Everyone has climbed a ladder, right? At home or at work. Of all possible dangerous tasks, climbing a ladder is the most common. And it is risky. Approximately 164,000 emergency room visits occur every year due to falls from ladders, according to the Centers for Disease Control and Prevention (CDC). More than 300 deaths from ladder falls occur annually, reports CDC.
Yet routine ladder-climbing resulting in injuries and deaths resists simple, black-and-white incident analysis. Let’s say an employee is outside climbing a ladder when the employee falls and twists his left knee and hurts his back. It is puzzling why this occurred. Most often the actual cause or causes go beyond jumping to the conclusion that the employee was to blame and the solution is “to be more careful,” cite OSHA’s ladder standard 1926.1053, and to deliver more ladder safety training.
The analysis of this incident, or any safety-related close call, injury or fatality, must dig beneath immediate surface explanations. Most often there are numerous pieces to putting together the puzzle. In the instance of a ladder fall, the context of factors can be far-ranging:
What were the weather conditions? What type of surface was the ladder on? Flat or sloped? Concrete, dirt or grass? What was the slipperiness of the surface? What was the condition of the ladder? How clean were the ladder rungs? What was the height of the ladder compared to the height of area the employee was trying to reach—was the ladder tall enough? What was the horizontal distance from the ladder to the area the employee was trying to reach? What was the load rating of the ladder compared to the weight on the ladder—the person plus all equipment? What was the employee trying to do on the ladder? Is this the way the task is normally done? Was a taller ladder available? Why was this particular ladder used? Did anyone help the employee stabilize the ladder while it was being used? Was the ladder inspected before use? Did the employee receive ladder safety training?
Answering these questions requires close observation, a detailed description of what happened, engaging the perspectives of employees, analysis and interpretation, avoiding biases that can influence conclusions, critical thinking—an objective evaluation of an issue or incident to form a judgment—risk assessment and prioritization, communicating findings to all level of personnel, and implementing interim (if necessary) and permanent hazard mitigation solutions.
We may never have all the pieces of the puzzle (or incident) to be 100% confident that we know how something happened, such as the fall from the ladder. Still, we need to arrive at a reasoned hypothesis so we can take action and not be paralyzed into doing nothing.
An Important Tool
Visual literacy is an important tool we can use to piece together the causes of a close call or incident. It is the ability to make sense and to bring meaning to a broad range of visual information. The data points are usually physical and can include documents—recordkeeping and reports. Trained safety and health professionals, employees, supervisors and other personnel become fluent in articulating what they have seen, can speak accurately about their observations and their critical thinking, be cognizant of and put aside any biases, communicate their findings, and take remedial actions.
It is important to note that analyzing incidents and close calls is a reactionary practice. It is putting the puzzle together after it has been broken apart. Visual literacy is important also as a proactive approach to safety. This practice is commonly called hazard recognition or hazard identification. It is followed by proactive risk management. It may take the form of “hazard hunts,” audits, walkarounds, individualized reports by employees—anonymous or otherwise—or a component of a sustained safety and health management system.
Seeing hazards is challenging. Certainly, many workplace hazards are hidden. This is especially true of health hazards and psychosocial hazards. Gases and vapors may be invisible, often have no odor, and may not have immediately noticeable health impacts. Solvents, adhesives, paints, toxic dusts, sources of infectious diseases, molds, toxic or poisonous plants, or animal materials need to be assessed using safety data sheets at times, exposure limits, volatility, sources of radiation, and the effectiveness of ventilation. Quantitative exposure assessments using air sampling may be necessary. Storage facilities and handling procedures require visual perception.
Unintended Consequences
Failing to notice a hazard in your visual field, missing the obvious, is called inattentional blindness. These obvious hazards become part of the noise and part of the background. This can be due to confirmation bias—we tend to see what we expect to see. We can walk past exposed wiring, through inadequate lighting, poorly maintained workstations, or a missing machine guard 1,000 times without noticing. Research shows we may only see as little as 10% of what we look at. The remaining 90% is filled in by our brain based on memory and past experiences. We may not see up to 90% of the risks. Relying on memory and history heightens the risk of close calls, and both minor and serious injuries and fatalities.
Putting together the pieces of a puzzle relating to an incident, close call, odor, smell, complaint about harassment or bullying, or other safety and health issues is all the more challenging when compounded by intentional blindness, not seeing up to 90% of the risks due to relying on memory and experience, the blame game, jumping to conclusions, any number of biases, focusing too narrowly on a particular hazard and not seeing the large picture—the important context surrounding an issue.
Critical Thinking
Critical thinking skills, taught with visual literacy training, involve questioning, analyzing, interpreting, evaluating and reaching a judgment about what you see (what does it mean and what are you doing to do about it?), hear or intuit based on clear, precise, fair and flexible thoughtfulness. Critical thinking is core to solving safety and health puzzles. Politics and conflicting interests can complicate problem-solving. Personal likes, dislikes and other favoritisms can enter the equation. Politics in the management or executive levels can draw resources away from safety efforts that are out of favor. Critical thinking lends insight into these complicated problems.
Organizational culture can allow conflicting objectives/priorities to interfere with problem-solving. Observations, audits and incident analyses may be governed by the need to correct quality problems that arose with the injury/close call or to meet production quotas. If the culture emphasizes production, corrective actions seen as decreasing production will not be entertained. Cultures that prioritize efficient use of time will inhibit consideration of time-consuming critical thinking and risk assessment and prioritization (determining the potential frequency and severity of exposure to a hazard).
Almost daily we confront safety and health scenarios that are puzzles to solve. Visual literacy competencies including observation skills, holistic perspective, awareness of biases, communication skills, descriptive skills, critical thinking and problem-solving skills help put the fragments of the puzzle where they belong to give us a correct, accurate understanding of what created the puzzle in the first place.
