Sometimes, unsafe acts are promoted and reinforced by working practices and working conditions. For example, consider the case of a machine operator on a night shift, who operates a cutting tool with a colleague.

Both employees have three years of experience operating this equipment together. However, for several months, they have been operating the cutting tool without the guard in place.

The first time they “rigged” the guard, it was done because they were behind target, having come back late from their break. As they were required to complete a set number of pieces, it was important to make up the time.

However, on subsequent shifts, they always worked without the guard because it was quicker. Without having to continually engage and disengage the guard, they saved time, and they could have an extra ten minutes on their break while still meeting their target.

On the night of the accident, they behaved exactly as they had done for the previous four months – but this time, the tool operator judged the timing slightly inaccurately, and lost the tips of four of his fingers.

The unsafe acts were violations – operating that piece of machinery without the guard was against operating procedures. The initial violation was motivated by time pressure, because the operators were behind target.

Subsequent violations became routine, in order that the operators could always have some extra time on their break. However, these unsafe acts were reinforced because for four months they had successfully violated the procedures with no consequence.

There were no near misses and no close shaves, and perhaps they gradually came to believe that operating the cutting tool wasn’t so risky after all. Since the shift supervisor only visited their part of the line infrequently, and never made any comment to them about their failure to use the guard, the violation became habitual.

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