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:
- choice of materials (players),
- 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