The Safety of Work

Drew and David discuss how falling injury rates can hide rising severity, why one country's data showed serious injuries but almost no minor ones, and how different reporting practices can make aggregate numbers meaningless. Most importantly, they describe what happened in the boardroom: with a single number, leaders speculated about causes, but with a second metric, conversations slowed down and became curious and data-driven. As Drew Rae puts it, "I can't give you a better metric. I can give you a metric that will give you a different type of conversation." The episode closes with four practical takeaways, including the case for continuous severity measures over categories.

Discussion Points:

• (00:00) Why injury reporting conversations matter and past metrics episodes
• (03:44) Introducing the Geddert Dekker and Rae paper on injury rates
• (07:24) What safety can learn from financial reporting
• (10:00) Research design and three ways to measure injuries
• (14:48) Case study one where falling injury rates hid rising severity
• (20:14) Case study two and why the combined rate stays stable
• (22:16) Case study three and inconsistent reporting across countries
• (27:23) How a second metric changes executive conversations
• (30:33) Practical takeaways including continuous severity metrics
• (37:14) The answer to our question is to add one more metric
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Quotes:

Drew Rae: "If you've got one number, that number can only do two things. It can go up, it can go down."

David Provan: "Once you've got one metric with nothing else to have the conversation around, you can tell any story you want about that metric."

David Provan: "Multiple metrics will result in better conversations than any one metric."

Drew Rae: "I can't give you a better metric. I can give you a metric that will give you a different type of conversation."

Drew Rae: "When I'm lying in hospital, the last conversation I want two senior managers in my organization to be having is should they classify me as a moderate injury or as a high potential event."

Resources:

Injury rates tell an incomplete story, but a more complete measurement narrative may be possible - Kevin Geddert, Sidney Dekker, Drew Rae. Journal of Safety Research, Vol. 98, 2026 (open access)

Paper:  Signs of safety: An investigation of how OHS professionals interpret injury metrics. James Pomeroy and Colin Pilbeam, Journal of Safety Research, 2025.

Organization:
 Construction Safety Research Alliance. 

Previous episodes referenced:

Ep. 136: What is the symbolic purpose of injury rates?

Ep. 133: How do policies and metrics shape the outcome of investigations?

Ep. 109: Do safety performance indicators mean the same thing to different stakeholders?

Ep. 104: How can we get better at using measurement?

Ep. 97: Should we link safety performance to bonus pay?

Ep. 85: Why does safety get harder as systems get safer?

Ep. 74: Is a capacity index a good replacement for incident-count safety metrics?

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The discussion traces how bonus structures, unrealistic targets, and "green" dashboards (99.4% on-time closure, later revealed as closer to 60%) pushed the lie from front-line workers up through management, with middle managers who once flagged the problem later normalizing it once promoted. As David Provan puts it, quoting the paper: "If you put workers in a position where it's very difficult, if not impossible, to meet the target, then organizations cannot be surprised if this results in gaming." The episode closes with five practical takeaways for auditing your own organization's incentive structures.

Discussion Points:

• (00:00) The paper – a case of collective lying
• (05:06) Pge and the dial before you dig background
• (08:16) The whistleblower and 110 million dollars in fines
• (12:44) Four types of lies and why organizations breed lying
• (24:19) The gas leak bonus scandal
• (28:09) When 99 percent on time hides the real number
• (33:59) How middle managers become senior managers and keep lying
• (40:34) You cannot blame workers for impossible targets
• (47:15) Practical takeaways for safety leaders
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Quotes:

Drew Rae: "Organizations are not made up of robots. If everyone is doing the same bad behaviour, this has got to be coming from somewhere other than individuals wanting to do the wrong thing."

David Provan (quoting the paper): "If you put workers in a position where it's very difficult, if not impossible, to meet the target, then organizations cannot be surprised if this results in gaming."

Drew Rae: "We're not lying. We're just turning off the alarm while we finish getting the order."

David Provan: "A safety culture, a good safety culture, is one that lets the boss hear bad news."

Drew Rae: "Yes, 100% we are lying about our safety performance."

 

Resources:

"A Case of Collective Lying: How Deceit Becomes Entrenched in Organisational Safety Behaviour" — Jan Hayes, Sarah Maslen, Paul Schulman, Safety Science, Vol. 176, 106554 (2024)

Open access: https://doi.org/10.1016/j.ssci.2024.106554 
Diane Vaughan — introduced by Drew for her concept of "normalization of deviance," developed from her analysis of the Challenger launch decision. Her book: The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA (University of Chicago Press).

https://press.uchicago.edu/ucp/books/book/chicago/C/bo23528040.html 

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David and Drew unpack six organizational uses of injury metrics — from controlling work and motivating the workforce to self-promotion and risk signaling — before distilling these into four broad symbolic meanings: management control, image management, risk management, and trust in leadership. The episode reveals that injury rates are unstable signs whose meaning shifts depending on context, observer, and organizational culture. Understanding the emotional and symbolic dimensions of these metrics is shown to be essential for any safety professional seeking to challenge, replace, or engage more honestly with the measurement systems that shape how safety is understood and acted upon in their organization.

Discussion Points:

Quotes:

Drew Rae: "People are not dumb. These criticisms are fairly easy to understand, and there are so many of them from so many different directions that people know these criticisms and believe some of them. But injury rates still happen. That puzzle needs to be understood."

Drew Rae: "Something could be a bad measure of whether you're actually safe, but a good measure of how your injuries are affecting these other types of risks that you're facing."

Drew Rae: "Safety activities are driven by affect — emotion matters. We do things in safety because we are afraid, or because we are uncertain, because we are anxious. And our safety activities change those emotions."

Drew Rae: "We've now got both pieces of the puzzle. We know that they don't work objectively, and we know that people keep using them because of these symbolic meanings. That's pretty much the full story about injury rates."

David Provan: "Be curious about the meaning that's being ascribed to the injury rates in your own organization."

Resources:

Related papers referenced in the episode:

Rae, A., Provan, D., Weber, D. & Dekker, S. (2018). Safety clutter: the accumulation and persistence of 'safety' work that does not contribute to operational safety. Policy and Practice in Health and Safety. https://www.semanticscholar.org/paper/Safety-clutter:-the-accumulation-and-persistence-of-Rae-Provan/5bef7afb671b32977f688afbffe328407cf48039

Hayes, J., Slotsvik, T.N., Macrae, C. & Pettersen Gould, K.A. (2023). Tracking the right path: Safety performance indicators as boundary objects in air ambulance services. Safety Science. https://www.sciencedirect.com/science/article/pii/S0925753523000814

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Drawing on Edmondson's extensive psychological safety research, the episode provides practical guidance for safety leaders seeking to improve workplace conversations. The framework reveals that effective safety communication requires more than encouraging people to speak up—it demands deliberate leadership to create environments where contributions are productive, silence is reflective rather than fearful, and meeting goals are clearly articulated. The findings offer significant implications for safety professionals working to enhance organizational communication and change management capabilities.

Discussion Points:

Quotes:

"The employee voice and silence literature is a lot more precise because it's looking at a specific question: what do people speak up about, when do they speak up, who do they speak up to, what do they say?" - Drew Rae

"A good meeting is when all participants are either contributing or processing with minimal withholding or disrupting." - Drew Rae

"It's not just that disruptive people take up time and space, they raise the threshold for others to speak up." - Drew Rae

"Where there's diversity in the room, race or gender, it can make this a little bit more difficult because people might feel personally vulnerable." - David Provan

"We want an environment that promotes productive conversations, and that environment is more about when and how we speak up ourselves." - Drew Rae

Resources:

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The conversation explores how humor serves psychological purposes beyond entertainment, often functioning to establish power hierarchies and devalue professional contributions. Through survey data and qualitative interviews, the research demonstrates that passive coping strategies prevent organizations from understanding the true extent of harm. David and Drew argue that the "just joking" defense creates ambiguity that makes harassment difficult to report, particularly when supervisors are the perpetrators, emphasizing that effective psychosocial safety policies must explicitly address humor-based discrimination.

Discussion Points:

• (00:00) Defining psychosocial safety versus psychological safety
• (03:07) Introduction to workplace humor research in construction
• (06:44) Research aims and the construction industry gender gap
• (11:31) Research methodology using surveys and interviews
• (15:07) Theoretical framework on humor as communication
• (20:10) Survey findings on sexual harassment experiences
• (26:24) How humor is weaponized as cover for harassment
• (35:36) Conclusions on devaluing professional contributions
• (40:08) Key takeaways and practical implications for organizations
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Quotes:

"The harms are real. When we talk about expanding safety into the psychosocial space, however you might feel about that framing and whether safety people are the right people to be managing it, when we're talking about people getting hurt at work, gender based humour is a hazard." - Drew Rae

"I think this is the ultimate, you know, safety is not the absence of incident reports. This is clearly something that's happening to 50, 60, 70% of participants in this study and obviously representative of the broader population. If you're getting no insight into this through any of your systems, then you need to go looking." - David Provan

"The fact that something's a joke is being used almost like weaponised to mask or shield what's actually going on, we need to just like get totally away from the idea that humour is an excuse. The question isn't, is this a joke or not a joke? Question is, what was the underlying purpose of that joke?" - Drew Rae

"If no one's complaining, get worried. We know it's happening. We know that people don't complain. If you're not getting any complaints in your work site, that's not an indication that there's no problem or no harm. That's an indication that people are not feeling safe to complain." - Drew Rae

"Jokes are fine, but not these jokes. And I think this paper really helps us understand where we might be able to draw a less fuzzy boundary around what people can and can't joke about in the workplace." - David Provan

Resources:

Resource Link: https://ascelibrary.org/doi/abs/10.1061/JMENEA.MEENG-7109

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The discussion explores three critical constraint categories: structural elements like mandatory timelines, organizational factors including resource capacity, and relational dynamics affecting investigator access to information. Drawing parallels beyond healthcare, they challenge listeners to reconsider their investigation frameworks, suggesting that organizations inadvertently create systems where investigators focus on meeting procedural requirements rather than generating genuine insights. The discussion emphasizes that effective investigations require adequate capacity, flexible timelines that accommodate complexity, and environments fostering open relationships that enable thorough inquiry and organizational learning.

Discussion Points:

• (00:00) Background on NHS patient safety system and 2 million annual incidents
• (09:11) Research method and the seven investigation principles
• (16:24) Investigation framework with three levels and timeline requirements
• (24:56) Finding one structural constraints and how timelines became the focus
• (32:41) Finding two organizational capacity and resource mismatches
• (37:07) Finding three roles relationships and the independence dilemma
• (42:37) Summary deadlines over diagnosis compliance over comprehension procedures over participation
• (45:36) Practical takeaways on timelines capacity and relationships
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Quotes:
David Provan: "The more hoops and hurdles and constraints and requirements that you put into the investigation process, the more that those things become the focus of the investigator, as opposed to the learning and improvement outcome that we're trying to achieve."

Drew Rae: "If you wanted to improve investigations in your organization, one simple leadership practice you could take is when someone gives you the investigation report, basically just say, no, there's nothing here that surprises me. Go away, come back and learn something."

David Provan: "These are the outcomes we're trying to achieve and the investigation takes as long as it takes. And if it's being held up for any reason, this is the process to check in on progress. As long as it's being worked on."

Drew Rae: "Investigations are way more about relationships than I think people realise when they're planning them. And so we've got to create an environment in which investigators can build and use relationships."

David Provan: "There's no reason that if you learn something during an investigation that you need to wait till the report signed off and finished before you do something about it... as soon as we learn something that we become curious or concerned about, we should act on it."

Resources:

Resource Link: https://www.sciencedirect.com/science/article/pii/S0925753525002243

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The findings reveal that invasiveness drives negative reactions more than the stated purpose of monitoring, with participants showing skepticism about AI's ability to accurately measure teamwork quality. The hosts emphasize that even well-intentioned monitoring systems introduce psychosocial hazards and stress, requiring organizations to carefully balance potential benefits against worker well-being impacts when implementing AI-powered team support systems.

Discussion Points:

• (00:00) AI team monitoring invasiveness, AI workplace surveillance
• (03:16) Research paper introduction and authors from Germany
• (04:48) Previous research on electronic monitoring and employee reactions
• (08:49) Study one methodology with invasiveness levels and video scenarios
• (12:12) Study two simulation with teams designing fitness trackers
• (17:46) Study one findings on invasiveness and fairness perceptions
• (24:07) Study two results and participant skepticism about monitoring accuracy
• (32:48) Practical takeaways on invasiveness levels and stakeholder management
• (40:42) Final recommendations on balancing benefits and invasiveness
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Quotes:

Drew Rae: "The moment you divide it up and you just try to analyze the human behavior or analyze the automation, you lose the understanding of where the safety is coming from and what's necessary for it to be safe."

David Provan: "We actually don't think about that automation in the context of the overall system and all of the interfaces and everything like that. So we, we look at AI as AI and, you know, deploying. Introducing ai, but we don't do any kind of comprehensive analysis of, you know, what's gonna be all of the flow on implications and interfaces and potentially unintended consequences or the system, not necessarily just the technology or automation itself."

Drew Rae: People are going to have reactions. And those reactions are gonna have a big impact on their willingness for you to do this in the first place...You can't just force it onto them… All the things that you're trying to improve might actually get worse because of the monitoring.

David Provan: "But I think this paper makes a really good argument, which is actually our automated system should be far more flexible than that. So I might be able to adjust, you know, it's functioning. If I know, if I, if I know enough about how it's functioning and why it's functioning, and I realize that the automation can't understand context and situation, then I should be able to make adjustments."

Drew Rae: Most people don't mind if their car is giving them feedback on their driving, but most people don't like it if their car is phoning home to your boss, giving information about your driving.

Resources:

Intelligent automated systems to support human teamwork: perceived invasiveness impacts team members’ psychological reactions negatively

The discussion centers on two key design principles: observability, which ensures humans can understand what automated systems are doing and why, and direct ability, which allows humans to steer automation rather than simply turning it on or off. Using examples from aviation incidents like Boeing's MCAS system and emerging AI technologies, the episode demonstrates how these 25-year-old principles remain relevant for contemporary automation challenges in safety-critical systems.

Discussion Points:

• (00:00) Background on automation and natural experiments in safety
• (04:58) Hard vs soft skills debate and limitations of binary thinking
• (08:12) Two common approaches to automation problems and their flaws
• (12:20) The substitution myth and why simple replacement doesn't work
• (17:25) Design principles for coordination, observability, and direct ability
• (24:33) Observability challenges with AI and machine learning systems
• (26:25) Direct ability and the problem of binary control options
• (30:47) Design implications and avoiding simplistic solutions
• (33:27) Practical takeaways for human automation coordination
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Quotes:

Drew Rae: "The moment you divide it up and you just try to analyze the human behavior or analyze the automation, you lose the understanding of where the safety is coming from and what's necessary for it to be safe."

David Provan: "We actually don't think about that automation in the context of the overall system and all of the interfaces and everything like that. So we, we look at AI as AI and, you know, deploying. Introducing ai, but we don't do any kind of comprehensive analysis of, you know, what's gonna be all of the flow on implications and interfaces and potentially unintended consequences or the system, not necessarily just the technology or automation itself."

Drew Rae: "It's not enough for an expert system to just like constantly tell you all of the underlying rules that it's applying, that that doesn't really give you the right level of visibility as understanding what it thinks the current state is."

David Provan: "But I think this paper makes a really good argument, which is actually our automated system should be far more flexible than that. So I might be able to adjust, you know, it's functioning. If I know, if I, if I know enough about how it's functioning and why it's functioning, and I realize that the automation can't understand context and situation, then I should be able to make adjustments."

Drew Rae: "There's, there's gotta be ways of allowing all the animation to keep working, but to be able to. Retain control, and that's a really difficult design problem."

Resources:

Link to the Paper

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You'll hear about BP's attempt to create a fairer process using eight new questions that focus more on system factors like management influence, procedural clarity, and organizational goal conflicts. They discuss how even this thoughtfully redesigned framework still resulted in predominantly individual-focused interventions, with 80% of actions targeting people rather than systems, despite classifying most incidents as system-induced errors. The episode provides critical insights for safety professionals questioning whether just culture processes add value or represent organizational clutter that should be eliminated entirely.

Discussion Points:

• (00:00) Introduction to just culture models and their problems
• (03:00) Historical context of Jim Reason's culpability framework and industry adoption
• (07:37) Introduction to the BP case study research paper and methodology
• (15:19) Existing BP just culture process and its implementation problems
• (21:27) Literature review findings on just culture model weaknesses
• (29:20) The eight question redesigned BP just culture framework
• (43:25) Evaluation of the new process and classification outcomes
• (53:25) Practical takeaways and system versus individual focus
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Quotes:

David Provan: "I think the problem with the just culture model is that we have a just culture model." 

Drew Rae: "If your system problem is, we are not leaning hard enough onto individuals to behave correctly, then you are not really doing system thinking." 

David Provan: "Even though we are saying that, you know, this is great because 79% of these cases have now been classified as system-induced errors, over 80% of the actions as a result of those system-induced errors are at the individual leve.l" 

Drew Rae: "Every single outcome from the process is some sort of statement about disciplining a person, even when it's not disciplining a person. That's still the focus." 

David Provan: "Any process that you put in place in your organization that doesn't have these quality management aspects is likely to be something that drifts away from its intended purpose." 

 

Resources:

Link to the Paper

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You’ll hear six key principles for effective behavioral substitution, drawing parallels between healthcare and safety contexts. They discuss how these principles can guide both the removal of ineffective practices and the implementation of new ones, emphasizing the importance of considering practical needs, existing skills, and organizational resources when making such changes. The episode provides valuable insights for safety professionals looking to improve their organization's safety practices through evidence-based substitution strategies.

Discussion Points:

• ((00:00) Introduction and episode overview on swapping as a decluttering strategy
• (00:59) Background discussion on behavioral science and de-implementation
• (02:27) Understanding decluttering and de-implementation in healthcare context
• (05:08) Example of de-implementation in clinical practice and patient care
• (06:55) Introduction to the paper and authors' background
• (16:32) First principle: Evidence and rationale for substitute behaviors
• (19:49) Second principle: Meeting both clinical and practical objectives
• (24:51) Third principle: Clear explanability of new practices
• (26:29) Fourth principle: Time considerations for substitute behaviors
• (28:30) Fifth principle: Alignment with existing skills
• (31:40) Sixth principle: Cost implications of substitute behaviors
• (34:39) Three practical takeaways and implementation strategies, the answer to this episode’s question
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Quotes:

"You can't swap out something that people believe works for something that they don't believe works." - Drew Rae

"A lot of the safety, if not all the safety work we do in organisations is about anxiety reduction, not necessarily about improving safety.” - David Provan

"Rather than thinking about decluttering as just what we can reduce or take away, it may be more useful to think about it as a process of gradually swapping out each thing that's not working well." - Drew Rae

"If you can't explain the substitute behavior with the same ease which you can explain the behavior that you want to be implemented, then people have to work a bit harder and they might go. Why are we making this all so complex?" - David Provan

“That's the point they're making here, is like maybe the patient doesn't need care, but that doesn't mean that we shouldn't acknowledge their need for care and their need to be taken seriously.” - Drew Rae

Resources:

The Big Six: key principles for effective use of Behavior substitution in interventions to de-implement low-value care

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