Decisions That Set the Stage: The Leadership Cultures That Make Incidents Happen

Mousa Yassin (00:04)

By the way, what time is it over there?

Mousa Yassin (00:11)

It's 5:30 here in London.

Mousa Yassin (00:29)

Hey everyone. So today I'm joined by Dr. Tom Krause, one of the most respected voices in safety leadership. Tom has decades of safety transformation experience — over 45 years — which is older than I've been in this world. He helped leaders see how safety can be a window into culture, decision-making, and how businesses ultimately thrive. His book, 7 Insights into Safety Leadership, has been so impactful to me and the team. It's the first book our safety director Gokhan required all of us to read at Pixaera. It's amazing at distilling safety leadership as a topic into practical and powerful ideas that anyone can apply. Tom, it's amazing to have you here. I've been super excited to have this conversation with you. Welcome to the podcast.

Tom Krause (01:00)

Thank you. It's a pleasure to be here.

Mousa Yassin (01:29)

So Tom, I know you probably answer this question all the time, so I'll just have you reply the way you'd like. But what's the why behind why you do what you do?

Tom Krause (01:30)

You know, it's changed over the years. Early in my career, it was to translate empirical scientific findings that I thought were relevant to the safety task. And then it became a business — that provides some motivation and also some noise. Then I sold the company that I had started in 2012, took a few years off, got bored, and started another firm, which is the one that exists now. But this one is different. We don't want to lose money, but we're not really concerned about how much we grow or how fast we grow or how much money we make. At this point for me, it's fun to take on challenges that haven't been tackled as well as they could have been. It's fun to innovate, it's fun to see new stuff happening. The world is changing so rapidly — how do you keep up with that? What do these changes mean to organisational life? All that stuff is very interesting to me in and of itself. It's worth doing.

Mousa Yassin (03:06)

And do you feel like at certain points in your career it wasn't as fun? Or do you feel like that spark of enjoyment and exploration has always been there?

Tom Krause (03:07)

Running a consulting business can be very stressful and not necessarily fun. There was a lot of travel — across the ocean, across the country — so that means you're not getting a lot of sleep. That isn't particularly fun. You do it because that's what you need to do to run the business, but I don't miss it these days. I still travel, but not nearly as much. I do wonder sometimes about how much is lost when we're not in the same room. If you and I were talking face to face, would it be significantly different? My own take is that something is lost, but maybe not too much. You get accustomed to it and you can communicate anyway. And the gain is just so huge — our geographic difference is days of travel versus minutes on a call. I think there are better and worse ways to do it, and part of the adjustment is figuring out how to have the real conversation you want to have, irrespective of the mode.

Mousa Yassin (05:11)

Yeah, it's so interesting you bring that up. In my journey, because everything is so fast, I find myself running where everything is just a light-touch activity. I'm trying to invest more in seeing people face to face and slowing down — being more intentional and deeper. Whenever I can, I try to optimise for face-to-face conversations with our clients, because the comfort of always optimising our time impacts the relationship depth and learning depth we can create.

Tom Krause (05:53)

That seems right to me. You can tell the difference when you go out to dinner with someone and spend a few hours getting acquainted and talking at leisure. You learn things in that conversation that you never would have gotten to over a call. And then you say, gosh, that really was different.

Mousa Yassin (06:08)

Absolutely. And I think you're lucky — it seems like you're in this amazing stage of your life where you can just do things that are fun without having to operate a very complex business. We just had a company offsite a week ago — 45 people in one location for three days — and people were blown away by how much value they got and how much they were able to bond, despite having worked with each other every single day for the past 12 months. Body language, energy, connection — so much of that gets set aside in remote work.

So, if we were to take a step back — as I think about your journey and the evolution of safety leadership — what do you feel has changed the most? And what are you most excited about in today's world?

Tom Krause (08:29)

There has been an evolution. There was a time when the leadership function with respect to safety was primarily about support — providing resources, allocating sufficient time, making sure things were done. But that has changed to real leadership, meaning genuine influence over culture. And I think Paul O'Neill had a lot to do with changing that. I was fortunate to consult with him way back when he was the president of International Paper, and then he went to Alcoa and took me with him. I worked across his time at Alcoa, then in his government work, and then with patient safety, which was a very strong interest of both his and mine. I knew him over a very long period of time.

He was an incredibly effective leader and what he did was different. He didn't just allocate resources and ask if you had what you needed. He was inspiring. When he first took the job at Alcoa, he met with investors and they asked how they'd know if Alcoa was performing. He said, "If you want to know how Alcoa is doing, look at our safety numbers." They were completely shocked. He would also say things like, "Nobody should get hurt at work." Just straightforward. And he really meant it. He would visit a site and if he thought there were safety issues, he would give his personal cell phone number to the audience and say, "If there's something safety-related that you can't get done, call me."

That kind of cultural leadership — that kind of statement about values — is what makes a real difference. There aren't very many Paul O'Neills. Leaders will often ask me what they should be doing to get safety to work better, and it's not easy to convey that it's not just about going through the motions. There is a kind of cultural leadership that really matters, and you do see those people — but they're the minority.

Mousa Yassin (12:53)

Yeah, it's interesting — as you talk about this from a safety standpoint, it always feels like it applies fully to an office environment as well. As a CEO, prioritising something like "no one should be severely anxious or scared at work" — when people are mentally struggling or feeling psychologically unsafe, it's really disruptive to the person, to their health, to their happiness, to their families. If a CEO learns to prioritise that as a baseline, you should start seeing a similar impact. That's ultimately what O'Neill was doing, but focused on physical safety first.

Tom Krause (13:41)

I think that's right. The problem is that it's tough to do. It's not hard to say, but it's hard to do. You're running a business. You have shareholders who've invested their money and want a return on that investment. Running an organisation profitably is genuinely tough — you have government changes, geopolitical changes, tariff changes, all things you can't predict — and you're still expected to produce results. So in the midst of that pressure, taking into account people's feelings and experiences is a real challenge. O'Neill grasped that it's actually profitable — that having a culture that values safety means you value people, and it turns out that creates profitability. So there's really no conflict. But that may or may not be obvious to a given leader.

Mousa Yassin (17:03)

Yeah, and it's definitely an art. Approaching it from the heart is key. There are scenarios where I know I could have handled situations differently. The way I approached certain situations made someone doubt their skill set, doubt whether they'd be staying at the organisation — I was completely blind to it, and it did have an impact. I feel like the root of what you're saying is: never compromise on treating humans with compassion, while still being tough on decisions where you need to be tough. But the moment we break the concept of care, things fall apart. And truly believing that it's good for the business and good for profit is a journey that CEOs have to go through. It's difficult to believe at first.

Mousa Yassin (18:28)

If we were to pinpoint some examples — you've done quite a bit of consulting, some very successful and some less so — ultimately it's all about human transformation, right? You're trying to help people learn and understand how they can do better. What comes to mind as fundamentals that leaders should try to adopt?

Tom Krause (18:57)

So I was doing an assessment of an organisation once, and in the course of interviewing people, I kept hearing about this one person who was described as a great safety leader. The first time I heard it I thought, that's nice. The second time, I thought, that's really nice. The third time I thought, I want to meet this guy — something really good is happening here. Fortunately, he was on my list to interview.

When I met him, it was obvious that he was genuinely committed to safety in the right ways with a deep-seated commitment. I asked him, "Have you always been this kind of safety leader?" He thought for a minute and said, "No." So I asked what changed.

He said it was a long time ago, when he was a plant manager. He had twin daughters who were getting ready to go off to college. He and his wife were very concerned about their wellbeing — they'd grown up in a small rural area and the city would be a different life. About a week after both daughters left, at around three in the morning, his phone rang. He knew, like every plant manager knows, that a three a.m. call was not going to be good news. He remembered vividly thinking, "I wonder if this is about my daughters." He picked up the phone with that fear in mind.

It wasn't about his daughters. It was about a young man who had been at the plant for about a month and had been killed there. He said the juxtaposition — being worried about his own children, then hearing about somebody else's child who had been killed at his plant — was overwhelming. Something reset deep inside him.

I asked what he did differently after that. He said it wasn't so much what he did differently — it was the way in which he did the same things he was already doing. He still served on incident investigation teams, still went out into the workplace and talked to people, still considered expenditures that would make the workplace safer. He continued to do all those things, but they meant something different to him. They carried a different weight.

Mousa Yassin (22:22)

Yeah, it's beautiful. The moment a leader loses the compassion behind the people they're dealing with, it just becomes an activity, a job. That's the key twist. And what's very interesting is that leaders typically hop back and forth — when I'm stressed because something is going badly with a client and I'm just trying to fix it, suddenly I'm a different person. And if I'm in that state for a long time, I see the impact on the business, on performance, on people. I feel like the founder's or CEO's mental state has a direct impact on the whole organisation's performance at a very fine level. If you're at peace — observing, giving people space, being compassionate — everything goes well. And if you're not at peace, you start seeing that reflected back. Do you see that too?

Tom Krause (23:22)

I do. And the question for me as a consultant is: how do you help leaders who are not there to get there? Over the years I used to think the best approach was behavioural — does this person exhibit the right behaviours, do the right things? I've changed my view. I now think about it in terms of decision-making. The way that inner state shows itself in day-to-day work is through the decisions people make. And that's something we've studied a lot over the last ten years — specifically in relation to serious injuries and fatalities.

Mousa Yassin (25:10)

Can you elaborate a bit more? What sort of decisions do you see across different organisations?

Tom Krause (25:16)

The way we've studied it is through serious injuries and fatalities. As you know, many organisations have seen a consistent decline in smaller, recordable injuries over the years. But at the same time, they do not see that same decline in serious and fatal injuries. We studied this fifteen years ago with a group of companies to understand what that was about. Out of that came a rethinking of the traditional Heinrich triangle and a different way of emphasising what needs to be done to address serious injuries and fatalities. That research was seminal in changing how the field thinks about this.

As part of that work, we were aware of Daniel Kahneman's work on cognitive bias. We thought: what if we studied individual fatal events and looked at them through the lens of decision-making and the kinds of biases that undermine good decisions? We developed a method to find the set of decisions that preceded a fatal event. So, for example, there's an explosion, people are killed, and the worker failed to follow the procedure. The incident investigation might stop right there — "the employee didn't do it right again, how do we fix the employees?" But that turns out to be exactly the wrong reaction.

The better reaction is to ask: what decisions were made previously that set the stage for that employee to not follow the procedure? When you run that down, you find a whole set of decisions made over a period of time — sometimes years — that made it possible for that event to occur. In one particular case, combustible dust had been allowed to accumulate across a facility. There were actually two explosions — the first killed the operator, the second killed two more people. But the decision to allow the accumulation of combustible dust had happened several years before the event.

Mousa Yassin (28:29)

So it's like a huge volume of decisions manifested in that explosion — many things connecting to each other, starting with probably someone being in a poor state and making a poor decision early on.

Tom Krause (28:36)

Exactly. And what we're doing that's innovative is making it more clear — specifically — what actual decisions were made to create what James Reason calls the "normalisation of deviance": where we get used to doing things a certain way, we don't think about it, we don't realise it's substandard, because that's just how we've always done it. That is the result of leadership decision-making.

Now, does that mean the employee's behaviour doesn't matter? Of course not. If someone's going off to their first factory job and they ask what to pay attention to, you're not going to say, "Don't worry about following the procedures — it's the leadership decisions that matter." You absolutely want them to wear the protective equipment, follow the procedure, do all those things. The point is that there's a relationship between the two. If you want to get behaviours right, blaming the employee isn't going to do it. What will is looking at the overall system factors — the decisions that leadership makes — and that creates the conditions for the right behaviour.

Mousa Yassin (31:58)

And ultimately it's a lesson for every leader to always take responsibility for every outcome in the organisation — to ask: what could we have done differently? What sort of decision-making culture should we promote so that we're always shifting accountability upward, away from where the incident happens, and asking what leadership should do differently to prevent it in the future.

Tom Krause (32:00)

Yes, exactly.

Mousa Yassin (32:32)

So — something I was thinking about before we got on the call — all of this is so tied to the person growing and becoming a better version of themselves. But if you reflect on today's tools, and you've done so much of this work hands-on, visiting sites and talking to people — how do you foresee technology, and specifically AI, influencing safety leadership and businesses going forward?

Tom Krause (33:07)

I think there are big changes coming, and they could be very positive and also very negative. AI is, in my view, much bigger than most people think — much more profound. Historians will eventually say, "Was that before AI or after AI?" It's just huge. And it goes to organisational life very directly.

In the safety space, the worry is the temptation to put cameras throughout a factory to catch people doing things wrong. That is happening. And it's utterly wrong — it will make things worse and will create exactly the culture you do not want. Now, it's tricky — knowing what actually goes on in the workplace is extremely valuable, so it's tempting to think cameras could help. But there are 99 ways to do it wrong and maybe one way to do it right. There may come a time when sufficient trust with the workforce makes something like that workable — with their involvement and engagement. But in the meantime, there are better approaches.

One of them is using AI to find the combination of variables that accelerate risk. In the pre-job planning process, if you knew that a particular combination of variables present that day — in that situation, doing that job — raised the risk level significantly, you could take different action. That could be extremely beneficial. Similarly, incident investigation is generally done poorly across the industry. Call up a dozen safety leaders and ask how effective their investigation process is — nine out of ten will say they spend a lot of time on it, get bogged down, and don't get proportionate value for what they put in. Properly done, a consistent incident investigation process across a large organisation can be extremely valuable. I think AI has a real role to play there. The question isn't whether the AI is good enough — it's whether we're good enough to use it properly.

Mousa Yassin (39:01)

Yeah, absolutely. There's just so much transformation ahead. Something we're seeing hands-on now is that the learning process — upskilling workers — is going to become far more adaptive than one-size-fits-all. You can learn about a person much more quickly. Imagine a world where, based on your inputs and the mistakes you make, your learning journey becomes genuinely personalised. And then after the worker is onboarded and goes out in the field, using voice or a quick photo to do a pre-task check — breaking that down, getting feedback like "great job, you captured most risks, but did you consider this?" — and feeding all of that back into the system so that if certain risk signals are triggered, they get flagged. Understanding the person better, understanding the supervisor and team better — I think the world of safety is going to become so much more elegant and personal. A lot of it will become individual-based rather than organisation-based, going back to the human doing the work.

Tom Krause (39:40)

And like any new technology, new things are going to happen that we never even dreamed of. Those things are going to become important. The question isn't whether the AI is good enough — it's whether we're good enough to use it intelligently.

Mousa Yassin (41:22)

As we wrap up — anything you'd love to share? Any work you're doing that's exciting that you'd like people to know about?

Tom Krause (41:24)

We're working on applying AI to incident investigation in the way I've already described. That's very exciting. And if that's combined with the decision-making analyses we've done, I think it becomes very powerful — though we're still in the early days. We'll probably form a study group with a group of companies, which is a method we've used a lot in the past — we did it with leadership development, we did it with serious injury and fatality prevention. So that's the direction we're heading.

Mousa Yassin (42:35)

I love it. You're going deep into the world of AI, and honestly, spending time there right now will probably get you the most fun and the most impact. Awesome — I hope we hear more about it over time. Thank you so much for coming on, Tom. It's always great to learn more about your journey.

Tom Krause (42:51)

My pleasure. It's fun to talk.

Mousa Yassin (43:06)

Awesome, great stuff. We'll chat soon.