ROI Case File No.205 | 'The Shaken Safety Culture of Central American Mining Company'

Chapter 1: The Shadow of Consecutive Accidents—The Price of Growth

The week after the Delicioso Foods brand integration case was resolved, a client bearing heavy concerns visited 221B Baker Street.

"Detective, we may be losing the most precious thing in exchange for growth."

Maria Rodriguez, Safety Director of MinaCorp, spoke with grave expression. In her hands was a thick file of accident reports from the past two years.

"We are South America's largest copper mining company. With soaring resource prices, business performance is excellent, and our workforce has doubled in three years. However..."

Maria's voice trembled.

"Accidents are occurring in succession. Fortunately we've avoided fatalities, but at this rate, something irreversible may happen."

MinaCorp's Growth Record: - 2022 revenue: 280 billion yen → 2024 revenue: 520 billion yen (86% increase) - Workforce: 8,500 → 17,200 (doubled) - Mining volume: Annual 1.2 million tons → 2.3 million tons (92% increase) - Operating profit margin: 12% → 18% (significant improvement)

Numbers alone showed an exemplary growth company. However, different numbers Maria showed were serious.

Deteriorating Safety Indicators: - Work injury rate: 2022: 0.8 cases/1000 people → 2024: 2.3 cases/1000 people - Near-miss reports: Monthly 50 cases → Monthly 180 cases - Safety training participation: 95% → 67% - Safety violation incidents: Monthly 12 cases → Monthly 45 cases

Chapter 2: Invisible Organizational Culture—Truth Hidden Behind Numbers

"Ms. Maria, please tell us about the specific nature of the accidents."

Holmes asked quietly.

Maria answered with heavy tone.

"Just last month, three major incidents occurred."

Recent Accident Cases:

Accident 1: Heavy Equipment Operation Error - New operator failed to conduct safety checks, contacted worker - Injured: 1 person (fracture, 2 months recovery) - Cause: Insufficient training, supervision failure

Accident 2: Rock Fall - Rock fall in tunnel where regular inspection was postponed - Injured: 2 people (minor injuries) - Cause: Delayed maintenance work

Accident 3: Chemical Leak - Chemical contact due to improper protective equipment use - Injured: 1 person (chemical burns) - Cause: Disregard of safety procedures

I noticed a pattern.

"The common factor in these accidents is 'human factors.' They stem from human actions and judgments, not equipment failures."

Maria nodded deeply.

"Exactly. We've made sufficient equipment investments. The problem is... in organizational culture, I believe."

"Specifically?"

"Due to rapid growth, new employees comprise over 60% of our workforce. We believe we're providing adequate safety education, but in actual field operations, a 'productivity-first' attitude remains deeply rooted."

Chapter 3: SBI Illuminates Behavioral Causality—Visualizing Invisible Structure

⬜️ ChatGPT | Catalyst of Vision

"SBI makes vague culture visible by specifically recording 'situation-behavior-impact.'"

🟧 Claude | Alchemist of Narratives

"When safety narratives fade, organizations get swallowed by danger narratives."

🟦 Gemini | Compass of Reason

"Let's break it down behavior by behavior with SBI and chart the path to improvement."

The three members began analysis. Gemini deployed the "SBI Feedback Model" on the whiteboard.

SBI Feedback Model: - S (Situation): Situation - B (Behavior): Behavior - I (Impact): Impact

"Ms. Maria, first please tell us about specific situations and behaviors in actual field operations."

Field Observation and SBI Analysis:

Case 1: Safety Check During Morning Assembly

S (Situation): - Daily safety assembly at 8 AM - 15 new hires participating - 5 veteran workers also present

B (Behavior): - Safety officer reads rules aloud (5 minutes) - Majority of participants looking at smartphones - Veterans chatting: "Same talk again" - New hires listening seriously but don't ask questions

I (Impact): - New hires: "If veterans aren't serious, it must not be important" - Overall: Safety rules perceived as formality - Result: Tendency to skip safety checks in actual work

Case 2: Field Training Instruction

S (Situation): - New hire practicing heavy equipment operation - Production targets behind schedule - Site supervisor feeling pressure

B (Behavior): - Supervisor: "No time, keep safety checks simple" - New hire: As instructed, skips confirmation procedures - Surrounding workers: "Business as usual," remain silent

I (Impact): - New hire: Learns "productivity over safety in emergencies" - Team: Disregard of safety rules becomes normalized - Organization: Gap between form and reality expands

Claude made a sharp observation.

"This is the negative side of 'learning organization.' New hires acquire behavioral patterns from 'informal learning' in the field rather than formal training."

Chapter 4: Safety Culture Regeneration—Behavioral Change Through SBI

Detailed field investigation revealed structural problems in organizational culture.

Root Causes from SBI Analysis:

1. Contradictory Messages (Word-Action Inconsistency) - Official: "Safety first" - Reality: "Productivity-first" behaviors are evaluated

2. Learning Environment Dysfunction - Atmosphere unwelcoming to new hire questions - Culture of hiding failures (reporting lowers evaluation) - Veterans teaching inappropriate "time-saving techniques"

3. Lack of Feedback Function - No positive feedback for good safety behaviors - No immediate correction of dangerous behaviors - Result-only evaluation (process neglect)

Maria was stunned.

"We invest 200 million yen annually in safety training, yet the opposite is being taught in the field."

Culture Change Plan Using SBI:

Phase 1: Current State Visualization (1 month) 1. Conduct SBI interviews with all workers 2. Record specific situations, behaviors, and impacts of dangerous behaviors 3. Simultaneously collect examples of good safety behaviors

Phase 2: Behavioral Standards Clarification (2 months) 1. Create specific behavioral guidelines based on SBI analysis 2. Develop "Situation-Specific Safety Behavior Manual" 3. Incorporate safety behaviors into evaluation criteria

Phase 3: Continuous Feedback System Construction (3 months) 1. SBI feedback training for site supervisors 2. Introduce immediate behavior correction systems 3. Create recognition system for good safety behaviors

Chapter 5: The Detective's SBI Analysis—Root of Accident Proliferation

Holmes compiled the comprehensive analysis.

"Ms. Maria, the power of SBI feedback is that it can decompose vague 'culture' into specific 'behaviors.' And behaviors can be changed."

Core Principles of SBI Application:

1. Emphasis on Specificity - "Bad attitude" → "Looking at smartphone during assembly" - "Inattentive" → "Completing left-right check in 0.5 seconds instead of 2 seconds" - "Low safety awareness" → "Not fastening helmet chin strap"

2. Impact Clarification - Impact on individuals - Impact on teams - Impact on entire organization

3. Presenting Improvement Behaviors - "How to" solutions rather than "why" analysis - Propose specific, actionable behaviors - Behavioral reinforcement through positive feedback

Emergency Improvement Measures (30-day plan):

Week 1: Site Supervisor Behavior Change - SBI feedback training (all supervisors) - Break free from false "productivity vs. safety" dichotomy - Introduce mechanisms to evaluate safety behaviors

Week 2-3: Practical Guidance for New Hires - Review veteran pairing system - Create "Safety Mentor" certification system - Create question-friendly environment

Week 4: Establish Feedback Culture - Implement daily SBI feedback - Immediate recognition of good safety behaviors - Welcome and implement improvement suggestions

"Organizational culture doesn't change abstractly. It changes through accumulation of specific behaviors, one by one."

Chapter 6: The Path to Safety Culture Revival

Six months later, a report arrived from MinaCorp.

Safety Culture Reform Results from SBI Implementation:

Quantitative Results of Behavior Change: - Safety check behavior implementation rate: 45% → 89% - Near-miss reports: Monthly 180 cases → Monthly 75 cases (quality improvement) - Active safety training participation: 67% → 92% - Safety questions from new hires: Monthly 8 cases → Monthly 35 cases

Dramatic Safety Indicator Improvement: - Work injury rate: 2.3 cases/1000 people → 0.6 cases/1000 people - Major incidents: Monthly 3 cases → Monthly 0.2 cases - Safety violations: Monthly 45 cases → Monthly 8 cases

Cultural Change Indicators: - Employee satisfaction (safety): 3.2/5 → 4.7/5 - "Easy to consult about safety": 32% → 84% - "Company truly values safety": 28% → 78%

Maria's letter conveyed deep emotion:

"SBI feedback enabled us to convert 'invisible culture' into 'visible behavior.' Through specific behavioral guidance rather than abstract safety education, we built true safety culture. Most important was showing 'how to be safe' specifically, rather than 'why it's dangerous.'"

Detective's Perspective—Behavior Creates Culture

That night, reflecting on the case, I considered.

The MinaCorp case demonstrated the essence of organizational culture transformation. Culture isn't an abstract concept, but an accumulation of daily specific behaviors. SBI feedback was a practical tool for visualizing and improving those behaviors.

Particularly striking was the "word-action inconsistency" problem. The organization said "safety first" while actually evaluating productivity-priority behaviors. New hires sensitively detected this contradiction and acquired behavioral patterns from informal field learning rather than formal training.

"True culture change begins with behavior change. And behavior change begins with specific feedback."

The value of SBI feedback lies in its specificity. Because it's feedback based on observable facts rather than vague impressions, it leads to actual behavior change.

"Culture is behavioral patterns repeated within organizations. If you want good culture, you must start by repeating good behaviors."—From the Detective's Notes