Safety Improvement: Fix the system, not the workers

by Thomas A. Smith, CHCM, CPSM

Traditional safety management views the employees as the problem. Since the 1930's the philosophy of accident prevention has been based on the premise that "unsafe actions" of the worker cause 85% of accidents at work. So here’s how the typical safety program shapes up:

  • Management sets safety policies and procedures.
  • After employees are hired, they’re trained on safe work practices.
  • Supervisors watch workers or have them watch each other to prevent unsafe actions.
  • Inspections find safety problems which are then corrected.
  • Managers set tough safety goals.
  • Every accident is thoroughly investigated with corrective actions following.
  • Incentives are arranged to motivate employees to work safe and keep morale high.

But, after decades of using this approach, the results are not impressive. We’ve seen little or no improvement in our national safety statistics in the last 15 years!

Inhibiting factors

Why? There are several reasons:

  • Power and control rests with line supervision. This perpetuates the "park your brains at the door," syndrome. Employees are seen as the problem, not the solution.
  • A lot of time goes into blame and fixing problems after-the-fact. The emphasis is on mastering what has already gone wrong.
  • Inspections and audits are always too late and inaccurate. They provide snapshots, not the full picture.
  • Accident investigations - or interrogations - are way too late, and prejudiced by presumptions of guilt about the employee. Another flaw is that investigations are only good for the specific accident you are investigating.
  • Methods focus on maintaining the status quo.
  • Rewards, reprimands, and positive and negative feedback destroy the natural motivation everyone possesses to work safely. It’s the system that creates the behaviors of workers.
  • "If employees simply behave safely than accidents will stop" is a naive view based on the false assumption that employees are in control of their own actions at all times.

What’s needed

Traditional safety is based on detection, not prevention. True prevention focuses on the upstream causes of safety problems. It focuses on the dynamics of how a system operates, not on separate events or outcomes. Continual improvement goes even further by aiming to make the entire system better for everyone. How? By using statistical process control and treating employees like customers.

W. Edwards Deming taught us that you must use statistical process control to understand the system and make needed corrections. Control charts are a solution to irrational organizations and poor communication between managers and hourly workers. Everyone sees problems the same way.

When you look at a control chart showing accident statistics you should only be interested in the underlying causes. Keep in mind these points:

  • Processes, including those that produce accidents, do not operate in isolation but are intertwined and interdependent with the rest of the system.
  • Variation is part of every process in the system. No two people will behave the same in similar situations.
  • Variation in processes creates scrap, rework and accidents. The goal should be to operate your safety processes with minimum variation from the target.
  • Management controls the systems which influence safety. Employees can do relatively little to prevent accidents.
  • Every system is at least somewhat broken. Everyone who works in the system is part of the problem. A good management system will run production with minimal accidents and high quality.

An SPC chart will show if the number and variation of accidents is due to a common cause or special cause in the system. Managers who understand SPC and control charts know that most safety problems result from common causes - the interaction of people, materials, training, methods, machinery, equipment, and environment. Common cause problems are deep in your system. To uncover them requires you to take a holistic view of how the components of your system interact and relate to each other. Control charts are the binoculars you need to see the big picture.

Here’s the key point: Fixing the system requires you to use all the mental labor available in your organization.

This means you can’t assume employees exist simply to follow safety rules. Treat them as customers. After all, the number- one customer of the safety system in a company should be the employees. And how do you improve any product or system to better meet the needs of customers? Strive to get the voice of the customer into the system.

The system is the problem, and we can continually improve it. But we must abandon outdated thinking and methods. Look for underlying causes and system interactions. And respect the voice of the customer.

Thomas A. Smith , CHCM, CSPM, is the President of Mocal, Inc., Lake Orion. Mr. Smith has worked with many companies to assist management and technical employees apply the methods of continual improvement to safety. He holds a B.S. from Northern Michigan University and is member of ASSE’s Greater Detroit Chapter. In addition he is past chairman of the SE Michigan Safety Council’s Insurance Division and a past safety committee chairman of the Associated General Contractors Detroit Chapter. He can be reached at 1-248-391-1818,, or via email.