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What If the Information That Prevents Your Next Fatality Is Already in the Building?

Serious Injury and Fatality (SIF) rates remain stubborn because critical warnings get filtered out long before reaching executive decision-makers.

I have said this in rooms across the globe, and I will say it again here, because I believe it more now than when I started saying it. If our profession actually adopted and enabled the deliberate pursuit of dissent, structurally, not as a slogan, it would be the single greatest differentiator available to us in preventing fatalities and life-changing injuries. It would finally move a number that has barely moved since the term SIF (Serious Injuries and Fatalities) entered our vocabulary in the mid to late 2000s. Sit with that for a moment.

We have refined our lagging indicators. We have built leading indicators. We have layered on observation programs, life-saving rules, critical-risk protocols, and human and organizational performance principles. Much of it has helped, and yet the serious injury and fatality rate has stayed stubborn in a way the recordable rate never was.

We learned, importantly, that the two are decoupled. Doing well on minor injuries tells you almost nothing about whether someone is going to die. That discovery matters, but leaves us with a harder question most of us have quietly avoided: What is the mechanism that actually prevents the catastrophic event? Here is my answer. It is not new; it is just rarely operationalized.

The catastrophic event is almost always preceded by someone who knew. Someone closer to the work saw the warning earliest. The information existed. The problem was never that the signal was absent. The problem was that the signal did not survive the trip up or through the organization.

The Trip of Voiced Concerns

A concern is raised. The concern is filtered. The decision proceeds on a confident version of an incomplete picture. The consequence arrives, and the investigation finds the warning that was there the whole time. Notice where the failure actually lives. It is not with the decisions being made.

Most leaders, given good information, make good decisions. The breakpoint is one step earlier, at the filter, where information is being censored, intentionally or unintentionally. That is the place in your system where a concern gets softened, delayed, reframed, or quietly attached to the wrong person and dismissed for who raised it rather than what they said. The filter is where your leverage sits. It is also the part of the system that most organizations have never once examined.

That is the gap I keep pointing at. For decades, we have audited whether concerns exist. We have spent almost no energy auditing the journey those concerns take. Where do they slow down? Where do they die? Who decided not to escalate? What happened to the last person who tried? That audit is uncomfortable, which is exactly why it is the most valuable thing a safety leadership team can do this year, and it exposes how little protection our usual answers provide.

The Ideal Channel of Dissenting Views

An open-door policy is not a channel. A poster in the breakroom is not a channel. A town hall where the CEO says, "I want to hear bad news," is not a channel. Those are statements. A real channel has four things: a known route, a named owner, a response time, and a closed loop. If you cannot trace, for one specific concern, the exact path it would travel from the worker who raised it to the leader who can act on it, with the context intact and the urgency preserved, you do not have a channel, you have decoration. Decoration does not prevent fatalities.

Hoping for Employees to Speak Up is Not a Strategy

None of this requires waiting for a brave employee to speak up. Hoping for the brave employee is not a strategy. The institutions that have handled the highest-stakes decisions for centuries never relied on courage. They engineered the challenge in. The Catholic Church created the Devil's Advocate. Mossad created the Tenth Man Rule. Different eras, same insight: unanimity is a warning sign, and dissent belongs inside the process as a designated role, not at the edges as an optional act of bravery.

We already have proof this is buildable. When Alan Mulally took over a hemorrhaging Ford, his leaders presented every project as green for weeks while the company burned cash. The first leader who finally showed a red expected to be fired. Mulally applauded him. Within months the meetings looked entirely different, not because the business had worsened, but because people had stopped performing with certainty they did not have.

Recovery started there. That is what engineered dissent looks like in practice. It is not softer management. It is more honest management, and in the end, it is faster. I think of this as an economics argument more than a culture argument. Every organization pays a tax on its safety decisions. The only question is when. You can pay it on the front end as slower meetings and harder conversations, or you can pay it on the back end as investigations, settlements, lost trust, and lost lives. The front end is always cheaper, by a wide margin. But that is the trade we keep declining to make.

My Challenge to You

So here is what I would ask you to do before this time next week. Pick one real safety decision currently in motion. Assign someone, by name, to argue the other side, and give them air cover to win that argument. Then trace the path a concern would take to reach you, and find the one place it would most likely die.

Finally, carry this question back to your team: who in your organization has tried to tell you something important about safety, and how would you know if they have stopped trying? If you cannot answer it, the most important information in your safety system is already invisible to you. The good news is that this is fixable.

It is fixable by structure, by ritual, and by leaders willing to go first. Nobody is going to build that capacity for you. The dissent capacity of your organization is the dissent capacity you choose to build. There is no third option, and I am increasingly convinced this is the one we have left to try.

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