1. Health and safety is an emergent system property not the result of a single person's action or inaction, a single component or device, or procedure.  OSHA incidents rates are not an accurate measure of health and safety performance.

2. Many health and safety improvement efforts fail because they were not based on systems thinking.

3. Safety management systems must lead to system improvement through learning and action resulting from feedback and integration, not a bureaucratic exercise to create a paper program -- lots of three-ring binders full of stuff that no one will read or act upon, pretending that this is a health and safety system.

4. An organization's assumptions, biases and mental models significantly affect how health and safety is implemented. Don't believe everything your organization thinks!

5. Workers are a critical source of improvement because they are at the 'sharp end'.  They are continually adapting to ever changing circumstances (context)  to get the job done and be safe within the patchwork of procedures, methods, organizational factors and weaknesses, resource constraints and goal conflicts.  Given the opportunity, workers can lead operational learning and provide critical feedback to those at the 'blunt end' to facilitate organizational learning.  

6. The transformation from the old view to the new view requires sustained senior leadership action - not support or backing or some vague 'commitment'.  Only leadership can redefine safety and health as an organizational operational issue owned by operations.  New view leaders recognize that safety and operational issues are one and same.  The separation between the two is artificial misleading the organization and undermining continual improvement potential.

7. Current measures not only fail to accurately measure safety and health performance but often grossly mislead organizations.  Many organizations with award winning low incident rates have experienced catastrophic failures.  A new processes are needed to develop leading indicators. 








 

 

 

 

 

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