Becoming Safer, by Design: Reducing Operational Risk

"Design is not just what it looks like and feels like. Design is how it works."

— Steve Jobs

The Challenge: Investigating Incidents Keeps Organizations One Step Behind

Organizations invest heavily in safety programs, yet incidents continue to occur with frustrating regularity. The pattern repeats. An incident happens, an investigation follows, corrective actions are assigned, and everyone returns to work assuming the problem is solved. Until the next incident.

This reactive cycle persists because most safety systems are designed around compliance and incident response rather than prevention and capability building. Safety lives in policies and procedures that don't reflect how work actually gets done. Leaders make decisions based on lagging indicators such as incident rates and lost-time injuries that only tell them where they've already failed.

The fundamental problem isn't lack of effort or commitment. It's that safety is treated as something added to work rather than designed into it. Procedures are written for ideal conditions. Training focuses on standard cases. Investigations look for individual actions to correct rather than system conditions that need improvement.

By the time an incident signals a problem, someone's already been hurt. A process has already failed. Trust has already eroded. The system has been showing signs of stress long before through near misses, workarounds, overtime patterns, and the daily trade-offs people make under pressure. But without intentional design to capture and act on these signals, organizations remain blind to risk until it manifests as harm.

In a previous article, we explored the three blind spots that keep organizations stuck in reactive mode, such as the wrong diagnosis, the checklist trap, and the failure to anchor. These five shifts are practical for breaking free from those patterns.

The Opportunity: Design Safety Into Everyday Decisions

When safety is designed into work from the start, organizations gain the ability to see and respond to risk before it causes harm. Patterns become visible early. Systems support better decision-making in the moment. People develop the capability to handle variability and exceptions, not just follow checklists for standard cases.

This shift from reactive to proactive safety doesn't require massive technology investments or wholesale reorganization. It requires changing where attention goes and how work is designed. Instead of investigating only after incidents, organizations can learn from the everyday signals their systems are already generating. Instead of blaming individuals for poor decisions, they can examine the conditions that shaped those choices and remove the traps that make failure likely.

The prize is substantial. Reduced operational risk, increased resilience, and a workforce that doesn't have to choose between safety and getting the job done. When safety is built into workflows, procedures, and decision-making structures, it stops competing with productivity and starts enabling it. People can work safely not because they're more compliant, but because the system makes safe work easier than unsafe work.

Organizations that embrace this approach move from managing safety as a compliance burden to leveraging it as a strategic capability. They catch problems upstream. They adapt faster to changing conditions. They build cultures where people speak up because systems are designed to listen and respond.

The How: Five Strategic Shifts

Shift 1: From Incidents to Indicators

Focus on patterns, not just events

Stop waiting for incidents to tell you where problems exist. Instead, identify and track a few key indicators that reveal system stress before it results in harm. Near misses, rework, overtime patterns, and schedule pressure all signal increasing risk. The key is reducing noise by choosing indicators that matter and reviewing them consistently. Pick one indicator and examine it frequently enough to spot trends. When investigating concerns, document system conditions such as workload, resource constraints, and competing priorities before identifying individual actions. This reveals the environmental factors that shape behavior.

Shift 2: From Blame to System Learning

Investigate systems, not individuals

When something goes wrong, the instinct is to identify who made the mistake and retrain them. But individuals operate within systems that shape their choices. Poor decisions often reflect rational responses to difficult conditions such as inadequate resources, conflicting priorities, time pressure, or misaligned incentives.

Effective learning means understanding the conditions that shaped decisions rather than simply correcting the people who made them. Look for system traps, which are situations where the wrong choice is easier, faster, or more rewarded than the right one. Remove these traps through better design, clearer priorities, or improved resources. Only after addressing systemic contributors should individual capability be considered.

Shift 3: From Compliance to Capability

Build capability, not just checklists

Procedures are essential for standard work, but they can't cover every situation. Gaps emerge during handoffs, exceptions, and time pressure, precisely when risk is highest. Compliance-focused safety assumes procedures are sufficient; capability-focused safety recognizes that people need judgment, skills, and support to handle variability.

Design supports for the natural variation that occurs in people, time, and task complexity. Build in considerations for exceptions, not just standard cases. Most importantly, treat workarounds as valuable feedback. When competent people consistently deviate from procedures, the procedure likely doesn't fit the reality of the work. Use these signals to improve design rather than punish deviation.

Shift 4: From Work-as-Imagined to Work-as-Done

Design for real work, not ideal work

There's often a gap between how leaders imagine work happening and how it actually gets done. Procedures describe ideal conditions. Training covers standard scenarios. But real work involves workarounds, shortcuts, and informal steps that emerge from practical necessity.

This gap isn't evidence of poor discipline. It's evidence that the formal system doesn't match operational reality. Close this gap by understanding how jobs are actually performed. Observe work directly. Talk to practitioners about the differences between procedure and practice. Then remove friction by improving tools, streamlining workflow, and ensuring information is available when and where it's needed. Make priorities visible in schedules and resource allocation so they align with stated goals.

Shift 5: From Slogans to Everyday Decisions

Reinforce decisions, not just messages

"Safety first" or "Safety is a top priority" are common slogans, but what happens when schedule pressure mounts, staffing is short, or goals compete? Daily work is full of trade-offs, and the choices people make in these moments reveal true priorities far more than any poster or speech.

Safety becomes real when it's reinforced through decisions rather than just communicated through messages. Identify where trade-offs appear in daily work such as schedule pressure, staffing gaps, and competing goals, and make priorities clear through how time, attention, and resources are actually spent. When leaders consistently choose safety even when it's costly or inconvenient, the message becomes credible and actionable.

Take Action Today: Choose Your First Move Toward Prevention

Don't try to boil the ocean. Instead, assess where your organization stands and choose which of these shifts to focus on this month.

Ask yourself these questions:

✅ Which shift is your strongest today?

🎯 Which shift is your biggest opportunity?

Your strongest shift represents capability you can leverage. Your biggest opportunity represents where focused effort will yield the most significant impact.

Then take one concrete action:

1. Shift 1: Choose one leading indicator (near misses, rework, or overtime) and establish a weekly review rhythm
2. Shift 2: During the next incident investigation, list out various system conditions before identifying any individual actions
3. Shift 3: Identify one known workaround in your operation and ask why competent people use it instead of the formal procedure
4. Shift 4: Shadow someone doing frontline work and note every difference between procedure and practice
5. Shift 5: Review the last significant decisions made and determine what was revealed about actual priorities?

Share your chosen shift with your team. Discuss what success would look like. Set a checkpoint for one month from now to assess progress.

Safety isn't shaped by chance. As Steve Jobs reminds us, "Design is not just what it looks like and feels like. Design is how it works." Safety works when it's designed into every decision, every system, every day.

Safer, by Design.