work procedures in inclement weather, including stopping work.
After employees experienced this victory they then began reporting at-risk behaviors around the (non)use of respirators. This got fixed quickly by changing a chinstrap that was uncomfortable. In both cases, these behaviors were now done safely 100% of reported cases. And, the employees were more likely to identify other, more personal areas of risk like body mechanics. This reporting behavior, in my opinion, is the opposite of pencil whipping.
d) Change your Behavioral Observation Card Frequently.
Sometimes it’s as simple as the old card had just gotten stale. You’ll have to fight the impulse to use the same card across all work units forever. The impulse comes from the great data analysis you can get from long-term common observations (I fall prey to it myself as a researcher).
Instead, you may want to follow the example of a national grocery distribution company who designs changes into their behavioral observation process. In their process the employee team chooses only 3-4 items to appear on a card. Observations and resulting feedback is easy. The data are trustworthy. The % safe for each behavior is posted prominently in the employee lunch area and is mentioned daily at the beginning of shift. Once one of the behaviors reaches 98% safe for three consecutive months a celebration ensues and the behavior is “retired”. The team then picks a new behavior to take its place, the card changes, and the system begins anew. Pencil whipping does not ever factor into the equation.
In the immortal words of DEVO:
“Crack that whip
Give the past a slip
Step on a crack
Break your momma's back
When a problem comes along
You must whip it
Before the cream sets out too long
You must whip it
When something's goin' wrong
You must whip it
Now whip it
Shape it up
Try to detect it
It's not too late
To whip it
Whip it good”
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.
Tim, your pencil whipping write up on web is an eye opener. Pencil
whipping as you have rightly termed it is really happening on sites that
have rewards for observation score or reprimand / performance debit
points on performance appraisal. I have done no research, but while
trying to read some observation cards, we came across observation of an
activity that was planned but got postponed for some reason. An observer
had filled in observations to indicate that some at risk behaviours
occurred! Upon informal talk he pointed at his HOD's behaviour of severe
reprimand and threat because when departmental score of observations
did not meet target, HOD had to explain! Hence BBS requires a great deal
of organizational maturity across the board.
Your suggestions on identifying the focus behaviours and acting on those one block of identified frequently occurring behaviours that are common pathways for an injury really helps. However, one of the sources of identification of these focus behaviours was observation cards besides several others. I do recall that in 2005, five of 35 prioritized behaviours of drivers could be significantly reduced by focusing observations by their peers on these prioritized behaviours with a system of informal peer feedback.
Hey thanks for the pencil whipping article, I sent it out to our Community of practice for OBS (observation based safety) the response was great. Your right, admit what you already know? We for reasons that were explained, but not listened to, we have suspended our incentive program at our site, a nice lunch and raffle once a month, (suspended not removed… “this was the not listened to part”) and there went our participation. We went from 73% to 29% in three months… as to be expected. Our site has also purposely removed “fix it” items from our observation sheet as we strongly believe that the feedback is the most important part of our behavior change. Did we shoot ourselves in the foot?
Do you think that the common work force sees “fix it” items tied to observations as an incentive, or just what should get done because someone handed in a sheet with some tally marks?
Timothy – you make an excellent, and sadly familiar, point. It is not just about the fact that it happens – the pencil whipping. It is also the elephant in the room – that people apparently just don’t see it, or ignore it, despite all the available signs.
A few thoughts:
You use observation sheets as your main example. It is even worse if it happens for safety critical activities such as plant checks or writing permits.
I believe that sometimes the conclusion of an investigation into suspected pencil whipping should lead to disciplinary action. Deliberate falsification of documents is bad, if not criminal. Would you agree?
It isn’t just long runs of everything “OK” that are suspicious. It is very difficult to fake ramdomness. With only a bit of skill this can be used as a way to look at a number of documents, or their contents, to see if there is (possible) evidence of pencil whipping.
a further thought.
While there is no excuse for pencil whipping – it is a dishonest act – it may show that there are too many forms to complete (as you note).
The answer so often to a problem is to set up a new checklist, or other bit of paperwork. That may be a good idea in isolation, but operations managers and supervisors etc ought to be encouraged from time to time to challenge the value of various bits of paperwork.” Because it is in the procedure” should not be an acceptable answer.
The concepts of Lean address some of this.
Thanks for the article.
An excellent article. I have to admit I had never heard the term pencil whipping but had been told about it in round about terms by some of my students who refered to box ticking and that management were not interested in the safety of the employee just profits and getting the work completed. Obviously pencil whipping has an adverse affect on safety and behavioual safety management techniques as workers see through it and understand safety is the last thing on the mind when in truth it may be as indicated in this discussion it is just that too much paper work is taking its toll on safety and health.
By David Harris