One morning I was asked to step into a meeting where a report was up on the projector showing the last fifteen years of injuries and the costs associated to the company. It was staggering.

“We can’t see why people are getting injured. We don’t know why the incidents are repeating themselves. Can you tell us if you see a pattern from these reports?” I worked with these numbers for two days and could come up with nothing. The data was incomplete. So I asked them for data related to the people injured from HR. Who they were and when they were hired. When we connected the two data sources, I noticed a ray of light emerging from the otherwise gloomy gray skies of Seattle. It was profound.

The data showed that factory workers had the highest injury rate in the first two years of being hired. There was no safety training on the factory floor. Designing safety posters and videos meant little to the factory workers when they were unaware of the operational details of how to work in a safe environment.

The first step was to show how the dots connected. How narratives were emerging from these huge reports that were previously just numbers.  All these injuries needed a reason for why they kept happening despite the best efforts to prevent them.

I teamed up with the group to conduct factory walk-throughs to ask workers questions about what they felt about their work, what improvements they thought were needed and why they were injured.

We classified all the personas within the factory floor. We noted down their sequence of work based on the famous checklist methodology. We found that there were no logs maintained between shifts, no knowledge transfer between the experienced machinists to the newbies. The new workers would eventually catch up, but we didn’t want them to get severely injured or worse until they got to that stage.

With research in hand, I collaborated with senior members of the EHS group to generate concepts for future ways of working and preventing accidents. Together we redefined the safety initiative, shifting the focus from traditional ways of training to a holistic enterprise communications experience. We defined concepts for a powerful platform that would support natural human communication behavior across a range of work styles.

Root Cause Analysis of Injuries

Root Cause Analysis for injuries on the factory floor at Boeing

Data showing industrial accidents