Pull the Domino and Build your Safety Culture 

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My Mom’s family in Texas were big dominoes fans.  When I visited as a lad, Grandpa would come from the day at the ranch, grab a beer, and play dominoes with Grandma and Mom and Dad.  I remember his big hands holding all seven dominoes in one hand as they played “Texas 42”.

As kids, my brothers and I would take the dominoes and make up our own games. All kids with porcelain tiles probably shared these same games.  The first was the cascading tumble of dominoes lined up optimally an inch apart.  We would try to line up as many as possible in as many interesting patterns as we could.  But we never got as extravagant as this example

Heinrich asserted nearly 75 years ago, ““88% of worker injuries are due to the worker’s unsafe act”.   He proposed a Safety Domino Theory that suggested the worker’s ancestry and social upbringing (first domino) led to being at fault (second) which led to an unsafe act (third) which led to accident (forth) and injuries (the last domino to fall). Heinrich was an insurance investigator. He certainly didn’t understand behavior, which he blamed for injuries. 

Assumptions that the worker is to blame for an injury has led to incident investigations that list “Human Factor” or “Worker Error” to be a “root cause” of an incident.  We know this leads to bad problem solving and further injuries (See “Don’t Turn out the Lights by Playing the Blame Game”). 

This “blame the worker” message kills cultures.  Somehow Heinrich’s stat has been attributed to behavior-based safety programs (United Auto Workers). If you know behavioral science you’d know that we follow the works of B.F. Skinner; not Heinrich.  Behavioral science always looks at environmental influences on behavior and never blames the worker.  

Brad Gardner, an amazing safety speaker, tells his poignant story that led to the loss of his arm by a turning auger at a potato factory.  He admits that he left the auger running to better clean the gook that had built up in a casing.  He knew the danger but he timed his reach into the auger to avoid the slow moving blade.  He was distracted momentarily and his arm was gone.  Human Factor?  Human Error?  It was easy for even Brad to blame himself. 

But blaming the injured does not solve the problem nor does it help us avoid risk and injury in the future.  Instead, we see human behavior not as the cause of injuries; we see at-risk behavior as a result of other factors. 

A Different Domino Theory

Instead, lets consider a different Cascading Dominoes Theory to describe the real cause and effect relationship between behaviors and injuries.

See, there are other dominoes, cascading well before the behavior, setting the context for the worker, either knowingly or unknowingly, to be in the position to take the risk.  Then physics and chemistry sometimes take over and the injury occurs.

In behavioral science we recognize that your system is perfectly designed to get the results you earned.   In other words, your system is perfectly designed for the worker to take the risk.  When we fail to set up the right environment we leave the dominoes ready to fall.

What are the other dominoes?  Many are obvious when we look at hazards related to equipment and facilities.  Badly designed facilities, aging equipment, missing or broken tools create the environment that will interact with behaviors to build the setting for an injury.  Those that manage the physical environment have left a domino in place. 

But is it possible to mitigate all the hazards at a worksite?  Efforts to engineer guards, protective equipment, and barriers take a big bite out of injury rates, however, constantly changing people, processes, tools and equipment conspire with their aging counterparts to keep hazard mitigation a moving target.  In Brad’s case, the auger was designed to self-clean but the plumbing leading to the auger had busted.   This plumbing wasn’t budgeted to be fixed until the next fiscal year.  The domino remained in place.

Indeed, management decisions, especially decisions made without considering the safety implications, can fail to remove the dominoes or worse, put new dominoes in place.   Well-documented manager decisions favoring production over safety stand out when major disasters such as the Deepwater Horizon and Big Branch Mine are investigated.  However, we must realize that managers are humans too and act under the same behavioral principles as their workers do.

Brad had been asked the clean the auger because the normal person wasn’t at work that day.  He had been told to “be safe.”  All the dominoes remained ready to fall because he had not been fully trained or instructed on the safe cleaning of the auger.

To promote safe work, managers attempt to pull dominoes by putting systems in place targeting worker behavior.  These systems include training in all its forms, discipline procedures, rewards & recognition schemes, and different ways of communicating including management delivery of instructions and expectations as well as front-line reporting and suggestion systems. 

How do we help target the dominoes that need to be pulled?  Some safety culture surveys designed to measure employee perceptions of management systems can help.  One such survey that my lab helped validate asks employees and managers where potential dominoes remain because of limitations in their safety management systems.  We found that the survey targets key systems such as work pressure, incident reporting, communication, training, discipline, and rewards and recognition.  The survey could also target where behavioral programs may benefit manager and/or employee behaviors to enhance interpersonal support for safety.  Survey results then help managers know where their efforts are most needed to do their part in pulling the dominoes.  If you need to get really bored you can read the full article here or contact me for a copy.

It starts with the Culture

When I am speaking to employees about these cascading dominoes I sometimes get some animated workers start complaining how safety incidents are mostly management’s fault because they have “failed” to provide safe equipment and facilities, or push production and budget over safety, or rely on the workers to do all on the job training with folks to green to know better, or blame the workers through their discipline program, or…or…or…typically pointing at an imaginary manager named “they”.


I learned in elementary school that when you point a finger at someone you think is at fault, you have three pointing back at yourself. 

The very first domino at the beginning of the chain… the one, if pulled, could protect the worker even if the rest of the dominoes are perfectly set up for failure… that very first domino is the Safety Culture cultivated by the workers.

In the midst of all the hazards, in the midst of faulty tools or equipment, in the midst of untrained tasks… there are your fellow workers.  Fellow workers know where the hazards are.  Fellow workers know the risks being taken.  Fellow workers are aware of the changes being made around them.  Fellow workers are more likely to have influence to change behavior.  Fellow workers care.  Fellow workers are most likely to also benefit from safe behaviors.

If the culture has been built around actively caring, where fellow workers recognize risk and are willing and able to coach their peers to avoid risk, then we can pull the first domino out.  In Brad’s case the equipment, staffing, and even supervision put him in a position to take the risk he did.  What if there had been fellow workers aware of the hazardous tasks going on around them and if one of them would have checked up on Brad, telling him about the risks he was taking, instructing him in the safe alternatives, lending additional hands, helping him problem solve to reduce the hazard, or being willing to help him stop the job and speak to management?  What if that first domino was pulled?  Brad would still have his arm.

Considering the physics of cascading dominoes where a 5mm high domino can eventually topple the empire state building in a 29 domino string, we begin to see how even the smallest behavior could start (or stop) the cascade that could avert catastrophe … a lesson for those of us trying to impact process safety.

One of the things we kids did with dominoes when the adults were not playing “42” was to stack the dominoes and build fortresses.  The idea was to build a fortress strong enough to withstand the impact of a sliding domino slung at the structure by your opponent.

Perhaps that’s what a safety culture does.  It pulls the dominoes out of the cascading lineup and builds a stronger culture, one domino at a time.  The pulled dominoes now stacked as a united front representing trust and determination to withstand hazards.

Check out Union Pacific Railroads “Pull the Domino” program.  UP’s Houston Service Unit’s Total Safety Culture (TSC) team adopted a program where TSC members hand dominoes to anybody, employee, manager, or contractor to thank them for “working safe, giving a helping hand, or stopping a line.” 

"When one domino falls, they all fall," said John Hughes, TSC coordinator. "'Pulling the domino' refers to stopping that cycle; it means that we vow to remove any 'pieces' before they cause a problem."



Timothy Ludwig’s website is Safety-Doc.com where you can read more safety culture stories and contribute your own.  Dr. Ludwig is a senior consultant with Safety Performance Solutions (SPS: safetyperformance.com), serves as a commissioner for Behavioral Safety Accreditation at the non-profit Cambridge Center for Behavioral Studies (CCBS: behavior.org) and teaches behavioral psychology at Appalachian State University, in Boone, NC.  If you want Tim to share his stories at your next safety event you can contact him at TimLudwig@Safety-Doc.com.




We had Brad Gardner in Texas last year for our BNSF Railway meeting for Roadway Equipment. He and his wife did Great and we got our Safety Hardhat sticker from there speech.



Jed Harting



As usual I enjoy your articles and would like to make the following statement about injuries: We attempt changing a safety culture without taking social culture into consideration and it is impossible to change a behaviour or a culture without considering the culture within a community or country. This is what I am talking about in my concurrent session at the conference. An example of what I say is the following – in Zambia one of the effects of poverty is lack of sanitation and means of waste disposal – on site housekeeping and the washing of hands forms part of our safety systems as this may cause injury through tripping hazards or becoming ill when not washing hands before consuming food etc. We have an expectation (correctly so) that people are not able to meet because even though we provide these facilities we LACK TEACHING PEOPLE HOW TO CREATE THIS WHEN THEY HAVE NOTHING. They do not have ANY facilities when they go home, they literally just dump everything where they want to. Should we not rather focus on quipping these people to create or develop some form of system that they can apply at their homes as well rather than expecting them  to comply to ours.  There are significant cultural differences that we do not take into consideration when establishing a safety culture within a country in Africa.


Connie Engelbrecht

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