I had the great pleasure of attending the IEEE 2011 Sections Congress in San Francisco, CA this past weekend. At the Saturday Keynote, IEEE debuted an amazing little video called the “IEEE Solutionists” and I wanted to share it with you.
If you aren’t already an IEEE member, you might consider it after watching this!
Special Co-Author, Tom Doyle
Last week we saw the Boston Bruins earn the Stanley Cup. I was rooting for the green, blue and white, and the ruin of my voice on Thursday was ample evidence that no amount of cheering helped. While I was watching the game with friends and colleagues, I realized that Roberto Luongo and Tim Thomas were their respective team’s PPE*. Sound odd? Let me explain.
Equipment designers need to understand OHS* risk. The only proven method for understanding risk is risk assessment. Once that is done, the next play in the game is the reduction of risks by eliminating hazards wherever possible and controlling those that remain.
Control comes in a couple of flavours:
These ideas have been formalized in the Hierarchy of Controls. Briefly, the Hierarchy starts with hazard elimination or substitution, and flows down through engineering controls, information for use, administrative controls and finally PPE. As you move down through the Hierarchy, the effectiveness and the reliability of the measures declines.
It’s important to recognize that we haven’t done a risk assessment in writing this post. This step was skipped for the purpose of this example—to apply the hierarchy correctly, you MUST start with a risk assessment!
So how does this relate to Hockey?
If we consider the goal as the worker — the thing we don’t want “injured”, the puck is the hazard, and the act of scoring a goal as the act of injuring a person, then the rest quickly becomes clear.
By definition, if we eliminate the puck, we no longer have a game. We just have a bunch of big guys skating around in cool jerseys with sticks, maybe having a fight or two, because they’re bored or just don’t know what else to do. Since we want to have a game, either to play or to watch, we have to allow the risk of injury to exist. We could call this the “intrinsic risk”, as it is the risk that exists before we add any controls.
The Center and the Wingers (collectively the “Forwards” or the “Offensive Line”), act as hazard “substitution”. We’ve already established that elimination of the hazard results in the loss of the intended function—no puck, no game. The forwards only let the other team have the puck on rare occasion, if they’re playing well. This is a great idea, but still a little too optimistic after all. Both teams are trying to get the puck in the opposing net and both teams have qualified to play the final game. If they fail to keep the puck beyond the other team’s blue line, or at least beyond the center line, then the next layer of protection kicks in, with the Defensive Line.
As the puck moves down the ice, the Defensive Line engages the approaching puck, attempting to block access to the area closer to the goal. They act as a movable barrier between the net and the puck. They will do whatever is necessary to keep the hazard from coming in contact with the net. As engineering controls, their coördination and positioning are critical in ensuring success.
The system will fail if the controls have poor:
These risk controls fail regularly, so are less desirable than having the Forward Line handle Risk Control.
In a hockey game, the information for use is the rule book. This information tells players, coaches, and officials how the game is to be played, and what the intended use of the game should be. Activities like spearing, tripping, and blind-side checks are not permitted.
The awareness means are provided by the roar of the fans. As the puck heads for the home-team’s goal, the home fans will roar, letting the team know, if they don’t know already, that the goal is at risk from the puck. Hopefully the defensive line can react in time and get between the puck and the net.
Information for use from the previous step is the basis for all the following controls. The team’s coaches, or “supervisors”, use this information to give training in the form of hockey practice. The Forward Line and Defensive Line could be considered the Suppliers and Users. They all need to know what to do to avoid hazardous situations, and what to do when one arises, to reduce the number of potential failures.
A “Permit to Work” is given to the players by the coach when they form the lines. The coach ensures that the right people are on the ice for each set of circumstances, deciding when line changes happen as the game progresses, adapting the people permitted to work to the specific conditions on the ice.
All of this brings me to Roberto Luongo and Tim Thomas. So how is a Goalie like PPE?
Goalies are the “last-ditch” protection. It’s clear that the first 5 levels of the hierarchy don’t always work, since every type of control, even hazard elimination, has failure modes. To give a bit of backup, we should make sure that we add extra protection in the form of PPE.
The puck wasn’t eliminated, since having a hockey game is the point, after all. The puck wasn’t kept distant by the Forward Line. The Defensive Line failed to maintain safe distance between the goal and the puck, and now all that is left is the goalie (or your protective eyewear, boots, hardhat, or whatever). In the 2011 Stanley Cup Final game, Luongo equaled long pants and long sleeves, while Thomas equaled a suit of armour. The Bruin’s “PPE” afforded superior protection in this case.
As anyone who has used protective eyewear knows, particles can get by your eyewear. There are lots of factors, including how well they fit, if you’re wearing them (properly or at all!), etc. If the gear is fitted and used properly by a person who understands WHY and HOW to use the equipment, then the PPE is more like Tim Thomas, and you may be able to “shut out” injury. Most of the time. Remember that even Tim Thomas misses stopping some shots on goal and the other guys can still score.
When your PPE doesn’t fit properly, isn’t selected properly, is worn out (or psyched out as the case may be), or isn’t used properly, then it’s more like Roberto Luongo. Sometimes it works perfectly, and life is good. Sometimes it fails completely and you end up injured or worse.
Goalies are also like PPE because they are RIGHT THERE. Right before injury will occur. PPE is RIGHT THERE, protecting you—5 mm from the surface of your eye, or in your ear, 2 mm from your ear drum. By this point the harmful energy is RIGHT THERE, ready to hurt you, and injury is imminent. A simple misplacement or bad fit condition and you’re blinded or deaf or… well you get the idea!
On Wednesday night, 15-Jun-2011, everything failed for the Vancouver Canucks. The team’s spirit was down, and they went into the game thinking “We just don’t want to lose!” instead of Boston’s “We’re taking that Cup home!”. Even the touted Home Ice Advantage wasn’t enough to psych out the Bruins, and in the end I think it turned on the Canucks as the fans realized that the game was lost. The warnings failed, the guards failed, and the PPE failed. Somebody got hurt, and unfortunately for Canadian fans, it was the Canucks. Luckily it wasn’t a fatality! Even being #2 in the NHL is a long stretch better than filling a cooler drawer in the morgue.
So the next time you’re setting up a job, an assembly line, a new machine, or a new workplace, check out your team and make sure that you’ve got the right players on the ice. You only get one chance to get it right. Sure, you can change the lines and upgrade when you need to, but once someone scores a goal, you have an injured person and bigger problems to deal with.
Special thanks to Tom Doyle for his contributions to this post!
*Personal Protective EquipmentOccupational Health and Safety
There are two key factors that need to be understood when assessing risk: Severity and Probability (or Likelihood).
Severity seems to be fairly well understood—most people can fairly easily imagine what reaching into a spinning blade might do to the hand doing the reaching. There is a problem that arises when there is an insufficient understanding of the hazard, but that’s the subject for another post.
Probability or likelihood is used to describe the chance that an injury or a hazardous situation will occur. Probability is used when numeric data is available and probability can be calculated, while likelihood is used when the assessment is subjective. The probability factor is often broken down further into three sub-factors as seen in Figure 3 below [1]:
Whether you use probability or likelihood in your assessment, there is a fundamental problem with people’s perception of these factors. People have a difficult time appreciating the meaning of probability. Probability is a key factor in determining the degree of risk from any hazard, yet when figures like “1 in 1000″ or “1 x 10–5 occurrences per year” are discussed, it’s hard for people to truly grasp what these numbers mean. When probability is discussed as a rate, a figure like “1 x 10–5 occurrences per year” can make the chance of an occurrence seem inconceivably distant, and therefore less of a concern. Likewise, when more subjective scales are used it can be difficult to really understand what “likely” or “rarely” actually mean. Consequently, even in cases where the severity may be very high, the risk related to a particular hazard may be neglected if the probability is deemed low.
To see the other side, consider people’s attitude when it comes to winning a lottery. Most people will agree that “Someone will win” and the infinitesimal probability of winning is seen as significant. The same odds given in relationship to a negative risk might be seen as ‘infinitesimally small’, and therefore negligible.
For example, consider the decisions made by the Tokyo Electric Power Corporation (TEPCO) when they constructed the Fukushima Dai Ichi nuclear power plant. TEPCO engineers and scientists assessed the site in the 1960’s and decided that a 10 meter tsunami was a realistic possibility at the site. They decided to build the reactors, turbines and backup generators 10 meters above the surrounding sea level, then located the system critical condensers in the seaward yard of the plant at a level below 10 meters. To protect that critical equipment they built a 5.7 meter high seawall, almost 50% shorter than the predicted height for a tsunami! While I don’t know what rationale they used to support this design decision, it is clear that the plant would have taken significant damage from even a relatively mild tsunami. The 11-Mar-11 tsunami topped the highest prediction by nearly 5 meters, resulting in a Level 7 nuclear accident and decades for recovery. TEPCO executives have repeatedly stated that the conditions leading to the accident were “inconceivable”, and yet redundancy was built into the systems for just this type of event, and some planning for tsunami effects were put into the design. Clearly was neither unimaginable or inconceivable, just underestimated.
Significant results also show that better information frequently has no effect on how risks are judged. More weight is put on risks with immediate, personal results than those seen in longer time frames. Psychometric research has shown that risk perception is highly dependent on intuition, experiential thinking, and emotions. The research identified characteristics that may be condensed into three high order factors:
“Dread” describes a risk that elicits visceral feelings of impending catastrophe, terror and loss of control. The more a person dreads an activity, the higher its perceived risk and the more that person wants the risk reduced [4]. Fear is clearly a stronger motivator than any degree of information.
Considering the differing views of those studying risk perception, it’s no wonder that this is a challenging subject for safety practitioners!
Some aspects of probability are not too difficult to estimate. Consider the Frequency or Duration of Exposure factor. At face value this can be stated as “X cycles per hour” or “Y hours per week”. Depending on the hazard, there may be more complex exposure data, like that used when considering audible noise exposure. In that case, noise is often expressed as a time-weighted-average (TWH), like “83 dB(A), 8 h TWH”, meaning 83 dB(A) averaged over 8 hours.
Estimating the probability of a hazardous situation is usually not too tough either. This could be expressed as “15 minutes, once per day / shift” or “2 days, twice per year”.
Estimating the probability of avoiding an injury in any given hazardous situation is MUCH more difficult, since the speed of occurrence, the ability to perceive the hazard, the knowledge of the exposed person, their ability to react in the situation, the level of training that they have, the presence of complementary protective measures, and many other factors come into play. Depth of understanding of the hazard and the details of the hazardous situation by the risk assessors is critical to a sound assessment of the risk involved.
The challenge for safety practitioners is twofold:
I don’t suggest that this is easy, nor do I advocate “dumbing down” the information! I do believe that risk information can be presented to non-technical people in ways that they can understand the critical points.
Risk assessment techniques are becoming fundamental in all areas of design. As safety practitioners, we must be ready to conduct risk assessments using sound techniques, be aware of our biases and be patient in communicating the results of our analysis to everyone that may be affected.
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