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Will your critical controls actually stop a fatality?

Most SIF programs verify that controls exist. LFNW field tools test whether each control holds under the conditions your crews face, and find the gaps before an event does.

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First Quantum Minerals Coquille Hitachi Johnson & Johnson Wärtsilä TE Connectivity

How do we prevent serious injuries and fatalities (SIF)?

Prevent serious injuries and fatalities by testing each critical control where the work happens. Learning from Normal Work field tools examine how controls perform during normal operations and surface the four failure modes that standard barrier verification misses. The output is a specific gap to close for each control, while the work is still going right.

Written by Dr Marcin Nazaruk, lead author of IOGP Report 642

The numbers that should concern you

83% of mining fatalities in 2024 involved a critical control that was already named and in place. Source: ICMM Safety Performance, 2025
33 →42 fatalities across ICMM member companies between 2022 and 2024, despite broad adoption of critical control management. Source: ICMM Safety Performance, 2025

Four reasons why controls fail

People design your controls, and people make mistakes

Every critical control depends on someone to install it, maintain it, and verify it works. SIF frameworks specify what controls should look like but say nothing about the conditions facing the people who keep them working.

Organizational decisions degrade controls long before they fail

A maintenance budget cut three years ago creates a backlog today. A procurement team rewarded for cost savings switches to parts that cannot handle real operating conditions.

Error traps increase the chance of failure without carrying energy

Two identical fuel valves side by side on adjacent boilers with no visual distinction. Your SIF program will not find these because it starts from the hazard, not from how the task is actually performed.

Behavioral controls fluctuate across a shift

A spotter watching trucks at 8 a.m. and the same spotter at 4 p.m. after fatigue and two radio interruptions are not the same control.

How learning goes beyond verification

Verification

  1. Pre-existing checklist based on the management's mental model
  2. Compliant: yes or no
  3. Improvements are limited to the areas already known to management

Learning

  1. Structured discovery questions
  2. Description of challenges and dependencies
  3. Discovery of unknowns

What LFNW finds that barrier verification misses

Example

Barrier verification

Energy source
Chemical
Hazard
Diesel fuel spill during transfer
Specified control
Spill containment kit, drip tray under the connection point
How it is typically verified
Audit checks that the kit is present and the drip tray is in position

Error trap improvement

After discovery questions

Error trap
The fuel hose is too short to reach the far side of the tank, so workers join two hoses at a leak-prone connection point on every shift. The spill risk sits at the join, not at the point the drip tray covers.
Control required
A single hose long enough to reach every fill point, removing the join
How the new control should be verified
A Walk-Through Talk-Through with the refuelling crew confirms one hose reaches every fill point without joining. Repeat after any equipment change.

Every error trap on the shop floor was created higher up in the organization

Example

Error trap in the front line

A faded valve label leaves the worker to guess which valve to close.

Decision that created it

Maintenance budget cut by 15%. Label replacement was classed as non-critical and is now eight months behind.

Who decided

Regional maintenance manager, approved by the finance director in the annual budget review.

Constraints they faced

A corporate target to cut fixed costs by 10%. The manager ranked 340 open work orders by criticality, and label replacement scored low because no incident had been linked to it.

Our tools

Structured field tools that study how frontline workers interact with controls during normal operations.

PATH® Dialogue

A short field conversation leaders use to surface the constraints and error traps behind a control, with the crew who works it.

Tableau d'évaluation : sur les quatorze affirmations concernant l'outil PATH, les réponses se répartissent presque exclusivement entre « d'accord » et « tout à fait d'accord ». Cliquez pour agrandir
How leaders assessed the PATH tool

Walk Through Talk Through

A structured walk of the task with the person who does it, surfacing the gap between how work is planned and how it actually happens.

Tableau d'évaluation : sur les treize affirmations concernant l'outil « Walk Through Talk Through », les réponses se situent presque exclusivement dans les catégories « D'accord » et « Tout à fait d'accord ». Cliquez pour agrandir
How leaders assessed the WTTT tool

Mappeur de contraintes

Identify the systemic conditions that drive the adaptations your audits keep finding. Trace the constraint back to its organizational source.

Évaluation des risques+

Add error traps and human factors to your existing risk assessments and JSAs. Integrates with whatever framework you already use.

What this means for your role

VP / HSE Director

Before

Your critical controls are named, documented, and audited, but fatalities still involve controls that were already in place.

After

You have a verification layer that tests whether controls hold under the conditions your crews actually face.

HSE Manager / SIF Program Lead

Before

Your barrier management program verifies compliance against the written procedure and misses the conditions that degrade controls between audits.

After

Your field tools study the task under real operating conditions and surface the error traps that energy assessments cannot see.

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