The story begins at a large microprocessor manufacturing plant. In 1996 the number of recorded injury cases was in the high 50s per year. This was dangerous—it was bad for morale and productivity, and it was embarrassing. Manufacturing leadership created a strategic initiative and gave it the highest priority. The goal: to dramatically reduce the number of incidents and injuries. In 1999 the recordable cases dropped to below 10. Though this is significant, the measure was still not acceptable to leadership. Their vision was for an Incident and Injury-Free (IIF) plant. That meant zero recordable events per year.
The primary processes employed between 1996 and 1999 were based on compliance and punitive consequences. Though they reduced numbers, they also engendered a culture of “workarounds and non-reporting.” It became clear a new way of thinking about and engaging with the problem was needed.