Why Serious Injury and Fatality Prevention Efforts Stall

Studying the Data

RIn 2010, Dr. Tom Krause and his team sponsored the first major study on serious injury and fatality prevention. The study was triggered by data showing that recordable injury rates were declining while fatal injuries were remaining level or increasing.

Nine global organizations came together to study the problem and concluded that the trend resulted from applying an outdated prevention model. This traditional model assumed that reducing minor incidents at the base of the safety triangle would automatically reduce serious injuries and fatalities. The problem with this approach is that it does not target the precursors associated with SIF potential (SIFp) incidents. Additionally, the control systems and verification processes are not robust enough. Identifying and controlling exposures with SIF potential requires a critical risk management system embedded in operations, leadership, and governance. Watch this video to learn more about the study.

When well implemented, a SIF Prevention program will reduce not only life-altering, life-threatening, and life-ending exposures and incidents, but also non-SIFp incidents as well.

Since the original study, multiple additional country and industry-specific studies have reinforced the original findings. These studies have led to the widespread adoption of the SIF Prevention concept.

In January 2026, the American Society for Testing and Materials published Standard E2920-26, Guide for Recording Priority Occupational Injuries and Illnesses and Serious Injury or Fatality (SIF)-Related Serious Injuries/Illnesses and Fatalities. Learn more in A Response to the ASTM Reporting Standard.

Implementing and Sustaining a SIF Prevention Program is Not Without Its Challenges

BIn discussions with executives and safety professionals, they expressed concern that their program is not delivering as promised. These leaders have a perception that the program has lost momentum and is not advancing. We suspect they are correct.

Before discussing the challenges organizations face with implementation and sustainability, let us review the three distinct phases of implementation.

Phase 1: Alignment and Focus

A successful SIF Prevention strategy begins with senior leadership understanding the science behind the approach and recognizing the value the system can bring. Once leadership accepts the approach, the organization is ready to develop an implementation plan. There are multiple facets to the implementation plan, including:

• Integration of SIF Prevention into the Governance System
• Identifying SIF Precursors (High-risk tasks with inadequate controls):
  • Immediate Causal Exposures
  • Which exposures within each Causal Exposure will be classified as having SIFp
  • High Risk Task: Tasks with a known SIF exposure
  • Amplifiers: Conditions, factors, or situations that increase the severity of a hazard or increase the probability that an exposure will go uncontrolled
• Identification and Evaluation of Critical Controls
• Modification of the:
  • Incident Reporting and Investigation program
  • Incident Management system
• Expansion of Knowledge and Acceptance
• Creating SIF Prevention Metrics

It is during this phase that the organization must set up an implementation team with cross-departmental representation. Depending on the size of the organization, the implementation plan could easily stretch across 2 years.

In summary: Phase 1 is about setting up a winning game plan.

Phase 2: Making Exposure Visible and Understanding Exposure

Phase 2 requires substantial heavy lifting. During this phase, it is important to establish a historical perspective. This historical perspective includes understanding the:

• Causal Exposure Profile For All Incidents
• Frequency of SIFp Incidents
• List of Tasks with Known SIF Exposures
• Controls that are Designed to Rein in these Exposures
• Amplifiers that Increase the Probability that an Exposure will go Uncontrolled

This information is crucial for aligning language, expanding understanding and acceptance, and for adapting activities and systems.

Phase two also requires setting up a mechanism to, in near real time, identify incidents having SIF potential. In this phase, when an incident occurs, the organization must quickly determine the causal exposure and SIFp. Incidents with SIFp would receive elevated attention, including a root cause analysis (RCA). Additionally, for each SIFp incident, the organization needs to push for corrective actions that address the hazard, such as elimination, substitution, or engineering. Regarding incident investigation, the organization must look at how investigation results turn into organizational learning.

With the SIF Precursors understood and a baseline analysis completed, it is during Phase Two that the development of leadership knowledge across all levels can begin. Additionally, safety activities like safety contacts, job safety briefings, and critical control verification can be adapted to include a SIF Prevention focus.

In summary: Phase 2 is about setting up a solid defense.

Phase 3: Eliminating Exposure Pools and Linking Exposure to Decision Making  

The final component of SIF Prevention involves moving from reacting to incidents to proactively:

• Identifying SIF Exposures
• Verifying that Critical Controls Are Deployed Correctly
• Addressing Amplifiers
• Understanding How Decisions are Influencing SIF Exposures

One critical change during this phase is moving the organization away from defining safety success as a reduction in incidents and moving toward a multifaceted set of metrics.

In summary: Phase 3 is about taking the offensive.

Making a Long-Term Commitment

BFor most organizations, it can take years to move through the three phases because of turnover, changes in processes, and the introduction of different amplifiers. This leads to an organization never really completing the implementation. However, organizations with sustained success move the SIF Prevention methodology from being an EHS-driven effort to an effort that is integrated into all facets of the organization.

In phase 3, there is a powerful opportunity to leverage the power of behavior-based safety. Assuring that critical controls are being properly utilized and understanding how risk accelerators are being mitigated are perfect targets for BBS.

By now, you have determined that there are multiple causes for the SIF Prevention system to stall or even fail. Let’s look at the most common.

Causes of Stagnation or Failure

While there can be a variety of reasons a program fails, from our experience and discussions with Executives and EHS professionals, we find these to be the most common:

1. Lack of a comprehensive implementation plan: Success starts with a robust plan.
   Moving to a SIF Prevention approach requires a change in mindset, a change in systems, an understanding of the barriers to success, and a systematic approach to change. Adopting a system where EHS identifies which incidents have SIFp is not a SIF Prevention program.
2. Believing that once an implementation phase is complete, it does not need to be revisited.
   Even with a robust implementation plan, there is a need to continually review the status of the implementation. Key questions to consider:
   • How effectively are new leaders being introduced to the system?
   • Are incidents being classified accurately?
   • Are the metrics associated with the effort understood and discussed at the appropriate levels?
   • Has the incident reporting system been modified to collect crucial SIF Precursor information?
   • Have Operations taken ownership of the program?
   • Is the organization working diligently to find hazard-focused controls?
   • Are there multiple methodologies for uncovering SIFp exposures?
3. SIF Prevention remains an EHS-owned effort.
   Organizational Leadership own successful safety efforts. EHS can build a great program, but it is not until leadership embraces the program that it truly thrives. When leadership owns the program, it means they understand the basis, accept that it will reduce the likelihood of an actual SIF event, and are focused on the right metrics. EHS does have a role – it needs to monitor the program, provide data and analysis, make program enhancements, and provide expertise on how to move from a person-focused set of controls to a hazard-focused set of controls.
4. Failing to move to Phase 3 where exposure pools are eliminated and linked to decision making.
   Phase 2 is a heavy lift. There is substantial education that needs to occur; the number of incidents requiring root cause investigation increases, the incident management system requires updating with users being trained on the new system, and there will be increased pressure to find hazard-focused versus people-focused controls. The organization will also need to take a serious look at the effectiveness of action item implementation and whether there is an appropriate organizational response.
5. Failing to move away from measuring success based on lagging indicators.
   This may seem minor, but this signals a failure for organizational leadership to understand the SIF Prevention concept. It is problematic to SIF Prevention if leadership discussions and performance management systems continue to be related to lagging indicators like ASTM Level 1 and Level 2 incidents, reportability, recordability, or any other lagging metric. SIF Prevention provides an opportunity to introduce multiple new metrics that provide insight into the health of incident reporting and prevention. For a subset of these metrics, the focus should be on an upward versus a downward trend. For example, with unsafe conditions and incident reporting, more is better.

SIF Prevention is Well Worth the Effort

The challenge is that moving from an outcome-focused to a potential-focused system requires not only a systems shift, but more importantly, a mental shift. Senior Leadership must ensure that the SIF Prevention Program is adequately resourced and ownership of the effort is transferred from EHS to the whole of the organization.

At Krause Bell Group, we believe that SIF Prevention can have as dramatic an impact on strengthening the culture and reducing serious injuries and fatalities as behavior-based safety had in the 80’s and 90’s. We have had the privilege of helping organizations develop strategic plans for the implementation of SIF Prevention programs and for getting others back on track.

Learn more about Krause Bell Group’s capabilities and methodologies.