Safety management systems fail without one connected corrective loop

Most workplaces do not lack safety activities. They lack a safety management system that connects them. That was the core message from Jill Pulsifer, a workplace consultant with the Workers' Compensation Board of Nova Scotia (WCB Nova Scotia), during a webinar this week on building safety programs that keep pace with organizational change.

Pulsifer told attendees that when hazard assessments, written procedures, training and inspections are treated as separate compliance boxes rather than a connected process, the resulting patchwork behaves nothing like its designers intended. She coined a term for the pattern she says she encounters most often in her consulting work with Nova Scotia employers of every size.

The 'Frankenstein effect' behind broken programs

Pulsifer compared the way many safety programs take shape to Victor Frankenstein assembling his creature: piece by piece, with good intentions, but without a design for how the parts should work together. "I think that many safety programs have evolved into their current state much in the same way," she said, describing most as "built by an eager pioneer of safety who came before us."

The consequences show up in familiar ways, she said: outdated or conflicting written procedures, inconsistent training depending on who delivers it, and corrective actions that stall for months inside the Joint Occupational Health and Safety Committee process common to Canadian workplaces. Rather than tracing these problems to a common root, Pulsifer said most organizations respond to each one in isolation, adding a new form, a new control measure or another training session on top of what already exists. "We are just gradually accumulating more layers and more tools and more bulk," she said, describing the outcome as "death by documentation."

When workers stop trusting the program

Pulsifer argued the deeper cost is behavioural. When a worker consults conflicting or outdated procedures while completing a non-routine task, she said, they typically respond in one of three ways: ask a supervisor again, guess which version is correct, or improvise from habit. "None of these responses or choices indicate a problem with the worker," she said. "They would all be, I would argue, reasonable responses to what I would describe as a somewhat unreasonable situation." The underlying issue, she said, is that "we've transferred a risk management decision to the end user" instead of giving workers one clear, consistent direction.

From program to system: closing the loop

Pulsifer drew a distinction between a program, a list of steps for completing individual activities, and a system, in which the output of one activity feeds directly into the next. A hazard assessment should inform written procedures, which inform training, which is then verified through inspections and work observations, feeding back into the cycle. "A system connects activities through the flow of information," she said, adding that a fully compliant program only becomes valuable "when we start knitting those pieces together through the information."

That principle extends to the internal responsibility system that underpins occupational health and safety legislation across Canada, under which hazard information is meant to move up the chain of command rather than sideways to a safety committee or health and safety department. When a worker reports a hazard directly to a committee instead of a supervisor, Pulsifer said, the organization has effectively "axed out the department manager" and undercut the supervisor's own accountability for that area.

A single registry turns activities into a system

As a practical first step, Pulsifer recommended a centralized corrective action registry, even a simple spreadsheet in smaller workplaces, that pools findings from hazard reports, inspections, incident investigations and root cause analysis processes already common at Canadian employers and prioritizes them by the risk level of the hazard rather than by which process generated them. That structure lets a manager see overdue items and resourcing gaps across departments without cross-referencing separate inspection logs, meeting minutes and maintenance tickets.

"This isn't about going in and finger-wagging," she said. Instead, Pulsifer said the goal is to ask, "are we assigning these things to the people who have the authority, ability, resources to actually get them done?" Recurring procedure violations that persist even after procedures and training have been reviewed, she added, usually point to a supervision or leadership gap rather than a worker problem.

This article is part of our Monthly Spotlight series, which in July focuses on Contractor Management & Supply Chain Safety.