Some incident investigations find a broken procedure. Others find a missing barrier. A smaller but significant category finds something harder to fix with a form or a retraining session: two management systems, both functioning exactly as designed, quietly pointing in opposite directions — with nobody responsible for resolving the conflict between them.
The Pattern
The pattern usually looks like this: a safety briefing or toolbox talk consistently covers the correct procedure — safe stacking heights, safe handling methods, correct sequencing for a task. The briefing is accurate, current, and delivered on schedule. At the same time, a separate performance system — a throughput target, a productivity metric, a shift-based incentive — quietly penalises the crew that follows the briefed procedure to the letter, because doing it correctly takes longer than the version that cuts a step.
Supervisors are often aware of the gap. They know crews are working past what the briefing describes as safe. It rarely gets escalated, because raising it means explaining a performance shortfall that has a separate, unrelated story attached to it in whatever report tracks that metric.
Why This Isn’t a Training Problem
An investigation that stops at “the crew didn’t follow the briefed procedure” has found the Substandard Act, not the cause. The briefing wasn’t wrong, and the crew wasn’t uninformed. What actually determined behaviour on the floor was a performance system that was never designed with the safety briefing in mind — and nothing in either system was built to catch the conflict between them before it produced an incident.
In Tripod Beta terminology, this is an Incompatible Goals Basic Risk Factor: two legitimate management systems, each internally coherent, working against each other with no mechanism forcing a resolution. It’s distinct from a simple case of an unsafe workplace condition provoking an individual error — the condition here is organisational, not physical, and the fix has to be organisational too.
Why “Knew and Didn’t Fix It” Matters
The detail that separates this category from ordinary system failure is that the conflict was often known before the incident happened. Supervisors who see crews exceeding a briefed limit to hit a target, and who don’t escalate it, aren’t concealing anything maliciously — they’re usually managing an immediate pressure with no clear channel to resolve a conflict between two systems neither of them owns.
For an employer, however, a known and unresolved conflict between a safety control and a performance system is a materially different position than an unforeseeable failure. An investigation — and a subsequent legal or regulatory review — will treat “we knew the target was undermining the briefed procedure and didn’t fix it” differently from “we had no reason to suspect this conflict existed.” The first is a governance failure sitting above the person on shift.
What a Fix Actually Looks Like
The fix isn’t a stronger safety briefing — the briefing was already correct. It’s a mechanism that surfaces conflicts between safety-critical procedures and performance metrics before they reach the floor, and gives someone with actual authority the job of resolving them. That can mean building a check into how new performance targets are set — does this target make any briefed safety procedure harder to follow correctly? — or it can mean giving supervisors an actual escalation path that doesn’t require them to explain away a productivity number to use it.
The Practical Question
For any safety procedure your teams are briefed on regularly, ask whether a separate performance measure makes it harder, not easier, to follow correctly. If the answer is yes, and nobody currently owns resolving that conflict, the gap isn’t in the briefing — it’s in the space between two systems that were each built without the other in mind.
Want your investigation team able to identify conflicts like this — not just the individual action on the surface? Cikgu Barrier’s Tripod Beta Incident Investigation programme teaches the full range of Basic Risk Factors, including Incompatible Goals, so investigations trace causation to the actual management system conflict, not just the worker caught in the middle of it. Available in-house and as a public workshop across Malaysia.