A manufacturing plant was struggling with a recurring safety issue. Workers were frequently bypassing a safety guard on one of the machines. Despite multiple briefings, training sessions, and disciplinary warnings, the incidents continued.
Leadership concluded that the problem was cultural. They believed people were careless and didn’t take safety seriously enough.
After spending time on the shop floor, the real reason became clear.
The guard was designed in such a way that it made the job significantly slower and more uncomfortable. Every time an operator needed to adjust the part, they had to remove the guard, do the adjustment, and put it back. Doing this correctly added almost 40 seconds to each cycle.
In practice, most operators worked under time pressure. The faster they worked, the more they produced — and in some cases, the more they earned. Removing the guard became the fastest way to meet the target.
This was not a culture problem. It was a **design problem**.
The safety system was built on the assumption that people would always prioritize safety over speed. But the process itself punished those who followed the rules.
When leaders see repeated safety violations, they often ask: “Why don’t people follow the procedure?”
A more useful question is: “What makes following the procedure difficult or costly for the person doing the work?”
In this case, the solution was not more training or stricter punishment. The solution was to redesign the guard so that it could stay in place while still allowing operators to do their job efficiently.
After the redesign, the number of bypasses dropped dramatically — without any additional disciplinary measures.
Many organizations try to solve safety issues by changing people. Often, the better approach is to change the system so that doing the right thing becomes the easiest thing to do.
First published on zavodovskii.com by Dmitrii Zavodovskii.