Ameren Corporation Safety Improvement Inquiry

Purpose

While Ameren Corporation’s safety record has improved over the long run, recent history reveals
that the number of life-changing safety events at Ameren has increased, where a life-changing event
is defined as a death or permanent injury to an individual. The purpose of this safety improvement
inquiry is to comprehensively formulate the underlying problem so that a comprehensive solution
can be discovered and implemented and that life-changing safety events can be eliminated from
Ameren.

Ameren’s Chief Executive Officer, Tom Voss, believes it is best for all of us to treat the recent
increase in the number of life-changing safety events as a systemic issue instead of as isolated
incidents. Towards this end, Ameren has launched this inquiry to discover a comprehensive
formulation of the problem. We are committed to then taking steps to eliminate life-changing
safety events.

The paragraphs below provide an overview of the process steps and how these process steps
contribute to not only comprehensively formulating the problem, but also to developing and
implementing solutions.

Process

Sponsored by Tom Voss and led by Dennis Weisenborn, a diverse group of over 50 leaders were
assembled from around the company. To facilitate execution of the process, these individuals were
asked to join five teams running in parallel. The teams then went through the process depicted in
the graphic below:
FIND Phase
In the FIND Phase, several individuals from Ameren with experience facilitating were asked to
receive training on facilitating the process (which is called Collaborative Structured Inquiry—CSI
—and was developed at Washington University in St. Louis). Dennis then reached out to assemble
a diverse set of leaders from around Ameren that collectively are likely to possess information and
knowledge that span the issue and are likely to be involved in implementation. The process requires
as much diversity as possible in a team, yet teams are limited in size as they should not exceed 15
individuals. With this in mind, the specific team that developed this report is composed of:

Name Position
Tim Barren Machinist Repairman, Rush Island
Tim Brower Sr. Safety Supervisor, Supply Service
Bob Flatley Superintendent, MO Substation/Relay
Kevin Glaspy Electric/Gas Supervisor, AIU Division IV
Gabe Jones Journeyman Lineman, AIU Division I
Steve Mooney Machinist Repairman, UEC Labadie
Jeff Myers Managing Supervisor, AIU Safety Administration
Adam Peipert Sr. Assistant Storekeeper, Supply Service
Carlton Richardson Stores Supervisor, Supply Service
Roy Smith Maintenance Supervisor, Newton, AER
Michael Wright Superintendent, Buidling Services
Karen Boulanger Project Manager-Integration, AIU (facilitator)
Patty Carrig Managing Supervisor, Emp. Dev. System Trng. (facilitator)

The process was built around the terminology of symptoms (an evidence of a disorder or
opportunity), problems, and solutions. The process is launched around a vital and organizationally
important symptom, which is referred to as the “spark” that launched the inquiry. In the case of
Ameren, Tom Voss identified the spark as the number of life-changing safety events at Ameren
has increased. The process is designed to discover and identify other symptoms correlated with the
spark as well as ultimately all of the root causes generating these symptoms. Such a comprehensive
formulation then provides the basis for thinking about solution components leading to a successful
implementation that treats root causes, thereby eliminating the symptoms.

FRAME Phase
The FRAME Phase identified a web of symptoms to characterize all symptoms correlated with the
spark. To do so, participants were asked to identify all symptoms correlated with the spark based
on their knowledge, information, and personal experience. For each symptom to be included in the
web, participants had to identify data, analysis, or vignettes to justify its inclusion. A key feature of
the web of symptoms is that the entire team had to reach consensus on the web of symptoms. It was
vital during this stage for participants to not discuss root causes or solutions. As indicated in the
diagram above, upon completion of the FRAME Phase this document will be shared to receive
feedback from co-workers across the company.

FORMULATE Phase
The FORMULATE Phase will identify an underlying set of root causes that produce the web of
symptoms identified by the FRAME Phase. A key feature of the list of causes is that the entire
team must reach consensus, relying on data, analysis, and vignettes, that each cause is related to one
or more of the symptoms. It is vital during this stage that participants not discuss solutions. As
indicated in the diagram above, upon completion of the FORMULATE Phase this document will be
shared to receive feedback from co-workers across the company. At this point in the process, the
work product of the parallel teams will be consolidated into a single document containing a
comprehensive problem formulation.

SOLVE Phase
The SOLVE Phase involves discovering solutions acceptable to all constituents that Ameren can
undertake to treat causes that underpin symptoms. Here again, the entire team must reach
consensus on the set of solution components to solve the problem. As indicated in the diagram
above, upon completion of the SOLVE Phase this document will be shared to receive feedback
from co-workers across the company.

IMPLEMENT Phase
In the IMPLEMENT Phase, the teams will be restructured along business segment lines to facilitate
developing an effective implementation plan based upon the set of solution components.

What follows is the work product from each team.

Evidence/Data
Category Symptoms
Bullet Form (shortened)
A-Resources 1. Workforce -HR Data
demographic -Personal Observation
show an aging -Injury data supports that older
workforce. workforce sustains more injuries
-Visual evidence of retirement-
age employees in the workforce
A-Resources 2. We as a -sources-HR staffing reports,
Company are budget reports, productivity
trying to do the reports, overtime reports, TRIS
same amount of reports, contractor reports and
work with less contractor budget figures
resources. -personal experience—bringing
in lesser skilled/untrained
workers to fill in for workers that
were not replaced.
-fewer “trained” employees, more
being brought in off the streets
Recorded Dialog
Not seeing it at all locations as having
an effect. Injury data that older
workforce has more injuries – physical
and psychology aspects of older
employees. We are looking at the
workforce overall. I would say yes, but
you would have to look at the injury
data. We are looking at the aging
workforce from the physical as well as
the cultural aspect. I do not agree that
the aging workforce is a correlation.
Don't know that there is a correlation
there. At this point my work group
accident rate is dropping rather than
rising even though we have an aging
workforce. Agree. Visual evidence.
Agree we have a whole group that is
aging. Quite a few guys can retire.
Agree.
How am I doing more with less. Ex:
my workforce has been reduced and
not replaced, but I still have the same
amount of work to do. Bringing
untrained workers in to fill in. People
are doing more of the job stepping
over, around, more smashed fingers
that are turned in. Agree – not
replacing retired workers, cutting
overtime, budget crunches, people
being hired off the street, people being
 instead of brought up through the
ranks. (Do we have an example
of this?)
-fewer resource results in more
shortcuts, sacrificing quality
A-Resources 3. First-Line -Source-current number of 1st-line
[D-Leadership] Supervisors are supervisors
overburdened -training requirements
-personal observation, fewer
supervisors, more time being
spent in the office instead of the
field/plant.
-personal experience, more
reporting and paperwork and
administrative type reports to fill
out, e.g. JBO, coaching, do
something in the field and go
back and fill out the formal report
on the computer.
brought up through the ranks. Agree –
fewer number of employees. Do more
with less – people, financial resources.
Could be two different symptoms. Are
we really doing more with less? Has
quality been sacrificed? We trying to
do more with less, but don't necessary
doing that. If you are taking shortcuts
and then have to come back and redo,
are you really doing more. Two
symptoms of that broader symptom.
Fewer people/not as much time. Now
I'm going to take a shortcut- Which
may cause an injury. Everyone
interprets doing more with less. We
are missing key parts of doing more
with less. Your eyes are watering,
your throat is sore, is this I ache, or is
this the cold. What are the things
under this that are the symptoms? It
is applicable to all of these things
finances, manpower, tooling, etc.
Fewer people, budget cuts,
manpower. Workforce reductions,
budget cuts, etc. We don't have the
same resources that we had before.
Those are all observable facts with
doing more with less. Do we need to
separate them? I think that is one
statement that can encompass those
things. We are having to do more with
less employees and having to adapt.
Are we doing less with less?
They used to have maybe a half hour
to do paperwork and then go out to be
with their crews. Now 65 to 75% of
their time is spent in the office.
Regulator, OSHA, DOT. Everything
has to be done on the computer. Less
of them. Where there used to be 5
there are 3, etc. I think that has an
effect on safety they are not allowed to
get out there and observe and stress
safety. Agree – personal observation,
no time to be in the field to observe
who works safely and who doesn't.
Struggle with the word overburden.
Not at his location. Do you see them
out like you used to. It is easier for our
supervisors to get out than yours.
Agree - Daily observation. I agree –
whole heartedly. Don't have the time
to supervise my crew. Additional
requirements administrative type
reports, can't just tell someone to put
his safety glasses back on. Now he
has to go back to the computer and fill
out the report. Job Briefing – getting
ready to do a job briefing. Additional
things being added to every job keeps

B-Behavior 1. We are -Recent Injury log review
becoming too indicated all due to complacency.
comfortable -Employees very comfortable
with our with repetitive work.
surroundings. -Visual evidence of employees
being distracted and not focused
on task at hand
-In ED crews are supposed to
walk their trucks every morning
and they are not doing (Do we
have evidence to support
this?)
-“always done it that way and no
one got hurt” attitude.
-example of an incident review
where emp actually used the
words “complacent” and “we
have been doing it that way
forever and no one ever got hurt.”
-plant safety steering committee
review of accidents of 2.5 yr
period—all low risk/high
frequency jobs—even the fatality
was low risk/high frequency.
B-Behavior 2. Challenging -weather conditions, e.g.
environmental temperature in plants, outdoors,
conditions exist etc.
on the job. -rough terrain
-results of injury analysis reports
show environment plays a factor
-improved working conditions
over the years
taking more time. Agree – I think it
has all been covered specifically in
power plants and stores. Not enough
guys to get things done. Peer
observation in plants. Supervisors not
being able to get to their job sites.
Their trusted guys coming back to
report. Agree – no additional.
Everyday evidence. Yesterday we
reviewed 4 injuries on our injury log
and they were all due to complacency.
If you change oil on your car over and
over you get very comfortable with the
repetition you let your guard down.
Yes, I agree due to the standpoint of
repetition-doing the same thing over
and over. Mind on task. We see
people that are just going through the
motions rather than being focused.
Distractions drive people to
complacency. Agree that
complacency is a symptom in the work
place through observations of crews
and they show indications of being
complacent. Agree – daily routine and
situations I have even put myself into.
Personal experience. Agree – ED
crews supposed to walk their trucks
every morning and they are not doing
that. Agree – always done it that way
and no one got hurt attitude. We have
an employee still on light duty. The
guys on the job actually used the word
complacent. Walked right into an
energized line, flew off ladder, and
broke bone. Their words were we
have been doing it that way forever
and no one ever got hurt. Incident
analysis from that. Agree – plant
safety steering committee looked at
the recordable accidents after the last
2 ½ year period all considered low risk
high frequency jobs - tasks they do all
the time. Even the fatality was a low
risk high frequency job.
My lights were out a couple of months
ago, the service guy couldn't find the
problem. He had to get out of his truck
in the rain, the ice, snow, I knew what
the problem was so I went out there.
Through my personal observation and
results on the injury analysis reports
show that environment plays a factor.
Is that a cause, our people have to go
into some really difficult conditions.
We don't always take into
considerations the conditions our
employees always have to deal with.
Challenging environmental conditions.
They all end of tying together. All of

B-Behavior 3. Acceptance -includes all levels of employees
[D-Leadership] of Unsafe Acts -visual evidence and personal
experience of fear of
confrontation, won’t address
someone who is doing something
unsafe, and confusion around our
safety rules.
-visual evidence and personal
experience of different cultures
based on location, different
unions, off the street hire, where
the emp came from—all have
different standards of what is
acceptable.
--seniority and time on the job
matters (applies to supervisors
too)
-informal leaders set culture for
what is ‘ok’, different standards in
different work groups,
acceptance of unsafe acts.
-supervisors might not address
something to avoid confrontation
to maintain working relationships.
the symptoms tie together to cause
the injury. I would stop at challenging
environmental condition. From an
overall standpoint we have challenging
conditions. By wording it challenging
environment conditions you cover it
all. Working conditions and
challenging environmental conditions
are a direct relation to our spark. I
think our working conditions outside of
environmental have improved. I don't
know that it is related to our spark. I
think our working conditions that we
can control have improved and are
getting better. We have shown
improvement the years before our
spark happened. Agree 100% those
are definitely issues in this company
but they have always been there. The
conditions if anything have improved.
– Agreeing with him... The working
conditions have improved, tools,
equipment, etc. it is contradictory to
say that. Safe working conditions
have improved; environmental
conditions have been the same. We
have always dealt with the rain, sleet,
snow ice. I don't agree because of the
word increased. For clarification I like
the whole thing. Challenging
environment conditions exist on the
job.
From peer to peer, supervisor to
worker, not a management/contract
thing. Unaddressed behaviors, this is
the way we have done it, and we keep
doing it the same way; specifically, a
life changer. We have all heard
enough about the things that have
happened in the last few years, and
something could have been done
about it. Fear of confrontation.
Observe people who won't address
someone who is doing something
unsafe Little accountability. Hold
employees accountable without doing
it in a non-confrontational way. There
is a lack of accountability. Wide
variance of our safety rules. Maybe
not wide, I should say that a different
way. Maybe confused. We all know
what an unsafe act is. The
acceptance of unsafe acts. Yes, it
depends on the culture where the
individual grew up; different unions,
different cultures, off the street -
different cultures. Different standards
of what is acceptable. Acceptance of
unsafe acts. Agree. What I've seen at
power plants are people not knowing
 how to speak up about something they
feel is unsafe. Coworker to coworker
seniority is a huge problem with
people being able to speak up.
Someone with very little seniority is
not going to address a person his
senior who has 25 years seniority.
Agree with acceptance of unsafe acts.
A guy that has been around a long
time the new folks won't confront.
Management and Contract. Tenure of
people accepting unsafe acts from
other. First line supervisors might be
more hesitant and will avoid
confrontation and supervisor didn't
address. Maintaining working
relationships. Agree, personal
observation: there are the rules and
then there are the rules. Different
workgroups – informal work group
leaders set culture. Different
standards in different work groups.
Personal observations – agree.
Behavior/Culture – fear of
confrontation. Lack of accountability
regarding safety. Acceptance of
unsafe acts.
B-Behavior 4. Distraction -Sources-economic reports, People who were planning to retire but
the poor DOW Jones, NASDAQ, didn't get to. Maybe – I agree with the
economy put on Ameren’s retirement numbers of distractions. I can't disagree with it.
everyone. the past 10 years, VPQ numbers. Change the initial use of the word
-visual evidence and experience 'stress' to distractions. Not replacing
of people who were planning to employees, rising fuel costs, and the
retire are still working, don’t want strains that have been put on our
to be here, distracted by 401K Company. The poor economy caused
progress, less engagement. distractions to employees. External
distractions, they have always been
there. I can't disagree we had guys
who were going to retire and couldn't.
They were disgruntled. Some of them
didn't want to be there. They were
checking 401ks, and talking about it.
Lots of distractions. The poor
economy distracted everyone.
Employees who did not want to be
there, they had plans to retire, and
their dreams had been shattered.
Weren't happy to be there
B-Behavior 5. Some -Personal observation that there Many employees believe that
employees is a perception that some achieving 0 unsafe acts is impossible
believe zero employees feel that zero unsafe – it is not going to happen. Target 0 –
unsafe acts acts is an unattainable goal. they say impossible. Culture is the
cannot be -employees feel getting hurt is issue. The culture was so hard to
achieved. part of the job. change how they want to do business
– not just contract, management too.
It is ingrained. Why do you think that –
it happens every day. That is
unattainable. You're putting a goal out
there that is unattainable – you're
defeating the purpose. Conversations,
 personal observations.
Management/Supervision is not
identifying. Agree – Lack of
accountability. Several employees
that said getting hurt is part of the job.
Getting hurt is part of the job. What is
crazy is too many injuries are reported
affects the yearly bonus both contract
and management. Personal
experiences.
B-Behavior 6. Near Miss -data on near miss reporting is The data we have for injuries does not
[D-Leadership] Reporting is low statistically too low based on the line up with the industry norm.
number of injuries we have Statistically we are below the norm.
-personal evidence of hearing Trust is the issue. Employees will talk
conversations about near misses, about what happened on the job
but never seeing the near miss where they have had a near miss, they
paperwork are not going to fill out the paperwork
and are afraid of being disciplined. All
in agreement.
B-Behavior 7. Distractions -smart phones have exploded in Smart phones have exploded in the
associated with the last 5 years and a lot of our last 5 years. The workforce is using
technology. emps use them smart phones. Your e-mailing, texting,
-there is a lot of technology on etc. A new explosion of distractions.
the job, e.g. Scholar, e-mail, Technology. Even Scholar and Co. e-
computers mail have become big distractions.
-technology is often a distraction Even linemen have their own smart
rather than a tool phones with them at all times. All of
which shifts your focus. Technology is
often a distraction other a tool.
B-Behavior 8. Employees -personal observation of Employees don't buy into the safety
are not employees not performing circle rules. They don't agree with all the
performing of safety safety rules. Circle of safety, they all
some safety -hearing fellow employees say agree not to do it because it has
rules they do not agree with a safety become acceptable. One more thing
rule they have to add to their day.
Employees don't understand the why.
Just a difference of having a
communication gap so that employees
understand why they are doing what
they are doing. Sometimes
supervisors are overburdening their
groups. There are a lot of extra
administrative things that need to be
done now that they did not have to be
done before. Sometime even though
things have been explained to them
again and again, they still don't do it.
Some employees argue that what they
are not doing is an unsafe act.
B-Behavior 9. Slow to -example is new policies come We are slow to accept change, ok with
[D-Leadership] accept change out and it takes a lot of reminders taking risks. When a new company
and enforcement before it policy comes out, it takes a lot of
becomes habit reminders and enforcing for it to
-lots of pushback on change become a habit. Lots of pushback,
change is hard to implement. Human
nature to avoid change. Agree –
personal observation. All agree.
B-Behavior 10. Employees -increased lawsuits in our society You can give me all the rules, but it is
[D-Leadership] are not taking in general up to me to hold myself accountable.
personal -example of injury analysis that No one else's fault but my own.
 accountability showed body positioning as Increased lawsuits, society as a whole
cause, but emp could not accept not holding themselves accountable.
that it wasn’t the tool he was Victim mentality. Feeling of
using. He wouldn’t hold himself entitlement. We had an injury at
accountable. Dorsett and did analysis. Cut fingers –
-personal experiences—lot of the decision was that it was body
victim mentality positioning, employee could not
accept that it wasn't the tool he was
cutting. There was no discipline
involved, but the employee didn't want
to hold himself accountable.
B-Behavior 11. Employees -personal experience of taking Supervisors are frustrated when
are frustrated leadership role and you’re held injuries occur, and feel powerless to
that injuries are responsible for actions of your prevent them. When you take a
occurring and direct reports even though you’re leadership position you are held
feel powerless not in the field with them. accountable for the actions of your
to stop them. -witnessing high levels of subordinates. How can I help an
frustration among all employees employee working safely when I can't
around what to do get injuries to be out there in the field? Contract
stop employees are equally frustrated. All
agree – personal observation, and
verbal communication.
B – Behavior 12. Distractions - DOT inspections, VPQ,
D - Leadership at work outside meeting, stretching, monthly
employees’ vehicle inspections, building
control inspections, safety committee
meetings, additional training,
celebrations
B – Behavior 13. Historical Data
Recordables
have dropped
significantly

C- 1. Conflicting -employees feel safety goals Is safety more important than

Communication Expectations conflict with customer service or
[D-Leadership] with productivity or with storm
work. Example of goals being
different during storm work--get
people back on as soon as
possible.
-leaders send clear messages
about what is important but emps
don’t believe it.
C- 2. Ineffective -Lots of safety information from
Communication safety varying sources, e.g. ELT, safety
[Leadership] communication depts., training groups, supvs,
etc.
-by the time the information gets
to the employees it can be
“misinformation”
-hard to focus on the right thing
at the right time.
-groups communicating need to
communicate on how to present
it and when.
customer service? Leadership is
putting the pressure. Good example is
storms – get people back on as soon
as possible. Our leadership has been
clear on trying to change the mindset,
but getting employees to believe it.
We are constantly showing them how
we are doing safety wise. They don't
care about those numbers they just
want to go home safe. Safety vs.
Productivity.
Lot of information gets thrown out
there from varying sources ex: safety,
training groups, ELT members etc.;
but how you deliver a message – clear
and concise, right message, right time.
Misinformation – by the time and
employee on the floor gets some
information it is all wrong. Ineffective
communication. Include the "why" part
of the instruction both to the
supervisor and the employees. All in
agreement. Say what you mean. So
many streams of information it is hard
to focus on the right thing at the right
time. The multiple streams need to

D-Leadership 1. Inconsistent -varying opinions from not seeing
safety strategy. any fresh safety initiatives in a
work location to seeing too many
safety program, initiatives, etc.
-varying opinions on whether
some safety programs should be
customized to a work group or
segment
-Standards Dept. sees tool
duplication and inconsistency
-multiple groups using
different safety approaches to
solve problems, eg ground rod
drive development
communicate on how to present it and
when.
Safety programs to keep the
momentum going from Safe Start to
current. No fresh safety initiatives. No
focused effort. No corporate wide
focus. Target Zero was a long time
ago. Too many new safety programs.
Was it corporate wide? No new
programs to keep the company
focused. Target Zero was company-
wide. No corporate wide safety
initiatives. Those were the only things
– we have all these different books.
The absence of any corporate
programs. The flavor of the month –
too many. Some people are trying to
come up with new safety things, focus
on what we have, and not saturate us.
We have the silo effect. What we are
doing here we have one group,
initiative, another group that isn't doing
anything, and another group doing
their own thing. The absence of focus,
inconsistency of safety initiatives.
Inconsistent safety initiatives. Rules to
Live By we all have different – vendors
vs. internal, contractors, ED vs.
Generation. We should have all things
that we should be doing consistently.
Hard hat areas. Totally disagree, too
broad of a statement. Too broad of a
trying to bring everyone under the
same umbrella that do different work
(relay, stores, lineman). ED MO – has
a black book of multiple unions that
used to be 5 books to make it simpler
for everyone. You have to go to 5
books to find out what the rule is.
Trying to take the broad approach
where it doesn't fit. Better training to
manager level saying these are the
guidelines we need to follow –
guidelines that fit your group.
Consistent safety approach, instead of
an inconsistent approach. Safety
books, working rules. Inconsistent
safety strategy. Different safety
programs at each plant. Too much
safety in some areas, and not enough
in others. If you travel from plant to
plant you see the consistencies. It is
different in every plant in Illinois,
districts, etc. AER traveling between
each group it is like different
companies. No I don't agree. I don't
think it is a symptom, it is a strength.
We have three different ones, but if
you ask them why they don't have any

D-Leadership 2. Line of Sight -One group makes a decision on
one end and doesn’t
communicate with other groups
and how it affects them
good reasons while we should. The
bottoms up approach which tailors to
each group. Inconsistent safety
strategy can be effective – Safe Start.
Flexibility among your work groups
and if you had some strategy to
customize it to your group. If the
strategy it weeds out the bad things
but keeps in the good things.
Inconsistency does happen – all
power plants are going to wear hard
hats under your welding hoods –
disgruntled employees – Ameren MO
publishes the Ameren with a welder
with no hard hat under his welding
hood. Inconsistency – a policy needs
to consistent. That could have been a
mistake in the picture, etc. Our jobs
are all different, our challenges are
different, should that be regulated, and
consistent. We are all different
companies with different business
needs. Different needs, but good safe
work practices are good for everyone.
All wear PPE, steel toed boots, etc.
where is the guidance that a local
garage can do what they want to do.
There has got to be some guidance
from Ameren. Certain things you want
to have from a corporate level but it
also needs to have flexibility.
Evidence of that – ladder safety.
Everyone knows the safe way to use a
ladder, but we have different
interpretations. If it good it should be
good. Consistent corp safety policies.
That is going to be the minimum we
need to do. It could be a positive or a
negative. Observation of
inconsistence, and the existence. We
all agree upon is that there is an issue.
Some say too much flavor of the
month, and the other saying we don't
have any.
Someone is making decisions on one
end and not communicating with other
groups on how it affects them.
 Causes Evidence Category
1 We do not have an effective succession plan Current hiring practice (don’t Process
(skilled craft) due to budget constraints, fill until vacant); journeymen Leadership
regulatory environment, leadership focus and to apprentice ratio; call out
skilled workforce availability. list contains emps that don’t
have the skills for the job
(A-1, A-2, A-3; B-3, B-4, B-8, B-9, B-11, B-12; C-1;
C-2; D-1)
2 Employees have a lack of buy-in to a safety We’ve always done it this Behavior
culture change due to a lack of accountability by way.
peers, supervisors and senior leadership. Employees not wearing PPE.
Lack of participation in safety
(B-1, B-3, B-5, B -6, B-7, B-8, B-9, B-10, B-11) programs.
Not wearing safety vests.
No accountability of
supervision.
Informal leader issues.
3 A lack of accountability for personal safety may Mistrust, history of past Behavior
be perceived as being more convenient and practice, no fear of
easier. retribution, won’t admit they
are wrong, fear of unknown
(A-3; B-1, B-2, B-3, B-5, B-6, B-8, B-9, B-10, B-11, consequences, non-
B-13) confrontational culture,
human nature, no reward,
OSHA violation, peer
pressure, fear of retribution
4 Employees make mistakes because feeling Feeling rushed is indicated on Resources
overwhelmed, distracted and frustrated due to: incidents reports, not enough Behavior
perceived lack of resources to perform the work, help, do too much with less,
reduced overtime, and same amount of work more people in the past,
with fewer employees to perform. change, less safety incidents
during storms because of
(A-2, A-3; B-3, B-9, B-12) heightened sense of danger,
less complacency during
storms, heightened
awareness, different mind-
set
6 Unsafe behaviors occur because employee So many accidents happen Behaviors
awareness levels are not where they should be every day on routine jobs. Education
due to complacency. Reacting in automatic mode.
Safe Start
(B-1, B-3, B-5, B-8, B-10) Complacency
Self-triggering

7 Employees don’t have sufficient situational Fail to trigger on changes in Education

awareness training. work environment;
 distractions
Fail to acknowledge and
(B-1, B-2, B-3, B-4, B-7, B-8, B-12) recognize distractions or
changes in the environment
around you that could lead to
a mistake around safety.
Lack of ability to self-trigger
Focus on the job
Hazard recognition
Recognizing state of mind
Be aware of where you are
for safety

8 Leadership puts people (cowboys) on the job Some employees enjoy Leadership
that are willing to accept and take unnecessary taking risks.
safety risks to get the job done due to residual Generational
culture, incentives, or not knowing. Supervisors do this to get the
job done, increase
productivity, customer
(A-2, A-3; B-1, B-3, B-8; C-1, C-2) service, reliability, availability
Reward/incentive for
supervisor
Individual pride
Sense of accomplishment
Reputation as the go-to guy –
they like that
Supervisors rewarding
certain behaviors and knows
the job will get done right.
A known risk and willing to
take it.
Leadership acknowledges it.

9 People don’t trust leadership to do what they People don’t believe safety is Leadership
say they will do because of inconsistent safety # 1 priority.
accountability. Lack of trust
Inconsistent discipline from
one group to the next
(B-3, B-5, B-6, B-8, B-9; C-1) VPQ shows trust in own
organization (group/dept)
but not outside their
organization
Not carried out in the actions
of discipline
Inconsistent accountability
Should be no risks at all
 Achieve job safely.
Major storms – safety msg
Customer response
Conflict in KPIs
10 Lack of commitment to leadership development What gets supv ready for Education
(e.g., crew leaders, safety committee leaders, their job? Leadership
supervisors, etc.) due to no long-term plan, no Inconsistent from one line to
senior leadership commitment, and an the next
inconsistent approach. Inconsistent training
approach.
(A-2, A-3; B-3, B-5, B-6, B-8, B-9, B-11; C-1, C-2; No real plans
D-1, D-2) We have programs
No clear expectations
Every 3-4 years we change
course
People in charge but with no
training.
No commitment from upper
management to
development in general.
limited resources because no
commitment
no money
no staffing to support
upper mgmt is not behind it.

11 Lack of safety alignment between contract Union newsletter didn’t align Leadership
employees, contract leadership and with union practice.
management leadership.

(B-3, B-5, B-6, B-8, B-9, B-10, B-11; C-1, C-2; D-1)

12 Our reward and incentive programs are Easy and measurable Process
completely based on downstream indicators.

(B-3, B-6, B-8, B-10, B-11; C-1)

13 We don’t properly analyze the risk along with Safety issues Process
the benefits when we utilize technology. Cell phones on the job
MDTs in trucks
(A-2; B-1, B-2, B-7) Blackberries; GPS devices