Culture, Safety, and Driving Results: A Conversation with Dr. Tom Krause

Watch the recorded webinar: A CONVERSATION WITH TOM KRAUSE: Culture, Safety, and Driving Business Results.

A Perspective on Behavior Based Safety

Rebecca: You introduced Behavior Based Safety (BBS) decades ago. When you look back now, what do you think we got wrong with BBS? What happened?

Tom: Those are actually two different questions—what we got wrong and what happened—and it can be hard to separate them. Let me start with what happened. What happened is that many organizations took on BBS without really understanding how it worked, and they did it badly.

When BBS is done badly, it tends to encourage leadership to blame the employee for incident events. That goes all the way back to Heinrich, who encouraged us to think that the behavior of the worker was the primary thing that needed to be addressed. At the time, everybody believed that was accurate. As a result, leaders took on the view that “if we could just get these people to do the right things, these problems would all go away.” That turns out to be false and, in many ways, counterproductive and quite negative when that point of view takes hold.

At the same time, it’s important to say that BBS was never one thing. There was tremendous variability across organizations. Some organizations did a terrific job with BBS. They had levels of engagement from frontline employees that were extraordinary. People who usually didn’t get involved in anything were suddenly involved in something important. They developed new skills, they had opportunities they wouldn’t otherwise have had, and as a result the workplace got safer. Those were extremely positive cases.

But then there were others where it was just “go through the motions.” The process became: go out, do these observations, follow these steps. In practice, that often devolved into “go see if you can find somebody doing something wrong and then tell them, ‘you’re doing it wrong, you’re the problem.’” When BBS looks like that, you’ve really missed the point.

Rebecca: Why do you think BBS went off the rails?

Tom: One of the things that went wrong is that BBS got too popular too fast. We wrote books and articles, gave talks, shared what we thought was good information—and I still think it was—but it became a fad. People would say, “What is that?” and the answer they heard was, “Well, that’s going out, looking for people doing things unsafe, and telling them about it.” And then they’d say, “We can do that. We don’t have to spend a lot of time being trained or learning the science behind this or what it looks like when it’s working well. I’ve read the first chapter of 7 Insights into Safety Leadership; I think we’re ready to start.” When organizations approach it like that—light on understanding, heavy on rushing to do something—they actually go the wrong direction. They go backwards.

The Challenge of Reducing Serious Injuries and Fatalities

Rebecca: Let’s shift to Serious Injuries and Fatalities. The SIF run rate hasn’t really changed, even when the traditional metrics look good. What is holding us back from breaking that cycle?

Tom: Getting the SIF piece right is not easy. It’s not a matter of three steps—step one, step two, step three, and then, bingo, we don’t have SIF exposure anymore. It’s subtle, layered, and inherently difficult to get to.

A step forward is simply recognizing that serious and fatal events are different from small events. Getting at serious and fatal events requires a different kind of understanding and a different kind of action. By its nature, SIF exposure is subtle and buried. You can’t just walk into the workplace, start talking to people, and see SIF exposure. It’s hidden. It requires diligence, investigation, and skill to get to the precursors that can result in a serious or fatal injury.

Rebecca: What did you learn about Heinrich’s triangle in the 2010 SIF study that changed your thinking?

Tom: For a long time, we all accepted Heinrich’s idea that frequency and severity were inversely correlated. The notion was that if you improved injuries across the board—if you reduced smaller injuries—you would also improve serious injuries. I can remember many times drawing a triangle on a flip chart, laying out the categories, and saying, “If you reduce these categories,” and then drawing a line up the side of the triangle, “you’ll see reductions all the way up.” The assumption was: reduce this type of injury and you reduce that type of injury—no distinction. Nobody questioned it, including me.

The shock came when a client called and said, “We’ve noticed something odd in our data. Our small injuries are coming down nicely, but we’ve started categorizing and tracking serious or fatal events, and they’re not declining at the same rate or in the same way as the smaller injuries. Shouldn’t those two lines be parallel over time?”

That question prompted us to look more closely. We brought together seven, eight, ten companies, aggregated their data, and studied that relationship. We saw the same pattern repeatedly: the overall recordable rate went down, but serious and fatal injuries did not follow the same trajectory. That told us something was wrong with the idea that reducing small injuries would automatically reduce larger injuries.

So, we went back and looked at the small events themselves. We asked, “Are these all the same?” And they weren’t. You find small events that are almost always going to be small. And then you find small events that, if they had unfolded slightly differently, could have been a fatality. Those are different categories of events; they don’t belong in the same bucket. Recognizing that was, in my view, a revolution.

Even though that was more than 15 years ago, and many large organizations have since taken this approach and made tremendous progress, many still haven’t. Some still labor under the delusion that if they reduce smaller injuries, they’ll automatically reduce larger injuries. Others understand that SIFs are different but still struggle with how to get at them, in part because there are so few to look at. If you’re a site with 500 employees, you might have very few SIF events—which is good—but it makes measuring progress difficult. There is not a neat “recordable rate”-type tracking mechanism for SIFs.

Learn more about the 2010 SIF Study in Serious Injuries and Fatalities – The New Paradigm.

Implementing a Practical, Effective SIF Prevention Strategy

Rebecca: So how would you respond to a leader who asks, “What do I actually do?”

Tom: The central idea is that you don’t wait for the SIF event. You look for the precursors—situations where, given the configuration, a fatality could occur. A precursor is a situation in which someone could be killed or seriously hurt if things go wrong. The work is to find those precursors and address them.

That means identifying your critical tasks and activities—the work where SIF potential exists. Then you identify the controls in place to protect people performing those tasks and study the health of those controls. Are they present? Are they complete? Are they functioning? Do people know how to use them? Very often, when you have a SIF or a near-SIF, you discover that those controls were absent, broken, incomplete, or unknown.

Then you look at what we call amplifiers—features of your culture or organization that increase those risks. It’s the combination of critical tasks, controls, and amplifiers that defines your SIF precursors.

Organizations can work through this in a group setting. It’s engaging, it builds alignment, and it makes getting after SIF exposure very practical. And, for those who like to measure things, it becomes a leading indicator because you’re looking at exposure upstream, before the event occurs.

The Importance of Effective Decision-Making

Rebecca: You’ve said that decision-making is central to reducing SIFs. How did you arrive at that, and what does it change?

Tom: We got there by analyzing SIF events in depth and asking a different question: “What decisions created this exposure?” We found that decisions made months, sometimes years, before the event created the conditions for that SIF. Nothing bad happened for a long time, and then suddenly someone got killed or seriously injured.

So, we asked: Where are the decision-making processes that create exposure? Where are they going wrong or where are they insufficient? Once you see that, it’s a huge step forward, but it requires a different way of thinking. We’re not just looking at what people do in the moment; we’re looking at how decisions set the stage long before the incident.

Rebecca: You shared an example about a four-person job done with three people. What’s really going on in a decision like that?

Tom: Consider a second-level supervisor who knows a job requires four people but only has three available. They know those three people, they trust them, they know they’ve done this job before. They might say, “I’ll tell them to be careful, they’ll figure it out, they’re good people.” At the same time, they don’t want to be the person who says, “We haven’t done that job because I thought it was unsafe with three people.” They’d much rather be the person who says, “We got it done.”

What’s happening there is overconfidence. That’s a kind of bias. The supervisor has confidence in those three people and believes they will compensate. They’re not consciously thinking, “Someone might get killed, but I’ll do it anyway.” They’re thinking, “This will be fine.” The bias is often unconscious; they don’t know they’re underestimating the risk.

Rebecca: How do you define bias in this context?

Tom: I think the best way to think about bias is as an improper assessment of probability. You’re not assessing the likelihood of something accurately.

Take a simple example outside the plant. Suppose someone is driving down the highway, going a little too fast, is talking and listening to the radio. They’re not experiencing that situation as high-risk. They might even be thinking, “This is fun.” The true probability that they could kill themselves or someone else in that moment is much higher than they think. Only when a crash happens—if they survive—do they look back and say, “What on earth was I thinking?”

In organizations, we see the same patterns. People make decisions all day long that have safety implications, but they don’t experience those decisions as safety decisions. They experience them as scheduling decisions, financial decisions, staffing decisions. The bias is that they underestimate the probability that those decisions create serious exposure.

Rebecca: Can training fix this?

Tom: Training can help if it’s done well. The first step is simply awareness: recognizing that a decision has safety implications. In many of the SIF investigations we’ve done, when we trace decisions back in time, it becomes clear that the people making those decisions never asked, “What are the safety implications?”

For example, an organization may decide to change a process or undertake a major construction project. The decision is framed around cost, schedule, and business benefit. Nobody pauses to ask, “Does this introduce new SIF exposure? Have we thought about the controls? Are there precursors here?”

If you build that kind of questioning into your decision processes—if you deliberately stop and ask about safety implications—you start to bring those risks into view. You’re not going to catch everything, but you’ll catch more of it.

Alignment with Deming and HOP (Human and Organizational Performance)

Rebecca: How did Deming influence your thinking about safety?

Tom: W. Edwards Deming was a major influence on me. Early in my career, I was working with a statistician I really respected, and he handed me an unpublished manuscript of Deming’s book Out of the Crisis and said, “You ought to read this.” I took it home, started reading, and after about an hour I thought, “This guy has got it.” I became a Deming fan on the spot.

For me, all that early BBS work was entirely consistent with Deming when it was done right. Deming is about process, about systems, about variation and continual improvement. That’s exactly the spirit in which I believe BBS works best—not as a way to find and fix “bad workers,” but as a way to improve the system through data, feedback, and engagement.

Rebecca: What about HOP? Some people see behavior, decision analysis, and HOP as competing approaches. Do you?

Tom: No, I don’t see them as incompatible at all. Done well, behavior-based approaches and decision analysis are quite consistent with HOP principles. HOP emphasizes that humans make mistakes and that systems need to be designed so that people are protected even when they err. I think that’s right.

When you look at SIFs through a decision lens and you look at behavior thoughtfully—not as a way to blame people but as a way to understand what’s happening in the system—you’re very much in line with HOP. These approaches can reinforce each other.

Conclusion: Leadership Actions to Create Safer Workplaces

Rebecca: If you had to leave leaders with a few key ideas from this conversation, what would you emphasize?

Tom: I’d highlight three things. First, with behavior-based safety, the way you do it matters enormously. Done badly, it drives blame and makes things worse. Done well, it engages people, builds capability, and makes the workplace safer. It is not one thing; it has to be understood and implemented with care.

Second, serious injuries and fatalities are different from smaller events. We were all wrong for a long time in assuming that reducing smaller injuries would automatically reduce serious ones. We now know that some small events have SIF potential and others do not, and that SIF precursors deserve their own attention.

Third, decision-making is at the heart of SIF exposure. Decisions made months or even years ago create the conditions for today’s events, often without anyone realizing the safety implications. If leaders can start asking, systematically, “What are the safety implications of this decision?” and “Are we creating or reducing SIF precursors?” they can change the trajectory of serious injuries and fatalities in their organizations.

A recording of the full webinar is available at  A CONVERSATION WITH TOM KRAUSE: Culture, Safety, and Driving Business Results.