Why Safety Procedures Don’t Always Lead to Safe Behaviors

For most of the last 70 years or so safety leaders have emphasized the importance of safety-related behavior. On the surface, it seems obvious that their approach is the right way to think about it. Following a safety breach, the line of questioning centers around why the incident happened. And the answer usually comes down to how the workers didn’t follow procedures. Therefore, they reason, if we fix the worker and change the behavior, we’ve solved the problem. Right?

Not really. In some instances, worker behavior actually was the cause of the incident. But these are the exception rather than the rule. A closer look at the context in which the behavior occurred shows that the great majority of the time a series of leadership decisions had been made that influenced and set the stage for the workers’ behavior. Yes, the explosion was triggered by the worker’s failure to follow the procedure, but the procedure was cumbersome, overly time consuming, and the “norm” in the facility was to go around it.

Frontline leadership may know that this is the case. Or it may have slipped into the background. “Have we had any incidents because of this?” may have been asked, but it’s the wrong question. The absence of injury isn’t reassuring if the potential for injury is high—especially if the injury potential could be life changing or fatal.

Gemba walks—a management practice of walking through the work site and observing workers in action—are highly effective if done properly, which means that it leads to meaningful safety conversations. This is the process that brings important exposures to light.

The state to avoid is called “normalization of deviance” in technical terms. It means that the culture of the organization has set a “new normal” in which work is done unsafely and goes unnoticed until an incident occurs.

Sadly, it may take an explosion and a severe injury to make visible at the leadership level that the burdensome procedures were disregarded.

We’ve been studying this for the past 10 years and have analyzed hundreds of SIF events (serious injuries and fatalities) across a range of different organizations. In our work of identifying the decisions that lead up to the event, we’ve found that the cultural attributes of the organization usually contribute significantly to enabling a disaster to occur.

For example, poor upward communication is a common type of cultural failure that leads to lives being lost. This is more than “we don’t really have a strong culture of safety here.” It extends to how well employees feel supported in pointing out a problem that should be confronted. Or whether they feel free to say, “I need help figuring this out” without a negative repercussion. If the cultural environment is to only tell management what they want to hear, safety will quickly diminish.

The extent to which your organization values safety is a cultural attribute, but it’s one of many. By itself, valuing the safety of employees has influence, but how far it reaches depends on a set of cultural attributes that influence performance broadly.

So, what needs to happen to ensure a culture that contributes to good performance? Start by understanding what organizational culture is, then assessing your strengths and weaknesses, and then developing a plan and strategy to close the gaps.

Understand that there’s what we do and how we do it. The latter is the cultural part. If restructuring requires layoffs, for example, it isn’t so much that people were laid off that’s remembered. It’s how they were treated that sticks. Were people talked to, was the necessity explained, were questions answered, was appreciation and respect shown? Or, were people notified by email and then shut out of contact? 

Trust, communication, credibility, and justice are important cultural attributes that predict performance outcomes, which include safety alongside productivity, absenteeism, job satisfaction, and turnover. This is why performance improvement broadly tends to lift safety performance, and it goes in the other direction as well.

If you want to improve safety, take a look at the culture of your organization and the ways in which your leaders are generating it. You’ll find that leadership decision making is central, and employee behavior is peripheral. Both are important, but understanding how they work together is essential.

This article was originally published in in EHS Daily Advisor in March 2025

To explore organizational culture in greater depth, you can read Tom Krause’s book If Your Culture Could Talk:  A Story About Culture Change.