Accidents Don’t Happen Because Systems Fail – They Happen Because People Are Driving

As HSE professionals, we often spend considerable time designing, documenting, and refining management systems. We build frameworks, layer procedures, and invest heavily in technologies to control risk. Yet, incidents continue to happen. Why?

Because systems don’t run themselves, people do. And just as cars don’t crash on their own, organizations don’t fail on their own. They are driven, steered, and sometimes misdirected by the people at the wheel.

In this article, we’ll explore why human performance is the true driver of safety outcomes, how even the best systems fail when operated by unprepared individuals, and what leaders and HSE professionals can do to bridge the gap between systems and people.

Why Do We Have Accidents? Because People Are Driving

Imagine standing at the scene of a vehicle collision. Rarely do you hear someone say, “It was the car’s fault.” Instead, we ask: Who was driving? What decision did they make? Were they distracted or under pressure? The same logic applies to workplace incidents.

Systems, no matter how robust, are inert without human interaction.

Management systems are much like modern vehicles, loaded with features, structured for performance, and engineered with precision. But without a competent driver, even a high-performance machine becomes a liability.

In this analogy, the “vehicle” is your safety management system. The “driver” is your workforce. Which raises the critical question: are you training Schumachers, or handing the keys to unprepared novices?

Management Systems Are Complex - and People Add Even More Complexity

Management systems are built from layers of documents, tools, workflows, and procedures. They are designed to bring consistency, control, and repeatability to safety-critical operations. But let’s be clear: a system is only as good as the person using it.

Humans introduce complexity. Each individual brings with them a unique combination of:

• Training and competence

• Experience and familiarity with the tools

• Communication styles and cultural norms

• Confidence, stress tolerance, and decision-making behaviors

This variability is both the strength and the weakness of any system. On one hand, people can think creatively and respond to unexpected problems. On the other, they can bypass steps, misinterpret procedures, or act under pressure in unpredictable ways.

You can have the best tools in the world, but they become ineffective, or dangerous, if used by someone who doesn’t fully understand them, or who isn’t engaged in using them properly.

The Schumacher vs. The Novice: A Metaphor for Safety Competence

Let’s revisit the metaphor from motorsport. Put Michael Schumacher, a Formula One world champion, behind the wheel of a Ferrari and you get elite performance. But put an 18-year-old with two weeks of driving experience in the same car, and you might get disaster.

Now look around your organization. You may have high-end systems, well-documented procedures, and state-of-the-art risk controls. But who’s driving them? Not everyone is a Schumacher. Many are learning, developing, or operating under pressure.

Expecting high performance from untrained or unsupported individuals is not just unfair, it’s dangerous. This is especially true in complex environments like oil and gas, construction, or manufacturing, where a single deviation from protocol can have cascading consequences.

Systems Don’t Fail, People Do

Consider a safety incident where a confined space entry procedure wasn’t followed. The document was there. The gas detectors were calibrated. The permit system was functioning. So what went wrong?

It’s likely that:

• Someone didn’t read or understand the procedure

• A supervisor was too busy to enforce the checklist

• The worker assumed “it’ll be fine, we’ve done this before”

These aren’t system failures. They are human failures in system use. And yet, we often respond by updating the procedure or adding another layer of paperwork, without addressing the underlying competency or culture issues.

Building the System Is Not Enough, We Must Build the People

We often talk about system maturity, but how often do we talk about operator maturity? Safety leaders must shift focus from purely technical enhancements to human performance optimization.

That means:

1. Investing in competence development: Training isn’t a one-off exercise. Competence is built over time through formal education, practical exposure, coaching, and mentoring. Use competency matrices to track growth, and refresh training based on job criticality and risk profile.

2. Promoting procedural fluency: It’s not enough to issue a document and hope for compliance. Are people fluent in using your safety systems? Do they understand why the procedure exists? Do they know what a deviation looks like?

3. Fostering situational awareness: Can your frontline identify when conditions have changed? Are they empowered to stop work? Are they trained to recognize subtle signs of fatigue, stress, or distraction in themselves and others?

4. Encouraging feedback loops: Often, the people who operate the system know exactly where it’s failing. But are they being heard? Integrate feedback mechanisms that allow for upward reporting and frontline-driven improvement.

Leaders Drive Culture, Not Just Compliance

Every organization has a culture, whether it’s intentional or not. And safety culture isn’t defined by slogans, it’s reflected in the everyday behaviors of leaders and workers.

Ask yourself:

• Are supervisors reinforcing safe behavior consistently?

• Do managers walk the talk, or only engage after incidents?

• Are near misses investigated with curiosity or blame?

• Is learning encouraged, or are mistakes punished?

The answers to these questions reveal whether your culture supports system use or undermines it. Safety isn’t built in documents; it’s built in conversations, decisions, habits, and accountability.

The Role of HSE Professionals in Shaping Performance

As an HSE professional, your job isn’t just to audit the system. It’s to understand and influence the people who use it. Your role spans:

• Educator: translating procedures into practice

• Coach: guiding behavior and building confidence

• Listener: collecting insights and identifying friction points

• Connector: aligning leadership expectations with operational reality

It’s a role that requires emotional intelligence, technical knowledge, and communication finesse. But more than anything, it requires seeing people as the solution, not the problem.

A Call for Human-Centered Improvement

True safety performance improvement happens when we stop trying to perfect the system on paper and start optimizing the people who bring that system to life.

Some proven actions include:

• Job shadowing supervisors to assess system application

• Using human factors tools (like task analysis or error mapping)

• Creating psychologically safe spaces for safety feedback

• Simplifying procedures to align with actual workflows

• Celebrating proactive reporting and small wins

The result? A culture where people are engaged, competent, and motivated, not just to follow the system, but to improve it.

Final Thoughts: Drive the Driver

In the end, it's not about having the best vehicle. It’s about having the best driver.

Yes, build strong systems. Document them. Certify them. But never forget the human behind the wheel. Whether they steer you toward success or a near miss depends on their training, engagement, mindset, and environment.

So the next time someone asks, “Why did that incident happen?”, don’t just look at the system. Look at the people who were using it.

Because systems don’t cause accidents. People do.

But people also prevent them. When empowered, educated, and supported, people become the greatest strength in any safety system.