2354 5. METHOD This paper synthesises patterns identified through direct professional experience: recurring issues observed during system reviews, control-verification activities, audits, and collaborative safety workshops. These reflections highlight practical system behaviours rather than theoretical constructs, drawing on insights from frontline workers, supervisors, managers, Site Senior Executives (SSEs), and Subject-Matter Experts (SMEs). 6. FINDINGS Across organisations, several consistent patterns emerge. Variation in system design is normal, but when the rationale for that variation is not captured and refreshed, clarity erodes and people begin to work from different assumptions. Loss of organisational memory is a central mechanism in this drift: the original design decisions, whether to integrate or deliberately separate health and safety processes from other operational systems such as work management, planning, maintenance, or process control, often become implicit, undocumented, or forgotten. As those decisions fade from view, taxonomies and thresholds evolve locally, and the definitions used to identify and prioritise material unwanted events diverge. These design choices extend to the selection and shaping of tools. Decisions about which tools are used at different layers and how they are designed, particularly task-based tools such as JSAs and frontline checks are frequently underpinned by assumptions that are not made explicit to users. Where the tools have not been developed with human-centred design principles, templates tend to start blank, provide limited scaffolding from higher-level analyses, and do not surface the specific controls that matter most for the task at hand. Frontline processes labelled as risk assessments often function as verification steps, yet without clear intent or reliable inputs they may focus on low-consequence hazards while under-testing the controls that prevent single or multiple fatalities. The cumulative effect is that supervisors and crews lack timely, task-relevant information about control status, investigations struggle to drive visible updates to improve control effectiveness, and governance signals drift toward activity counts rather than evidence that critical controls are present and functioning where work occurs. Across these cases, uncertainty about storage location, access pathways, and version currency is a consistent contributor: without a single, authoritative source in the tools supervisors actually use, frontline confidence in “what is current” remains fragile. 7. PRACTICAL OUTPUT: DECISION-POINT QUESTIONS TO USE BACK AT SITE The purpose is to equip leaders with practical questions that surface design decisions and test whether the system consistently delivers what matters most to the point of work: clear, task relevant visibility of critical controls that prevent fatal and severe harm, and confidence that those controls are in place and functioning before work begins. 1. Role clarity & competency Is it straightforward for supervisors and frontline workers to know exactly which controls/critical controls they own, what “effective” looks like for each? 2. Risk criteria & like for like responses Do current risk definitions and matrices produce consistent escalation for fatal and severe harm across sites and functions (no matter which tool is used), so that like for like risks receive like for like responses? 3. Integration of health and safety with operations Whether safety and health are integrated or deliberately separate, are there defined pathways that ensure exposure controls, monitoring results, and investigation learnings flow into operational planning, permits, and prestart briefings in language that supervisors and crews can act on? 4. Single source of truth for critical controls Where do critical controls “live” (risk register, safety system, work management, operational planning), what is the single source of truth, and are identifiers stable and consistent so verification
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