The Safety Anarchist

Relying on human expertise and innovation, reducing bureaucracy and compliance

Sidney Dekker

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781351403634
• Edition: 1
• Topic: Technologie et ingénierie
• Subtopic: Santé et sécurité au travail

Work has never been as safe as it seems today. Safety has also never been as bureaucratized as it is today. Over the past two decades, the number of safety rules and statutes has exploded, and organizations themselves are creating ever more internal compliance requirements. At the same time, progress on safety has slowed to a crawl. Many incident- and injury rates have flatlined. Worse, excellent safety performance on low-consequence events tends to increase the risk of fatalities and disasters. Bureaucracy and compliance now seem less about managing the safety of the workers we are responsible for, and more about managing the liability of the people they work for. We make workers do a lot that does nothing to improve their success locally. Paradoxically, such tightening of safety bureaucracy robs us of exactly the source of human insight, creativity and resilience that can tell us how success is actually created, and where the next accident may well happen.

It is time for Safety Anarchists: people who trust people more than process, who rely on horizontally coordinating experiences and innovations, who push back against petty rules and coercive compliance, and who help recover the dignity and expertise of human work.

1 A case for change

Welcome to paradise

Let me take you to Paradise Camp. It is located in the vast, hot, flat countryside not far from the Paradise open pit mine. The open pit is so far away from anything resembling human society that it has had to set up its own little version of it next door. That is what Paradise is for. At the Paradise accommodation and services camp, things are safe. They are very safe. Over the last year, they have not suffered a single lost-time injury or an incident that required medical treatment. Paradise Camp is actually run not by the mining company itself but by Captive Crowds: a corporation that also operates prisons on behalf of the government. They’ve got lots of experience with rough-hewn guys whose access to opportunities to fight and get in trouble needs to be carefully controlled. Paradise looks like a prison, too. It consists of eight straight rows of trailers, connected by concrete walkways, ringed by a fence (to keep animals out, they say) and light masts.

In order to win and keep the contract to operate the camp for the mining company, Captive Crowds has had to adopt some rules and make sure everybody complies with them. As the bus carrying miners from the pit arrives near the gates of Paradise, it first backs into its parking space before opening its door. Parking rear-in is a requirement set by the mining company, as backing out of a parking space has been shown to be risky. The bus backs into its space, and the screech of its intermittent warning horn can be heard by all wildlife up to a mile away. This is to comply with both mining company rules and state traffic regulations. Safely backed into its space, on the vast, entirely flat gravel plain with no other vehicle in sight, the bus door opens with a hiss, and the driver emerges into the waning light. Before setting foot on the gravel, the driver dons a hard hat and yellow high-visibility vest. The gravel plain in front of the gates of Paradise, after all, is owned and operated (what there is to operate, nobody knows) by the mining company. When ‘on site,’ all workers, visitors, contractors, managers and inspectors are required to wear personal protective equipment, which includes a hard hat and high-visibility vest. Visiting managers are easiest to spot, because their hard hats are unscratched and their high-visibility vests are immaculate. On the gravel plain, the mining company’s requirement for wearing hearing protection is waived, as the bus has actually shut off its engine before the driver and miners disembark.

Appropriately protected, the driver then takes the final step down onto the gravel. In her hand is a set of chocks, not unlike the ones seen at airports to stop docked jets from rolling away. The bus is parked, with handbrake engaged, on a perfectly flat piece of ground. If it wanted to defy gravity and roll in any case, it could only roll onto more of the same perfectly flat ground. The mining company, however, requires parked vehicles over a gross weight of 2.5 metric tons to be chocked when their use involves the boarding or disembarkation of personnel, or the loading and unloading of materiel. The driver chocks one of the wheels of the bus, walks back to the door and signals to the foreman that the miners are now safe to disembark. Before they set out across the gravel plain to the gates of Paradise, a distance of about 100 yards, they too are each handed a yellow vest and asked to put on their hard hats. The miners are already wearing high-visibility clothing, of course, because that is a requirement for working in the pit. But the requirement outside the pit specifically demands a yellow vest to be worn over clothing. As the line of double-reflective miners tiredly trudges toward the gates of Paradise, the only thing they could bump into is each other. The requirement for a hard hat is universal for Paradise mine property. Looking around the gravel parking plain, one would see nothing that could actually fall on anybody’s head – except perhaps the sky itself. But that is an old Norse myth that never made it to the country in which Paradise is located. The hard hat may come off once inside the gates of paradise, as miners are then protected against the falling sky by covered walkways.

Next to the gate, welcoming anybody to Paradise, is a sign with exchangeable numbers, like those used at gas stations to show the price of fuel. At Paradise, these numbers show how many days the camp has been blessed without an injury or incident. The number now is 297. Because 298 days ago, a miner who was wearing thongs (or flip-flops) to the shower, dropped a heavy shampoo bottle on his big toe. His injury was a subungual hematoma, which is a collection of blood under the nail. He was out of action for a day as the throbbing pressure of the blood pocket under his toenail built up and walking became painful. The pressure was finally released by a method called trephination, which involved making a small hole in the nail with a sharp, heated instrument (a pin in his case). The result was a little fountain of blood, followed by relief. Trephination was not administered by a doctor. This was a good thing because that would have counted as a medical treatment injury (of which Paradise Camp has not had a single one – ever, thank you very much; the sign next to the entrance tells you that as well). A pharmacist assistant, at the camp by herself to dispense the occasional paracetamol to the needy, had to be approved to administer trephination first by Captive Crowds headquarters through a number of phone linkups with a capital city many hundreds of miles away, and then by the mining company.

Not that the pharmacist assistant gets involved a whole lot in these sorts of things. Because there are no injuries to get involved in. Or at least not that she, or anybody else, knows of. Or wants to know of. Also next to the gates of Paradise is a big sign that claims “Nobody gets hurt today!” It has the form of a traffic warning sign. Miners are unclear about the status of that claim. It might be a warning, or an established fact (well, at least for the last 297 days), a Captive Crowds corporate aspiration. Or is it perhaps simply an expressed hope, a printed prayer? They can’t tell. Perhaps it is a bit of all of that. Because nobody gets hurt, obviously nobody gets hurt. The solution that most miners have is to wear a little hip pack (or have their breast pockets bulging instead). In the hip pack, or breast pocket, is a little homemade first aid kit. It meets the requirements of the injuries that they might typically suffer on their particular jobs: cuts, abrasions, lacerations. They learn about this nifty solution on their first rotation to Paradise. Veteran miners show them how to pack it and also where to fix themselves up when they get injured so that the safety intendents or supervisors are none the wiser. This tends to be the men’s toilet facilities, which is of course a highly sterile environment where miners can safely tend to open wounds.

To guard against injuries of the shampoo-bottle kind, miners are now required to wear steel-capped boots in the Paradise accommodation and services camp at all times. This includes their trips to the shower block. The intervention is a great success, as no toe injuries have been recorded for 297 days. Many miners now have onychomycosis, or tinea unguium. It is commonly known as toe nail fungus. This is a condition (importantly: not an injury!) that tends to thrive in moist, warm environments. The front of enclosed steel-capped boots, into which miners have to wedge their drying feet after showering, is an ideal environment. Most miners have only one pair of boots. Miners who are spotted not wearing their boots, or with laces that are untied to allow in a bit of air, are invited to have a conversation with a safety professional the first time (which is recorded). They are officially warned by the safety manager if they are caught a second time (which is recorded). And they are sent off site the third time. This also happens if workers in the camp break the mobile phone rule three times: they are not supposed to use a phone while walking around the camp – neither for texting, watching it or talking into it. “When we’re mobile, we don’t do mobile!” posters scream out from every wall along the footpaths and above the urinals in the men’s toilet (which, incidentally, is not a location where you want to be ‘mobile’). Being sent off site is called ‘being given a window seat.’ Because Paradise is so far from known human society, airplanes are used to ferry miners back and forth. Those who are fired are typically given a window seat – out of spite or perhaps as an act of noble charity: miners have their own thoughts on that. As the plane ascends, they can look out one final time over what they so recklessly gambled away and lost.

But there is much to enjoy in Paradise. Each miner is allowed a maximum of four cans of light beer a day (of one particular kind, on account of a subcontract that Captive Crowds negotiated at favorable rates with a particular brewer). There is no other alcohol, so choices of drink are easy and ordering is straightforward. The beers are served, and carefully counted, by a Captive Crowds employee in one of the trailers that doubles as a ‘bar.’ They can be enjoyed only in the bar trailer or its patio. The bar’s patio is of course fully fenced in for the safety of the revelers. The small patio is accessible by three steps up from the pavement. It is bordered by handrails, which are to be held at all times when ascending or descending the steps. A sign hanging over the entrance tells visitors to have “Four points of contact!” while using the steps. To this day, confusion about that is rife. Miners have tried to show each other how to climb the steps with four points of contact, but they get stuck immediately. As they lift one foot up to the next step, after all, they lose one point of contact. One lanky miner, who has very long arms, was able to simultaneously reach the handrails on either side of the steps with his fingertips. Even he got stuck until someone suggested that the fourth point of contact could be eye contact. Eye contact – with the steps! Everybody thought that was very clever. A younger miner, a precocious chap from up over the hills in the north, stubbornly believed that the four points of contact referred to his quota of four beers. But he hasn’t figured out a way of establishing contact with all four cans at the same time unless he squashes them when they’re empty.

For those who are more inclined to relax with fitness activities after their 12-hour shift in the open pit mine, there is a little gym in one of the trailers. Naturally, miners are required to wear their steel-capped boots in the gym, as the heavy weights could inflict even more injury on toes than a shampoo bottle. Weights are to be stacked or shelved not higher than the waist, so that temporary occupants of the gym trailer could be exempted from the requirement to wear a hard hat. A swimming pool was ruled out, even though the climate is appropriate for it, when Captive Crowds learned through an extensive risk assessment that drowning accidents can occur in water of 30 cm (about a foot) deep. Water shallower than that would preclude any meaningful exercise. But there is a tennis court, the height of luxury in Paradise. It is even fitted with an umpire’s chair, so that games can be appropriately and fairly adjudicated. Captive Crowds has adopted almost all of the mining company’s safety rules, which includes its stipulations regarding working at height. In a unique triumph of safety managerialism, it has discovered that the seating surface of the umpire chair measures in at 8 feet and 2 inches from the ground. This puts it just over the regulated height at which fall protection must be worn. Umpires – that is, volunteer miners who watch their buddies play a game and do the convoluted quasi-French counting demanded by the rules of the game – thus fit themselves with a fall-protection harness, carefully ascend the stairs of the umpire chair (somehow ensuring four points of contact) and click themselves into security once breaching the 8-foot limit. This doesn’t happen much nowadays. Nobody plays tennis in Paradise anymore, because it’s too hard to run after a little bouncy ball in steel-capped boots. And there’s not a lot of time in any case. At 9 pm, a curfew descends on the camp. Noise is banned; movement is frowned upon. Only the crickets have the freedom to party.

Total institution or straw man?

To some the story of Paradise might seem exaggeratedly dystopian. To some it amounts to nothing but a strawman: a sham opponent deliberately set up to be defeated in what follows. Some might even consider it absurd (these tend not to be the people who have actually worked in places like Paradise). Indeed, to others, it is very real; it is their lived, everyday reality. I cannot make you believe any of these. I cannot make up your mind about the validity of the examples offered. You’ll have to do that for yourself. But for the record, none of the rules or signs in the example of Paradise are made up, nor are the typical responses of workers to them. They are all, in fact, empirical: drawn from experiences across just three different workplaces. The strawman, such as it is, simply emerges from putting available evidence together.

Paradise Camp has all the trappings of what has become known as a ‘total institution’: a place of work and residence where a great number of similarly situated people, cut off from the wider community for a considerable time, together lead an enclosed, formally administered life. What typically happens in a total institution is that a paternalistic kind of authority seeps into every aspect of lives lived inside of it. Nothing that happens inside its boundaries is not somehow touched, constrained or controlled by people who are in charge of the thing. Those people, however, are not likely to all be living in the camp themselves. Studying these institutional living arrangements in the 1960s, Goffman saw similarities between asylums, prisons and, indeed, work camps. This doesn’t make it surprising that companies responsible for running and catering to prisons are also prominent in the running of work and residential camps like Paradise:

First, all aspects of life are conducted in the same place and under the same central authority. Second, each phase of the member’s daily activity is carried on in the immediate company of a large batch of others, all of whom are treated alike and required to do the same thing together. Third, all phases of the day’s activities are tightly scheduled, with one activity leading at a prearranged time into the next, the whole sequence of activities being imposed from above by a system of explicit formal rulings and a body of officials. Finally, the various enforced activities are brought together into a single plan purportedly designed to fulfill the official aims of the institution.

(Goffman, 1961, pp. 5–6)

Fewer injuries, more accidents and fatalities

But, you might protest, work has never been safer! This stuff, all these rules and safety precautions, they’ve actually had great results! They have. Or they might have. We should be proud of such an accomplishment. But behind this result hides not only a dystopian, Orwellian world of total surveillance and control. Behind it also lie complexity and contradiction:

• The thing is, work has not been safer for over 20 years now. In many developed countries, work was generally as safe in the late 1980s as it is now. Yet the amount of safety bureaucracy has doubled over the same period, without any noticeable increase in safety (Saines et al., 2014).
• Trying to lower an incident and injury count may look good, but it leaves the risk of process safety disasters entirely unfazed. The number of such accidents globally and the number of lives they claim have remained relatively stable over the past decades (Amalberti, 2013; National-Safety-Council, 2004). And what we know about injuries and incidents doesn’t help us prevent fatalities or accidents (Salminen, Saari, Saarela, & Rasanen, 1992).
• And succeeding in lowering a non-serious injury incident rate definitely puts an organization at greater risk of accidents and fatalities. In shipping, for example, injury counts were halved over a recent decade, but the number of shipping accidents tripled (Storkersen, Antonsen, & Kongsvik, 2016). In construction, most workers lost their lives precisely in the years with the lowest injury counts (Saloniemi & Oksanen, 1998). And in aviation, airlines with the fewest incidents have the highest passenger mortality risk (Barnett & Wang, 2000).

Regulating the worker does not prevent catastrophes

What lies behind the production of these accidents and these fatalities? Is it really because some people don’t wear their personal protective equipment – that some don’t wear gloves when rules say they should? Is it because a worker mounts Paradise Camp’s umpire’s chair without fall protection or because a worker doesn’t have four points of contact when staggering down the steps with a light beer in her or his system? Hardly. You probably know this notorious example:

For years BP had touted its safety record, pointing to a steep decline in the number of slips, falls, and vehicle accidents that generate days away from work, a statistic that is closely followed by both the industry and its regulators. BP had established a dizzying array of rules that burnished this record, including prohibitions on driving while speaking on a cellphone, walking down a staircase without holding a handrail, and carrying a cup of coffee around without a lid. Bonuses for BP executives included a component tied to these personal-injury metrics. BP cut its injury rate dramatically after the Amoco merger [the previous owner of the Texas City refinery]. But BP’s personal-safety achievements masked failures in assuring process safety. In the energy business, process safety generally comes down to a single issue: keeping hydrocarbons contained inside a steel pipe or tank. Disasters don’t happen because someone drops a pipe on his foot or bumps his head. They result from flawed ways of doing business that permit risks to accumulate.

(Elkind, Whitford, & Burke, 2011, p. 7)

They are, of course, not alone. Take the more than 7,500 gallons (close to 30,000 liters, or a medium-sized backyard pool) of toxic coal ash that was dumped into the Elk River in Charleston, West Virginia, in 2014. This was the third chemical spill to be inflicted on the Kanawha River Valley (also known as ‘Chemical Valley’), leaving 300,000 people without water for days. A year later, the West Virginia Senate approved Bill 357, officially named the Creating Coal Jobs and Safety Act. Perhaps the naming was cynical, because there were no safety provisions in it at all. Instead, the law prevented coal companies from being sued for Clean Water Act violations, if the standards that were violated were not specifically written into individual state permits issued by the Department of Environmental Protection. The bill also ruled out the application of these standards to future permits, and it relaxed the amount of aluminum legally allowed in the state’s drinking water. It doesn’t take a lot of imagination to predict that tighter regulation might help prevention and mitigation in such cases. But that is difficult to enact. Most corporate players in...