By Craig Tonks on Linkedin. Original article HERE 

Three Warning Signs Your Operation Has the Same Fatal Risk Pattern

Supreme Court Destroys Behavioural Safety Myth in $950,000 Ruling

Every week I hear manufacturing executives talk about behavioural safety as their silver bullet to drive down TRIFR. I’ll be blunt: behavioural safety isn’t the answer – it’s fool’s gold that distracts from engineering solutions while workers die.

As Principal Investigator for the case that led to $950,000 in Supreme Court-validated penalties, I collected the evidence that proved this point devastatingly. The court explicitly rejected arguments that relied on human vigilance to prevent fatal outcomes, stating that even with experienced supervision and proper training, “operators may become distracted” and workers can be “oblivious” to fatal risks.

My investigation revealed systematic patterns that the Supreme Court found compelling enough to uphold record penalties. Since publishing the case analysis, manufacturing leaders have asked: “How do we know if we have similar risks hiding in our operations?”

The evidence I gathered identified three warning signs that should concern every manufacturing executive – and the first one will challenge everything your leadership team believes about behavioural safety.

Warning Sign 1: Believing Behavioural Safety Controls Fatal Risks

Supreme Court Finding: Court “Rejected” Reliance on Human Vigilance for Fatal Risks

Your leadership team implements comprehensive behavioural safety programs, believing that experienced workers will keep trainees safe and that proper training prevents incidents. The Supreme Court rejected this assumption entirely, stating: “I reject that submission. AHRNS should have assumed… that operators may become distracted.”

The investigation evidence showed that even with an experienced operator supervising a trainee, there was still risk “even in circumstances of appropriate training, of an operator being in the crush zone oblivious to the tray being retracted.” The court found that behavioural controls fail because humans are predictably fallible.

The Behavioural Safety Trap: Every time leadership talks about driving down TRIFR through behavioural programs, they’re essentially saying “we’ll rely on the next person having the skills, knowledge, and experience to identify the risk and avoid it.” This is exactly when fatalities happen – not because people don’t care, but because behavioural controls are the weakest link in the hierarchy of controls.

Don’t misunderstand me – getting people aware of what they’re doing is valuable. But when behavioural safety becomes your primary control for fatal risks while $5,000 engineering solutions sit ignored, you’ve created the perfect conditions for preventable tragedy.

The Investigation Reality: The Supreme Court established that you cannot rely on human behaviour to prevent fatal consequences when engineering controls are available. Behavioural safety programs without addressing identified risks through higher-level controls are organisational negligence disguised as safety leadership.

Warning Sign 2: Supplier Warnings Don’t Trigger Independent Risk Identification

Supreme Court Finding: “Remarkable” Failure to Identify Obvious Risks

Your supplier clearly identified “risk of serious injury or death” with warning signs throughout the crush zone, but your team’s risk identification process concluded there was no significant injury risk. The Supreme Court called this disconnect “remarkable.”

My investigation evidence showed that despite manufacturer warnings, no meaningful consultation occurred with workers, engineers, or external experts to identify what controls were needed for the specific operational environment. The risk identification process failed to recognise obvious crush zone hazards that were literally sign-posted by the supplier.

The Critical Gap: When supplier warnings don’t trigger independent risk identification and expert consultation, you’re accepting someone else’s risk management without verifying it matches your operational reality.

Warning Sign 3: No “Capacity to Engage Others” Consultation Process

Supreme Court Finding: Legal Duty to Consult External Expertise

Your procurement team accepted manufacturer designs without consulting independent experts about site-specific control requirements. The Supreme Court rejected internal capability limitations, stating: “The defendant may not have had the expertise to eliminate or minimise the risk, but it had the capacity to engage others to find and implement adequate safety controls.”

My investigation evidence revealed no systematic consultation process existed to engage external engineering expertise when facing safety-critical risks beyond internal knowledge. The company made no attempt to seek expert advice until after the fatal incident, despite obvious risks and available solutions.

The Legal Reality: The Supreme Court established that “capacity to engage others” creates a legal duty to consult appropriate expertise, not just rely on internal knowledge or supplier assessments.

What This Means for Your Operation

These warning signs appeared months before the fatal incident. My investigation revealed they’re systematic patterns, not isolated oversights.

The critical question isn’t whether you have these patterns—it’s whether you have systematic processes to identify and address them before they align into preventable tragedy.

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