INVISIBLE ICEBERGS: LATENT SAFETY RISKS AND THEIR TOLL ON SAFETY PERFORMANCE
In commercial transportation, safety performance is often measured by what is visible - crash rates, incident reports, CSA scores, and compliance…
Every organization has two versions of work: the work described in policies, procedures, and training materials, and the work employees actually perform each day. This difference, often referred to as the gap between work as imagined and work as done, exists because real-world operations are far more complex than any written procedure can capture.
Organizations that do not consider the differences between work as imagined and work as performed may continue to see fluctuating claims outcomes. Employees routinely adapt to changing conditions, equipment limitations, staffing challenges, and customer demands. While these adaptations are often necessary for success, organizations can create risk when they fail to recognize how work is truly being performed. Bridging this gap is essential for improving safety, operational performance, and organizational resilience.
Understanding Operational Reality
Work as imagined reflects how leaders, managers, and safety professionals expect tasks to be performed. It assumes work will occur under reasonably predictable conditions and follows established procedures.
Work as done reflects actual operating conditions. Employees regularly adjust their methods to address unexpected challenges and keep work moving forward. These adjustments are not always signs of noncompliance. In many cases, they are practical responses to real-world demands.
Organizations that rely solely on procedures, audits, and compliance metrics can often develop an incomplete understanding of operational risk. While these tools provide valuable insights, they may not capture the challenges employees face in the field. To improve safety and performance, leaders must understand how work is actually accomplished, recognize the adaptations employees make, and identify opportunities to better align expectations with operational reality.
Learn From Employee Adaptations
Employees often develop workarounds and adjustments to overcome obstacles and maintain productivity. While these adaptations may help meet operational demands, they can also create latent conditions that increase risk over time. Latent conditions often arise when exceptions are made to established practices, such as hiring standards or safety requirements, including allowing drivers to exceed speed limits to meet business needs.
When leaders tolerate such exceptions to safety practices, they can influence the organization's safety culture. Employees may view these exceptions as acceptable behavior, leading to the gradual normalization of similar deviations throughout the workforce. Rather than immediately treating these actions as violations, organizations should seek to understand what these adaptations reveal about the system. Examining why employees feel the need to adapt can uncover underlying gaps, barriers, or inefficiencies and provide valuable opportunities for continuous improvement.
Increase Frontline Engagement
One of the most effective ways to bridge the gap between expectations and reality is through direct engagement with employees. Leaders should spend time in the field observing work, asking questions, and listening to employees describe the challenges they face. These conversations can reveal operational concerns that are not visible through reports or performance metrics.
By developing a deeper understanding of daily work activities, leaders can identify obstacles, inefficiencies, and risks before they contribute to incidents or operational failures.
Observe Work Before Changing Procedures
Procedures can be most effective when they are based on actual work practices rather than assumptions. Before creating or revising procedures, organizations should observe the task being performed under normal conditions. Doing so helps identify where procedures may be unrealistic, overly complicated, or disconnected from operational needs. When employees consistently deviate from a procedure, leaders should seek to understand why. The issue may lie not with the worker, but with the process itself.
Involve Employees in Safety Decisions
Frontline workers possess firsthand knowledge of the tasks, hazards, and challenges associated with their jobs.
Organizations should involve employees in risk assessments, procedure development, and process improvement efforts. Employee participation not only can improve decision quality but may also strengthen trust and engagement throughout the organization.
Focus on Systems, Not Blame
When incidents occur, organizations often focus primarily on individual actions. While behavior is important, lasting improvement requires understanding the broader system in which people work. Effective organizations examine factors such as:
By addressing systemic issues, organizations can reduce risk more effectively than by focusing solely on individual mistakes.
Learn From Success
Many improvement efforts focus exclusively on failures, incidents, and near misses. However, organizations can learn just as much from understanding why work succeeds. Every day, employees manage risks, solve problems, and adapt to changing conditions without incident. Studying successful performance can help organizations identify practices and conditions that support safe and reliable operations.
Understanding what goes right can provide insights that are just as valuable as understanding what goes wrong.
Conclusion
The gap between work as imagined and work as done is a normal part of organizational life because procedures, policies, and plans cannot fully account for the complexities and variability of real-world operations. Organizations that effectively bridge this gap actively seek to understand how work is actually performed by engaging employees, observing tasks firsthand, involving frontline workers in decision-making, and focusing on system performance rather than individual blame. By recognizing operational realities and aligning expectations with the conditions employees face every day, leaders can make better-informed decisions, strengthen safety, improve performance, and build a more resilient and adaptable organization.
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