By William C. Pope

Today a function of industrial safety must play a forceful role in shaping the way management manages by identifying rocks and shoals of bad decision making that causes misuse of corporate resources—human and material. Real service of the safety practitioner has more to do with management performance than mistakes of labor. Democracy within the work place does not pit one against the other in matters of industrial mishaps. Many corporate safety people fail to rise to this challenge because their management culture simply does not equip them to do so. Without realizing the potential of this function's contribution to excellence—strategy, style, systems, procedures, and principles — management tends to select a technically oriented person to run it.

True, improvement opportunities open up at the shop level but the ultimate process of correction resides at staff and executive levels of organizational systems. And these managers are, for the most part, concerned more with organizational malaise than mechanical mishaps. The best way to get more out of a safety manager is to select one who can address basic issues of management practice and risk taking to support engineering expertise for protecting people and things.

Many specialists in error-free performance are positioned to comply with demands of an organizational system that emanate from a part of the complex that does not understand and is, therefore, not really interested in day-to-day problems of man, machine, environment relationships. "Just do what must be done locally and don't rock the boat of busy executives" is the gap that keeps performers out of touch with tellers. The people within the work force becomes frustrated and indifferent when there is no ombudsman to carry the message through to the proper component official having responsibility to listen and act. Loyalty and commitment to goals of systems go down the drain without response to get things done right. But there seems to always be time and money to do things over. This is a factor to which a good safety function can, with appropriate support, give needed attention.

It is difficult to fault the dedication of managers as individuals in an entrepreneurial system. But system's reliability, the basis purpose, cannot be depended on if work is not done as planned—without performance mishaps. All operational mishaps should and can be reported. A safety function can be made responsible for investigation of anomalies (unexpected events or unexplained departures from past experience) that occur in plant operations. This is a key ingredient in any reliability and quality assurance in an effort to prevent loss directed by the corporate safety manager.

Pundits of management principles and practices would think they are demeaning quality control to label it as it is—error-free performance. But it would be hard to argue against: mishaps are symbols of mismanagement and will always downgrade its quality if it is performance measured. Without a problem-awareness safety function, informed decision making by key managers will not be possible. Failure history will not be maintained for study and future directing of planning, directing, and controlling.

Industrial mishaps are to industrial systems as disease is to the human system. In his scientific paper, "The Epidemiology of Accidents," Gordon pointed out rationale of equating industrial mishaps with biological diseases. His reasoning stimulated the conceptual framework for relating complex aspects of industrial mishaps to health of the corporate enterprise. This approach sought reasons for actions, conditions, and management in the organizational system with the same degree of intensity and basic research found so useful in the study of gross incidence of infectious and noninfectious diseases in the biological system.[1]

Gordon's concept brought about the development of a triadic approach to all industrial mishaps. It involved the use of three systems found in all mishaps by essentially sorting out failures of each system contributing to the total mishap. An orderly process was designed to collect data from a massive number of reports involving all first-aid cases in addition to minor, disabling, and fatal events. In order to obtain descriptive epidemiology of industrial mishaps in large heterogeneous groups, all repairs to tools and equipment were included in the study, as well as substantive losses due to fire, explosion, water damage, theft, etc. Industrial health claims as well as customer complaints and product liability suits were examined in the broad study of industrial mishaps. These were then grouped into three basic systems—biological, physical, and social. As the study progressed, certain causes relating to them began to appear. Being epidemic in nature, they demanded closer review by decision makers who were doctors of management practices and who could determine elements and principles of that practice being ignored or misused.

Most organizational systems today have some type of safety and health function acquainted with a band-aid operation to handle symptoms of serious industrial diseases. Here, a clinic of basic research is needed. Those assigned to diagnose reasons for managerial oversights may be selected without thought of qualifications; they are untrained and biased in their diagnostic views since they are predominantly supervisory managers called upon to critique the system they are serving.

Science Devoted to Management Improvement

More study about the science and use of the general theory of systems is needed than can be covered in this article. Other questions will come to mind: What systems must be covered? What practical use for them can be built into a new program designed to impress management? What changes are involved in the way of thinking, and what changes will occur with those managers who will now become more closely involved? Triadic analysis of flawed systems (TAFS)© is the answer to any curious manager who must ask how the function can be modified to do more than search, find, and change unsafe acts and conditions, and become a viable tool for evaluating management performance of systems.

Volumes of reasons for and correction of unsafe acts and conditions as factors of operational errors have been written. Very little however, has been done to cope with the influence of poor practices of management. The third factor of functional mismanagement lies dormant as an influence in unplanned, unwanted events other than to say "management has a responsibility for industrial safety and health." More attention directed toward substandard applications of a science of management improvement is needed by this responsibility.

While the TAFS approach to a new look at the safety mission deals with acts and conditions important to its objective, even more emphasis will be given to the way people and things are directed and controlled—important coordinates of an organizational system and its performance.

Management inputs into performance imperfections its need to revise policy, change instructions, study the financial picture, review authority and responsibility patterns, and the like. The production engineer sees a need to check design, placement, materials control, efficiency, quality, etc. Labor wants greater employee protection, better work conditions, stepped up benefits, more corporate involvement, more pay, and reduced workloads, The safety manager should be able to translate these forces into general desire of each to improve each office's own position in the organizational system itself by removing human errors, hardware failures, and management oversights.

Systems safety management is the process of melding unrelated resources of an organizational system (men, materials, machines, and money) into a total force that operates without failures. One should recognize quickly that this is also the task of practicing managers and not just an assignment to a safety function. For this reason, the task of all systems safety managers is to get things done by, with, and through other managers by guiding them to performance perfection in their work as well as the work of those they supervise.

Both safety professionals and managers they serve might consider the following steps to TAFS in order to set up a program with specific objectives for a systems operation.

1. Break away from traditional thinking about mission of a safety function: management improvement not accident prevention. Think positively and use words that generate interest of top management. Use safety jargon only with safety people.

2. Study the organizational system and its parts. With the aid of functional leaders, identify each system objective and how the safety function can be married with that purpose. Use a team approach, not a one-on-one concentration dealing with employee issues.

3. Expand the purpose of collecting and diagnosing systems' flaws (remember we are talking about all three systems) using a triadic approach to problem solving operational errors. This means educating top managers about what is new.

4. Blame systems for flaws and not personnel for faults. No one spends much time blaming himself for errors. Develop an unbiased report network. Give awards for the most operational-error reports, not the least, on the basis that first-aid cases are just as important in studying triadic causes as fatalities. Results of operational errors are not important to TAFS.

5. Redesign the reporting document to eliminate fault finding and make it compatible with computer analysis in order to handle the increase in report response by those who want to complain about system flaws.

6. Use the epidemiological approach to problem solving operational errors. Detect specific problems involving management in an effort to research changes needed to remove them. This will not be easy but solutions to real losses demand constant study just as cancer research must continue in the medical field.

7. Learn how to develop a cause-code dictionary and diagnose basic problems of risk. Design reports on specific safety issues applicable to the work. Use rifle, not shotgun tactics with management malpractice.

8. Do not overlook outside influence on the system. Customer complaints, sick leave for employees, excessive repair and maintenance, company security, and similar trade-offs are all related to flawed systems and communications networks you built.

9. Your bottom-up communication about what management is doing to retard hands-on safety and health is a great retrospective feature of mass reporting of operational errors. It will evaluate risk management in a way never before realized by staying close to the customer, employee, supplier, and general public anticipating what they think, feel, and act before it is too late to change the system.

10. Introduce an educational program for labor/management (not safety and health training already being used) to get employees and management talking to each other. Be generous with praise by making awards based on rates of system flaws (operational errors), not work injuries that have a stigma of blame.

Those familiar with behavioral science will see a trend in TAFS toward following principles of McGregor, Herzberg, Maslow, Argyris, Blake, and others (Behavior of management is an important factor in the study of its practice). They should also see that there is a wide variety of approaches used by TAFS to attract attention of high-level decision makers.

To Report or Not to Report?

As deviations from standard performance occur, operational errors are also happening. Every industrial action has potential for operational error. Logically, all will not be investigated. Our discussion of the accident/incident syndrome covers this loophole in managerial thinking about providing investigatory report—the fallacy of "if its result is small, do not bother to report it." In a presentation of TAFS, this problem arises again. Performance error refers to systems and their failures, not solely to performance of human beings as is inferred when most texts refer to what went wrong. Performance can include hardware as well as organizational oversights.

"How do we determine what operational error is to be reported?" will be the question that always comes up when talking about the TAFS approach and the need for more data instead of less, more reports instead of fewer, and greater attention to specific problems instead of generalities. Education will solve this. Consider what failure modes can occur that will have a great impact on systems involved. In some cases, this consideration will be directed more toward the human system. But, there will be failures of physical systems demanding great attention. Scaling of criteria for one kind of industry will not be the same for another.

The principle of result and chance in operational errors will not help much when deciding what should be reported. For example, would a beaker dropped on the floor of a chemical lab be reported if it did not break? If it did break, would that be reported? What if the bottle were full of sulfuric acid? Each case starts with, "Why did the bottle drop?" Employee decision is important. If injury occurs, there is no question of report. But, up to 80% of all operational errors will not involve personal harm.

Many reasons are advanced for management's reluctance to prepare industrial accident reports; some seem to have psychological overtones. For example, if one were to ask 100 supervisors of line activities if they object to filling out a report of work injury or property damage by accident, it would come as no surprise to find that almost to a person the reply would be in the affirmative. The standard reason, "Too time consuming." Most will reason that the investigation of trivial mistakes is upsetting important time schedules.

Actions that managers will take with regard to a mishap are largely determined by their concept of its seriousness to (a) employee(s) involved, (b) disruption of the process of work, (c) expense to the corporation, and (d) inference it may have on administrative ability/responsibility. Each is a conclusion changed by cognitive dissonance. This is the inconsistency between what the manager knows and the pattern of behavior accepted to be followed. In other words, a tug of war between belief and behavior.

Very few managers realize the importance of information about quality and skill determinants available for study in every mishap regardless of seriousness of outcome. Reports of unplanned events provide important data needed for improving the way management manages. The study of reasons for operational failures is the key to industrial excellence.

A host of reasons in organizational systems exists for not filing a report of performance problems that result in personal harm and property damage. Bird and Germain, in their study of accident/incident investigation, advance several real-world attitudes that tend to suppress filing reports of injury and damage in mishaps connected with work.

Problems of Reporting.

Keep in mind that two of the three vectors in the triadic approach to operational error-solutions will be labor and management. Both have strong philosophical prejudices that are commonly given as reasons for not reporting the unplanned event (and often accepted without challenge).

Corporate policy is stated and posted to comply with compensation laws that demand "every work injury, no matter how slight, must be reported." But this requirement is fully dependent on the immediate supervisor who must make certain that it is accomplished. What about a person's feelings regarding the need for investigation and filing of reports about mishaps? The two words every and report in this legalized policy that industry must follow are at the lowest cognitive level. Both employee and supervisor may know this specific action is required, but neither may choose to follow the rule because the mishap is too small to report or too insignificant to investigate the reason for occurrence. The time and effort expended to make certain that all people know about it may well be wasted.

There are psychological blocks to supervisory (management) reports of accidents that originate in strange ways. For example, if the report document has a title, it may be stated in such a way that the report can be avoided. Early documents were called "Supervisor's Report of Work Injury." That restricts anyone who does not consider himself a "supervisor" from filing a report—especially when there is no injury involved. Basically, if the fact that any operational error must be a symptom of supervisory incompetence is made important in safety training, one can feel how anyone might not wish to advertise an event that would downgrade one's image as a good administrator. Supervisors as well as their subordinates will have certain traditional reasons for not reporting operational errors in their area of responsibility.

Here we have two sets of views. Each opposes the general feeling that mishaps are valuable events for gathering evidence to improve the working conditions as well as support better management. Of course, if the injury is such that it must be compensated, neither labor nor management has a choice. The incident must be (a) recognized and documented as happening in the course of work, and (b) signed as such by the superior involved.

What about mishaps that occur when there is no personal harm to report? There is no legal requirement to cover these situations. In some instances, particularly in government, any damage by mishap not attended by injury, when the cost of that damage is less than one hundred dollars, is considered expendable. The practice by management of placing a dollar limit on property damaged by accident makes the judgmental factor of reporting easy. If the estimated loss can, in any reasonable way, be made ninety-nine dollars, ninety-nine cents, or less, then an investigation is not required. Everyone is satisfied. But the reason for the occurrence is lost to research. Facts needed to prevent repetition will never be available. This is why loss due to property damage may be several times the cost to the industrial enterprise than workers' compensation.

Executive insensitivity as to the how, why, and costs of property failures will continue to vary directly with the seriousness of result until TAFS brings about educational reform. If the "bang" is not loud enough in terms of discomfort, time, and money, the consequence of repair/maintenance expense seldom reaches the eyes of corporate watchdogs. Repair causes are not carefully recorded and separated as normal and abnormal expense of running the business. Avoidable loss does not appear on the balance sheet as an item of unnecessary expense.

A modern safety function under wise administration will supply the steam for industrial excellence with education and TAFS. Safety training, a constant, important factor of industrial loss prevention, traditionally is limited to workers and line supervisors. This is the level of productive "action" justified because it is where dangerous things are used and harmful tasks performed. Safety education for middle and senior executive managers is seriously limited because of inability of most safety practitioners to deal with decision makers—their tasks, responsibilities, and practices. TAFS will move top management to see performance imperfections of human and material resources in a new way. It will demonstrate that industrial safety is not spurious or random. It is a growing, maturing, legitimate function of management itself with unique services to improve the quality of managing.

TRIADIC originates from the Greek trias meaning a union of sets of three—people, things, ideas, systems, etc. Success of this approach depends on management insistence that everything harmed or damaged be reported and investigated regardless of its consequences. Reason for the incident becomes more important than loss. A new principle of safety management develops. Performance errors, operational mishaps, and managerial oversights are triune factors not to be separated from any unplanned industrial event. The first two have never been parted as acts and conditions in order to salve the conscience of labor law. The third now adds a science of management improvement important to support needs of industrial excellence for all.

To many, need for support of top management is a crisis problem. Thomas Kuhn sheds some light on this enigma faced by many in the field of safety management related to the way we "see" things and the philosophy of change. Kuhn argues that professional people tend to gather around themselves a set of beliefs about their work; and for whatever time frame under consideration, this becomes a dominant paradigm (pronounced pair-a-dime). As he explains it, those in the field of industrial accident prevention proceed very comfortably with a set of shared beliefs refusing to go outside its boundaries. Of course, small attempts to bring in theory or new ideas by research do occur, but they, too, give very little change to basic paradigm of our professions: "good old ways are best."

Response to Crisis of [Management Support]

Many still hold to and quote Heinrich's basic philosophy of industrial accident prevention, laid down in 1931, as the only one approach to accident prevention. Much of what Heinrich supported in 1931 is discussed in light of change needed to accommodate "paradigm shift" that makes old rationalities useless.

Paradigms set patterns of thought hemmed in by experiences of the past, lack of formal safety education, and personal phobias expressed by others as matters of true fact. The paradigm of preventing imperfect performance of people and things becomes a blinder influencing perception so we "see" only what we expect and program only what we know. Attempts to change the paradigm with new discoveries, new theories, and changes in the standard ways to support a new belief system make some people very unhappy. Change masters are unwelcome. Standard safety rules and laws are enough; principles and concepts needed to force management support are too hard to learn; and the science of management is too difficult to apply.

Perhaps lack of support by senior management for the function is more subtle than realized. Could it be that management and labor do not "see" a mishap in the same light? Does functional management visualize a safety function as an aid to its improvement? The systems approach to problem solving may provide a clue to this paradigm by raising some questions about our perception of common program interests used to describe an industrial mishap. Their interpretation may be one source of difficulty for a safety function to attract respect and attention of corporate leadership.

We tend to "see" some of the most familiar things around us in a different light. The message here is that paradigms are generally incomplete and are always being modified by those who have great imagination to "see" what others cannot because of tradition, localized experience, and professionalized blinders. Safety-engineering revision, for example, does not apply to change needed to remove flawed management practice. Addition of managerial to technical control of a safety function has been difficult to accept by many. If the theory about "systems thinking" is right, then differences between labor and management over interest and support for control of performance errors will be overcome in time by TAFS. What may seem impossible for today, with a paradigm shift might well be the answer to open new channels of management interest and support for tomorrow. All that is needed now is diagnostic imagination.

Many in management do not feel the average safety specialist today can cope with skills needed in order to be called a manager. As one interviewed expressed it, "On the whole, we do not see the calibre of safety people being comparable to most of the people who are moving up [the corporate ladder]. That is a serious problem." There can be no quarrel with this observation. One must realize that the educational process of learning how to manage is both tacit and parochial. It will not be learned easily by experience. Strong barriers of professional understanding must be overcome and the classroom is the better way to go. Being an expert in protection of people and things from harm and damage does not relate to qualities of leadership—ability to plan for others and allocate human and material resources within financial constraints to get things done for the corporate goal. At least, management does not appear to feel it so.

There are several steps toward achievement of better understanding between safety specialists and managers—whatever their position, line or staff—beginning with a common understanding of terms used to set the basic mission of a program for performance perfection.

Development of Theory "S" and TAFS shed light on this: management support is definitely dependent on the subtle use of certain words to excite attention of decision makers—words that relate to safety but heighten importance of error-provocative situations. Experimentally, it has been found that words used by safety people to address labor are not the same as those used to talk with management.

Words, such as accident, have a powerful influence to action. Management tends to surround itself with a fence of feelings about the subject of safety and accident. Few will go to a conference or lecture on the subject. It is a taboo connected with labor. Workers will react to the term differently than their supervisors. Unfortunately, it is such a common term, it becomes applied to anything and everything remotely related to a mistake. Those who study language differentials will give many examples: a covert operation becomes a "plausible deniability." Fat persons will react better to "portly" when buying clothes. A woman who would never go into a saloon does not hesitate to be seen in a cocktail lounge.

When we talk about error-free performance, does it conjure up the image of an accidental situation? If one talks about the quality of managing, will that bring about concern for responsibility to prevent accidents?

That an industrial organization has the same characteristics as a human being in respect to systems theory makes it a target for analysis of its performance a fact. Managerial practice can be flawed and probably is whenever there are human or hardware mishaps. Each of these systems is operating in a failure mode all the time.

Human, physical, and organizational systems are supposed to perform well at all times. But this is a utopian dream. Human systems start to fail early in life. Parts of a hardware system seldom last over a few years without maintenance/replacement. Industrial systems frequently close down or become absorbed by others in a decade for a number of unplanned reasons. One can ask a truly pertinent question of how well does the system work when its parts are not working well? The safety function takes on the task of determining why it fails and what can be done to prevent this from happening. Thus, the purpose of triadic analysis is to examine all systems in any mishap and, by diagnostic skill, determine the present and potential flaws of each much in the same manner as is now done in medical research.

Substandard acts and unacceptable conditions are correctable factors that will always be in the failure mode unless modified by an informed and better management that gets things done by, with, and through labor to improve performance. The modern safety function does not prevent operational mishaps. This is management's responsibility.

Within the safety profession and where management can be educated to accept it, imperfect performance will be found to be preferred to accident simply because (a) it is a softer, less faultfinding term, and (b) it is accepted as management-speak in industry. Here are some reasons to support this concept.

1. All managerial decisions involve some risk and, therefore, can be error provocative or flawed.

2. There is no essential difference between accident and error; but managers seem more alert to the correction of imperfect performance when it encroaches on their area of responsibility for work done wrong than for work connected with accidents.

3. Performance errors (human) and operational failures (hardware) seem to occur more frequently than do accidents in the minds of supervisory managers. This is due to their paradigm against accidents. This is a vital factor to be overcome by education and quest of industrial excellence.

4. The larger the bank of errors, failures, and oversights gathered from flawed systems, the more data will be available to aid improved decision making.

5. The science of TAFS creates an opportunity to rate flaws of all systems rather than only that of the human system (frequency rating of disabling injuries) and its performance errors.

6. Acceptance and support of TAFS and the systems approach to performance perfection will spread to become a part of management education in schools of business administration as an important adjunct to its own improvement.

7. A well constructed investigational technique will assist TAFS to identify reasons for bad management and claims for product liability as well as performance errors that generate them.

8. Because the science of TAFS deals with systems rather than personalities, it eliminates the double-edged sword of blame that seems to permeate all industrial accident investigations. Faultfinding will not change flawed systems.

9. TAFS is founded on principles acceptable to both labor and management. It supports the notion that systems excellence in productivity is a team effort dependent on trust, subtlety, intimacy, and coordination of labor with management.

10. TAFS, when properly managed, demands a program of action requiring joint employee/management participation in company-wide safety and health activities to eliminate problems neither wants.

Evidence is convincing that our present methods and practices for collecting, analyzing, and storing cause information need extensive revision. Examined in the space of time, the mission of the safety function has shifted from; "Why did the event occur? Why did you (employee) do it? What would you do to prevent its recurrence?" to a tool designed for management improvement. The accent no longer should be on you but on systems that create the climate for an operational error.

Unsafe acts must be documented in light of improved selection, training, supervision, etc. Condition defects are reviewed to improve purchase, maintenance, storage, tool selection, etc. Problems of functional management are a part of the examination of functional responsibilities related to acts and conditions.

Although more detail will be necessary to the reporting document used in a systems approach using TAFS, these questions might now be raised to stimulate thought:

1. The source document now being used today by the company was prepared by whom? Does it serve only an outside interest or is it asking questions of which functional managers want to know the answers?

2. Is the document designed for quick preparation (no more than one sheet on two sides) covering every possible performance imperfection?

3. Does the title imply a faultfinding document? Does it avoid you involvement in favor of systems critique? Is someone forced to sign it? If so, why? (A signature is not required in TAFS).

4. Is the document trying to serve two purposes while doing neither justice? An investigation of an operational error is not to be confused as, or combined with, data required to support a work-injury claim. The test: where does the report form go after it is prepared? It should not go to an insurance company that has no interest in management's problems of self improvement. Neither should it be sent to a state compensation commission unless it is related to state business.

5. Closely review each word on the report form. Does it say "supervisory report of accident"? If so, that form will prevent any one who is not or does not feel that he or she is a supervisor from filling in valuable data. It cannot be used by subcontractors, visitors, clients, etc. TAFS allows anyone having a work-error problem to file a report destined for the computer for data evaluation.

6. Are there questions that do not relate much to management improvement? Data required in motor-vehicle collisions is an example. The legal department may be using your form for claims adjusting to be used in court. Claims adjusting is not a function of safety management and your form is not to be used for that purpose. Let the legal department prepare and use its own forms.

7. Is the report lean and hungry for studies for management improvement? Discard nice- but not need-to-know information. Always remember that under TAFS, result of happening is not important. Facts needed for your data bank of causes will be found in every first-aid case and will be just as important for research value as those you get from a work fatality.

8. Can you identify functions of your organizational system on the form? Does it probe for systems oversights? What principles are being violated? What does it reveal wrong with managerial behavior? Keep in mind that your reporting system must be user oriented so that those who fill it in can recall data at any time making their own determinations of repetitive problems and their corrections.

9. Is the form designed most efficiently for its preparation? Are items located and grouped in proper sequence of procedural use? Is sufficient space allowed for data requested? Is it spaced for machine fill in? Are data arranged to flow left to right and top to bottom?

10. Has the correct kind of paper been selected based on the number of copies to be prepared, handling requirements, files?

From an effective source document one may see from data being collected for basic research that has potential for quality control, yield improvement, better customer service, methods improvements, and cost control. All have their roots in TAFS concept. The source document is in packets of four copies—the precise number required for each accident including one for local files. Each copy is printed on a different color paper and its destination is clearly shown. This handling guarantees that the right number of copies will be sent to proper places for review. One copy is passed through a reviewing officer making certain that all questions are answered and properly coded; then it is sent on to the computer. The document goes through a rigid need-to-know vs. nice-to-know testing that eventually reduces the total number of questions and allows more space for demand responses. Witness statements with enclosures are eliminated for all but serious operational errors reducing the need for typing by over eighty percent. The change lightens typing tasks and amount of paper to be filed.

Let us examine some key characteristics of an ideal reporting document:

1. All inferences of personal blame/faultfinding are minimized or eliminated.

2. The document must not project the impression that it is a tremendous task. This point must be backstopped by education of purpose accenting all short cuts.

3. Questions should elicit only the kind of data about which management can do something; for example, data about who hit whom, how and where in a traffic claim. The standard traffic diagram is eliminated and placed in a separate claims form for legal documentation. It is not considered a problem related to the organizational system.

4. Documents are required to flow through those functions of management (line and staff) having a responsibility for corrective action encouraging top-level follow-up for problems found to be epidemic in nature and costly—special performance-error projects assigned to specific functions of management and monitored.

Human beings and organizations are purposeful systems having goals that can be monitored and changed under constant situations and conditions. Performance is important to systems evaluation because it is the best indication of errors, failures, and oversights to be examined for results against expectations. This suggests a science to be formed that provides means for correction of systems defects. A slight change in the paradigm of loss prevention enables the safety and health function to develop this science that enables the purposeful system to operate with a set of outcomes of reasonable certainty.

A business enterprise is a social system and is organized systematically to accommodate at least two purposeful factors we call labor and management. Each has a common goal as far as industrial safety is concerned—to avoid all risk of personal harm inside and outside the system's orbit of control. This common purpose becomes cloudy when its references are provided solely in labor-speak or management-speak. Neither clearly understands the meaning and usage of the other's words related to risk of mishap. Use of words becomes the means for choosing different courses of action, or no action at all, when needed to curb imperfect performance of systems.

Creative solutions for flaws, failures, and oversights in systems analysis depend on cooperative mentality of labor and management. Personalized trouble shooting must be curbed. Terms used by labor to identify accidental situations should not be used by the safety specialist when communicating with management. In this sense, the safety profession must learn to be bilingual. This will not happen over night. A great deal of education and practice will be required. A tremendous obstacle to the science of performance perfection through TAFS is misuse of words that labor and management use to identify error-provocative situations. Central to the issue is the separation of terms that management understands in order to track down its own mediocrity from those traditionally used to label performance errors of employees.

[1] Gordon, J. E. "The Epidemiology of Accidents," American Journal of Public Health, 39:504-515, 1949.

[2] Bird, F. E., Jr., and Germain, G. L. Practical Loss Control Leadership, Institute Publishing, Loganville, GA, 1985, p. 57.

[3] Kuhn, T. The Structure of Scientific Revolutions, (2nd. Ed.), Chicago University Press, Chicago, IL, 1970, p. 89.

"Operational Mishaps and the Involvement of Management" (© 1989 by William C. Pope) is taken from the author's book entitled Managing for Performance Perfection.; The Changing Emphasis Mr. Pope was formerly the safety manager for the U.S. Department of the Interior. He is a renown author and lecturer.