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Hockey Teams and Risk Reduction or What Makes Roberto Luongo = PPE

Canucks Hockey Flag
This entry is part 1 of 3 in the series Hier­archy of Con­trols

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.

Risk Assessment and the Hierarchy of Controls

Equip­ment design­ers need to under­stand  OHS** risk. The only proven meth­od for under­stand­ing risk is the 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:

  • Haz­ard modi­fic­a­tion to reduce the sever­ity of an injury, or
  • prob­ab­il­ity modi­fic­a­tion to reduce the prob­ab­il­ity of a work­er com­ing togeth­er with the haz­ard.

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?

Hockey and the Hierarchy of Controls

Hazard Identification and Exposure to Risk

If we con­sider the goal as the work­er – the thing we don’t want “injured”, then the puck is the haz­ard, and the act of scor­ing a goal as the act of injur­ing the work­er, then the rest of this ana­logy quickly becomes clear.

Level 1: Hazard Elimination

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.

Level 2: Hazard Substitution

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 through the play­offs to play the final Cup-win­ning 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.

Level 3: Engineering Controls

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:

  • pos­i­tion­ing,
  • choice of mater­i­als (play­ers),
  • tim­ing,
  • coördin­a­tion, etc.

These risk con­trols fail reg­u­larly, so are less desir­able than hav­ing the For­ward Line handle Risk Con­trol. This is also com­mon in machine designs where the crit­ic­al para­met­ers are not taken into account prop­erly in the design.

Level 4: Information for Use and Awareness Means

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. In addi­tion, the Defens­ive Line play­ers are try­ing to keep eyes on the puck, act­ively track­ing it so they can get into pos­i­tion to defend the goal. This is a bit like some of the new machine-vis­ion based safe­guard­ing sys­tems that are cap­able of watch­ing the danger zone and stop­ping the machinery when they detect an intru­sion. Hope­fully, the defens­ive line can react in time and get between the puck and the net.

Level 5: Administrative Controls

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 (goals).

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.

Level 6: Personal Protective Equipment (PPE)

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, have 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 of the activ­ity after all. The puck wasn’t kept dis­tant by the For­ward Line. The Defens­ive Line failed to main­tain a 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 equalled long pants and long sleeves, while Thomas equalled 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!

*PPE – Per­son­al Pro­tect­ive Equip­ment

**OHS – Occu­pa­tion­al Health and Safety

Series Nav­ig­a­tionThe Third Level of the Hier­archy: Inform­a­tion for Use