Systems vs. Symptoms: We Need to Take a Deeper Look

Systems vs Symptoms

The Bureau of Labor Statistics just published its fatality statistics for 2019 and the results should concern us all.  Fatalities in 2019 jumped to 5333, the highest figure since 2007 and the fifth time in the last six years that we have seen an increase in fatalities.  Meanwhile, our total reportable incident rate (TRIR) stands at record lows.  What’s up!

As opposed to TRIR figures which are highly susceptible to pencil whipping, fatality data is hard to fudge.  Still, the data does imply that we are doing a better job of controlling non-serious incidents than with more serious incidents and fatalities.  There are, of course, various explanations for the disconnect between TRIR and fatality data.  I’ve concluded, however, that the principal cause is our fixation on addressing symptoms, such as unsafe actions and conditions, rather than the systems that spawn them. 

Many in safety still see safety primarily as a people problem rather than a systems challenge.  Attempting to control the worker, and his or her unsafe acts, consumes nearly the entire safety effort in many organizations.  But is much of this effort misplaced?

Nearly 40 years ago years ago management legend, W. Edwards Deming, argued that unsafe acts and human error were not so much personal failings as the product of system weaknesses – in short, symptoms, not causes! 

“The supposition is prevalent the world over that there would be no problems in production or service if only our production workers would do their jobs the way that they were taught. Pleasant dreams. The workers are handicapped by the system, and the system belongs to management.” (Deming, 1981).

Risk exists in an environment which is frequently beyond the workers’ influence. Risk and reliable performance are, therefore, systems issues, not personal issues. Bringing risk to an acceptable level begins with analyzing the work, not just the personal acts of the worker.

When you look at serious incidents and fatalities it becomes obvious that there are many system and cultural factors that often set us up to fail, or succeed, that are largely beyond the influence of the worker. For example:

  • Work hours and shift duration
  • Availability of resources (personnel, equipment, support, etc.)
  • Adequacy, and hierarchy, of controls
  • Production/time pressure
  • Inadequate skill set/training
  • Availability of safety equipment
  • Procedural adequacy
  • How safety issues are identified, tracked, communicated, and corrected (or not)
  • Maintenance of safety critical equipment
  • Human factors in design
  • How contractors are selected and controlled
  • How employees and contractors are hired, compensated, trained, and supervised

These, and other fundamental systems issues, not only factor largely in many catastrophic and fatal incidents, they are also principal determinants of worker behavior.  Unfortunately, rather than taking a deeper look at systemic factors impacting safety, we’ve kept doing pretty much the same traditional worker-focused tactics for at least 30 years.  Our workplaces are increasingly more dynamic and complex, however, and are populated by a new and different generation of workers.  Our safety efforts have not kept up.

Safety is an organizational challenge, not a personal problem.  If you primarily focus on the worker, without addressing the organizational culture and system weaknesses, you are only dealing with symptoms.  When you fail to meaningfully address these more fundamental organizational issues you are unlikely to achieve sustainable safety or do much to reduce to potentially more serious injuries and incidents.  Focusing on symptoms rather than root causes is like playing whack-a-mole safety where the same problems keep repeating themselves.  We can and must do better if we hope to reduce the frequency of serious incidents which continue to afflict so many of our industries.  Future articles will offer advice for how to identify and address systemic safety issues.

To achieve genuine progress the safety profession will need to break with much of the past and get smarter about what really drives organizational performance. We need to look at safety as a system, not a program, and commit ourselves to continuous improvement rather than just doing more of the same. American industry and commerce are changing much more rapidly than the safety profession. If we do not start to catch up, we could well find ourselves considerably less relevant, and employable, in the future.

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Jim Loud

Mr. Loud’s over 40 years of safety experience includes 15 years with the Tennessee Valley Authority (TVA) where he served as the supervisor of Safety and Loss Control for a large commercial nuclear facility and later as manager of the corporate nuclear safety oversight body for all three of TVA’s nuclear sites. At Los Alamos National Laboratory he headed the independent assessment organization responsible for safety, health, environmental protection, and security oversight of all laboratory operations.

Mr. Loud is a regular presenter at national and international safety conferences. He is the author of numerous papers and articles. Mr. Loud is a Certified Safety Professional (CSP), and a retired Certified Hazardous Materials Manager (CHMM). He holds a BBA from the University of Memphis, an MS in Environmental Science from the University of Oklahoma and an MPH in Occupational Health and Safety from the University of Tennessee.


Deming, E. W. (1981). Out of the Crisis. Massachusetts Inst Technology.

U.S. Bureau of Labor Statistics. (2019). Survey of Occupational Injuries and Illnesses Data – 2019. Retrieved on 3/1/2021 from

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