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 Nav­ig­a­tionUnder­stand­ing the Hier­archy of Con­trols

Author: Doug Nix

Doug Nix is Managing Director and Principal Consultant at Compliance InSight Consulting, Inc. ( in Kitchener, Ontario, and is Lead Author and Senior Editor of the Machinery Safety 101 blog. Doug's work includes teaching machinery risk assessment techniques privately and through Conestoga College Institute of Technology and Advanced Learning in Kitchener, Ontario, as well as providing technical services and training programs to clients related to risk assessment, industrial machinery safety, safety-related control system integration and reliability, laser safety and regulatory conformity. For more see Doug's LinkedIn profile.