April 6, 2023

Organizational Decision Making for Safety: Part 2

Organizational Decision Making for Safety: Part 2

Organizational Improvement Strategies


In the first part of this series, we introduced new research findings that point to site leaders having the greatest potential to impact serious injuries and fatalities (SIF).  Part 2 reviews the most significant situations and types of decisions for effective safety leadership. It also presents a new perspective on incident causation leading to improvement strategies aimed at SIF prevention.

Let’s examine one case from the study of over 600 decisions leading up to 60 life-altering and fatal events.

In 2010, a metal dust explosion, inside a metal blender, caused three fatalities and one serious injury.[i] One of the blender blades had struck the side of the blender, causing a spark which ignited the extremely explosive metal dust. During investigation, it was found that the workers had repaired the blade multiple times. When it continued to function improperly, they decided to replace it with a used blade from an older blender.

On its face, it might seem completely reasonable to point to the worker’s decision as a cause of the incident. However, the investigation revealed a chain of management decisions, years before the explosion, that set the stage for the worker to make that final, fatal decision.

  • When the site was first opened, the company decided not to purchase back-up equipment to keep on-site in case of failure.
  • The company decided to work on a 24/7 schedule that did not allow for equipment downtime and exerted time pressure on the operation.
  • The site manager decided not to enforce a known rule for closing the lids of the blenders while they were operating.
  • Months before the incident, site management became aware of the faulty equipment and decided to defer costly maintenance in favor of a ‘quick fix.’

Although the maintenance worker had the option of making a different choice, it became evident that decisions made by management had the greatest influence and created the conditions under which such a disaster could occur.

Which Decisions Matter to Safety?

When we think about the sheer numbers of decisions made by leaders the task of improving them all seems quite daunting. Although the case could easily be made that all decisions are indirectly related to safety, the study found a subset that appeared to have the greatest impact.

Situations in which site-level leaders made critical safety decisions included:

  • Designing, Maintaining, Purchasing & Installing Equipment
  • Troubleshooting Operational Issues
  • Designing, Changing, or Purchasing Facilities
  • Designing or Changing a Work Process
  • Formal Risk Assessment
  • Work Planning
  • Purchasing
  • Hiring
  • Designing Hazard Mitigation

Some common errors in those situations had to do with:

  • Developing Criteria & Specifications
  • Identifying Information Needed
  • Communication
  • Assigning People to Tasks

These situations and errors combine in powerful ways. For example, while doing a safety audit, these data suggest that it matters greatly who we invite to participate. When we’ve spotted a significant risk and are trying to come up with a way to protect people, it matters greatly what information we use to inform the problem. When we plan hazardous work for the day, it matters with whom we communicate, how, and on what we focus in those conversations. If leaders can learn to recognize which of their decisions are safety-sensitive, and in which situations they seem to matter most, we may be able to start with a relatively small number of decisions that have the greatest impact on safety. As these decisions improve, so will other decisions.

What is Cognitive Bias and What Role did it Play?

Cognitive bias is a systematic deviation from rational thought.[ii]  The study found evidence of bias in 85% of the decisions. Here are some examples:

  • Overconfidence in one’s knowledge: “I know everything I need to know about this problem.”
  • Overconfidence in the team: ”We don’t need Paul’s expertise … Peter knows what he’s doing.”
  • Preservation of the status quo: “We’ve managed this way for years, we can make it one more.”

Advances in psychology, biology, and technology have led to breakthroughs in our understanding of bias and where it comes from. For example, we know that our brains are structured in ways that trade off speed for accuracy, especially in stressful situations. And we have identified specific areas of the brain where bias is generated. This means that all humans, including the greatest leaders, are biologically predisposed to biases that can derail the most intelligent decision maker from making a sound choice.

Fortunately, bias-producing situations can be anticipated and we can learn to identify and reduce their negative impact. Better understanding of cognitive bias and practical tools will help leaders make better and safer decisions.

The New View: Focusing on decision making at the leadership level is a critical component to safety improvement.

What this all says is that we can get better at decision making. Every decision at the management level has the potential to create or reduce risk. What’s more, every decision influences the assumptions, values and beliefs of the organization (the safety culture).  And if you share the insight from Chapter 1 of the 7 Insights into Safety Leadership, then you know this means decisions have the potential to protect people and build organizational capability leading to improvement throughout the business.

Given what we know today about how to build safety leadership capability in an organization, combined with what we know about decisions related to SIFs, here’s what we recommend:

  1. Start with individual leaders, as high in the organization as is practical.
  2. Strategically select a set of decisions and situations to focus on first, based on the decisions’ impacts on serious injury or fatality potential.
  3. Assess individual leaders’ decision-making capability for safety and build skills as needed.
  4. Teach leaders more about the most common forms of cognitive bias and create checklists that can be used to help avoid them during decision making.
  5. Observe decisions as they are made, understanding both the decision process and the context. In especially critical strategic decision-making sessions, create a meeting role for the observer to watch for common bias pitfalls and spend some time after the decision is made to debrief to ensure cognitive bias was avoided.
  6. Provide feedback to the leader on the decision process; provide feedback to the organization on the context.
  7. Engage your senior-most leadership team in the effort of understanding and improving the context for decision making.


[i]  U.S Chemical Safety and Hazard Investigation Board. (2014, 07 16). AL Solutions Fatal Dust Explosion Report. Retrieved from CBS.gov: http://www.csb.gov/al-solutions-fatal-dust-explosion/

[ii] Khaneman, D. (2011). Thinking, fast and slow. New York, NY: Farrar, Straus and Giroux.


Christina Thielst contributed to the skillful writing and editing of this article.