A few years ago, a station staff member in my current hometown noticed a smoldering cigarette butt on a railway sleeper next to the platform. She briefly blocked the track (for which she followed an existing procedure) and put the smolder out with a bucket of water. Trains were running again within a few minutes. Then she was stood down for failing to follow written safety instructions. Like many organizations around that time, the rail operator had adopted a ‘Take Five’ (or five-point) safety plan. When a worker faces a potentially risky task, the five points to be followed are these:

Stop, look, walk around the task.

Think about the task; have a clear plan.

Identify and assess hazards that exist or that may be created by the task, and rate their risk levels.

Control the risks and communicate.

Do the task if risk is low, and keep a look-out for any changes.

In some organizations, these points need to be checked off on a little list, which workers keep in their pockets. The station staff member did not follow the steps or tick anything off on a list. She stopped a train from coming in, doused the smolder and got on with the business of running a station. Had she followed all the rules, she would have had to evacuate the entire station and call the fire brigade. Now she was at home, suspended for three weeks, as the events were investigated (Withey, 2009). A signal engineer said later that he was so disgusted by things like this that he was ready to resign. “This creates so much unnecessary extra risk,” he said. “Imagine all the sitting ducks [the non-moving trains] near the entrance to this station; and others are coming in from all over the network. You hope they respond to the signals. Delays rack up, tempers fray. There is much less risk in us going in for a short spell, fix the problem. What used to take five minutes is now taking up to 1.5 hours. It’s crazy.”