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From Aviation to Healthcare How System Factors Drive Safety Decisions



Don’t miss our latest episode on The Safety Guru! Join us as Norman MacLeod, a seasoned expert in organizational human factors, shares decades of experience and a wealth of knowledge with us. Drawing from his extensive background in both aviation and healthcare, Norman shares the critical system factors influencing safety decisions within organizations through riveting research findings and real-life examples. Gain invaluable insights and practical solutions to navigate system impacts in your organization. Tune in now!


Real leaders leave a legacy. They capture the hearts and minds of their teams. Their origin story puts the safety and well-being of their people first. Great companies ubiquitously have safe yet productive operations. For those companies, safety is an investment, not a cost, for the C-suite. It’s a real topic of daily focus. This is the Safety Guru with your host, Eric Michrowski, a globally recognized ops and safety guru, public speaker, and author. Are you ready to leave a safety legacy? Your legacy success story begins now.

Hi, and welcome to the Safety Guru. Today, I’m very excited to have with me Norman McLeod, who has deep expertise in Aviation Safety and a really good understanding of the impact of system and system factors on safety. Norman, welcome to the show.

Thank you very much, Eric.

Norman, let’s get started a little bit about your background because you’ve got a lot of years and a lot of experience in aviation safety.

Okay. Where to start? When you’re my age, there’s a lot to talk about. So, my degree is in Botany and zoology. So, I’ve always had an interest in systems from a biological perspective. When I was in the Air Force, I was involved with training young officers and leadership training. And then I moved into being a training specialist on the Charlie 130 transport aircraft. That led me to observe a lot of crews flying, and I was amazed at the differences between how crews function. That got me interested in this idea of, well, crew resource management, although we didn’t call it that back then. Sure. But it’s this whole thing about how people work together, but more broadly, how the system functions. How does the behavior of the crew, in this case, how does the bigger picture influence it? What are we trying to achieve by sticking people in an airplane and sending them to war? How do bigger decisions about, say, tactics and strategy elsewhere shape how the crew functions? Now, I know that probably sounds a little bit crazy, but it was this fascination, how you couldn’t really look at things in isolation.

You had to see the bigger picture to understand why things happened. So that’s what really got me going. And then when I left the Air Force, I moved into civil aviation. And again, I found it was how an airline works was probably more interesting than necessarily how individuals work. And it seemed that relationship between what are the business goals. What’s the airline trying to achieve? And how does that filter through to the operation and shape how individual pilots do their job? Pilots is where I’ve spent a lot of my work, but I’ve seen cabin crew as well. And then in the last few years, I’ve tried to get a foothold in health care. And there, unless you take the bigger picture, you really can understand the way a health care system works. So that’s a rough trajectory that gets me to where I am today.

It’s Phenomenal. So, your themes on systems are very complex. Many organizations are challenged to understand the linkage between different events, like what you talked about, and how the context in which I’m operating impacts my decision-making. One thing that really struck me when we first connected is that when you talked about the purpose of the business, you talked about this financial purpose. Tell me a little bit more about that theme.

Okay. Well, at the end of the day, an entity exists in a commercial sense to generate a return on investment. Sure. Even if you look at something like emergency helicopters or police helicopters, you’ve got similar constraints there in that although you’re not generating a return on the investment, you’ve got to generate capability within budget. So therefore, everything is driven by money at the end of the day, either in a constraint sense or in an output sense. And how a business configures itself to make money and then shapes things like, in an airline’s case, what routes do you fly? What aircraft do you operate? What’s the age of your aircraft? What technical support do you give to your crews? Where do you recruit your crew from? How many crews per aircraft? What’s the turnover rate? So, there are so many factors that are driven by those financial decisions, and half the time, managers are not necessarily aware of the relationship between their decisions. They think they’re just doing the best job for their shareholders. I don’t think they see the relationship between those decisions and what happens out on the line and how that affects safety because that’s the bit that I’m interested in.

How is it likely to either put people in a position they’re not prepared for or put people in a position that they are possibly not fully motivated to deal with? Okay, I’m going to be careful what I say here. Nonetheless, that relationship between business decisions percolates through into things like morale, motivation, and skills level. I’m doing work in health care at the moment. You have a high turnover rate. So, the problem you’ve got is staffing. Now, you’ve got to recruit them. You’ve got to train them. You’ve got to retain them. But if you have a high churn rate and also your gapping posts, you’re actually putting the load on the remaining healthcare workers. I was talking to someone recently. They’ve had a big recruitment drive. They’ve got a lot of new stuff. That sounds like a good idea. No, it just adds to the oversight because you’re constantly doing your own work and making sure the new people are doing their job properly as well. So that’s what I mean by the relationship between management decisions and safety out on the line.

And your point linking it to financial purposes is very good. And I think the other element is it translates indirectly What you talked about just there is the financial link to, say, the HR practices around the recruiting, which are also driven by the financials. We’re not saying we shouldn’t be financially driven. We’re not saying we shouldn’t be trying to provide a profit. But how do we also educate the rest of the organization about those decisions that I’m making that can ultimately impact safety? Is that a fair comment?

Yeah. It’s naive to ignore the need for financial viability. The airline wouldn’t exist if it weren’t making money. It’s as simple as that. But an example I gave when we first spoke is a carrier I worked with in Southern Europe. It is a very seasonal operation. So, they recruit seasonal cabin crew that just do the summer period. And I was able to track through their numbers, the baseline permanent crew, the arrival of the new hires, the time it took to train the new hires and get them out on the line, which lagged behind the increase in summer traffic. So, at the front end of the season, you have that tension between the speed of getting the new hires out into productive flying and the demand because you’re selling seats to holidaymakers. And the way that was manifested was two things. The first is at the front end of the season, you got this spate of slides being set off accidentally because you’ve got new hire staff who are not fully capable with the vessel in the world. You’ve got high operational demand. This was reflected at the start of every summer season, with all of these slides being deployed accidentally.

Now, it settled down as they gained their experience. But then the next thing you saw at the back end of the season, as the traffic started to decline and the summer hires started to go back to other jobs, your long-term sickness went up, and it was strange how it was lagging everything else. What it suggests is your permanent crew was working so hard that you had this bout of long-term sickness absence, usually stress-related, which you then carry through the winter. And that’s what led me to believe that it must be the permanent staff that is affected by the stress of getting through the summer because your summer casuals have left the company. Your high sickness rate is due to the permanent staff recovering during the winter period. So that’s what I mean by the relationship between the business model, which is seasonal, based on holidaymakers who want to go to the south of Europe, and then how that’s reflected in your recruitment policies, your training policies, and how you see the effect in adverse events and true sickness.

And for those who don’t come to aviation, a slide deployment is not a good thing. It could kill somebody very easily because of the impact and the force of the deployment of a shoot or slide and the pace at which it does it. Plus, it causes operational issues and costs. It’s a huge slowdown on aviation.

Exactly. The aircraft is taken offline. The slides have to be replaced. I have spoken to someone who was in the forward galley when a slide went off inside the airplane. Inside? Yeah. If you don’t go out of the way, it can hurt.

Oh, boy. Phenomenal example. You also had an example from an Asian carrier related to fatigue and scheduling. I’d love it if you could touch on that one as well.

Okay. Now, fatigue is a big burning issue in lots of safety-sensitive areas. It’s something that I’m looking at in health care at the moment. But I look specifically at a career as a pilot in an Asian carrier. I’m grateful to the pilots for tolerating me and answering all my questions. However, there are two types of fatigue. You can see, you can call it acute fatigue, which is in simple terms, and a real psychologist will shoot me for this. Just call it tiredness. You can usually recover from acute fatigue by having a couple of good night’s sleep. And that’s the fatigue that is measured in fatigue risk management systems that are commonplace in aviation. They’re trying to introduce them into health care in the UK. And that’s fine. But it only looks at one aspect of fatigue. The other aspect of fatigue is just basically the psychological effect of the daily grind. You can call that chronic fatigue, and that’s like having a rucksack on your back. And a good night’s sleep is not going to have anything to do with that. It’s your morale and motivation. It’s your work-life balance. And I was able to, on the one hand, look at the acute fatigue.

I tracked how fatigue built during the working day as such. I was able to look at relationships between that and error rates. So, this operator, they were 24/7. I looked at night cargo. And what I found was that if you were a local pilot operating night cargo, you were flying off your body clock. So, you were flying at the time of day when you should have been asleep. If you then compared those with the crew that operated long haul, so they were now flying during the night in the local area, but their body clock was still on home base. So, it was daytime for them. If you look at the relationship, the people who were flying daytime body clock, but local night, their error rates were less than half those that were forcing themselves to stay awake and fly through what we call that window of circadian load, that period between, say, I don’t know, 2:00 and 4:00 in the morning. When your body is just screaming out to go to sleep. So, that was one aspect of it. But when you then look at the chronic fatigue side, the psychological side of things,

Now, you’ve got to think of, first of all, what’s the baseline? And there haven’t been, and that’s the problem when you look at fatigue in particular. We don’t really know what normal looks like. So, the few studies that have looked at this idea of chronic fatigue in the normal population suggest that 30 to 40 % of the average person in the street, if they were tested, would be showing signs of chronic fatigue. You look at health care, you’re looking at 65 to 70 %. You look at aviation, and I know of four studies that have used the same benchmark. So, you can do the comparison. And for pilots, you’re looking at about 80 %. So, 80 % of the workforce is showing signs of chronic fatigue. Okay, the question is, so what? You’ve then got to look at what are the other effects that flow from that? And here’s where you see things like excessive daytime sleepiness. That’s a standard measure that’s used. It’s the propensity to fall asleep. So, you sit down in an armchair, and before you know it, you’ve dozed off. If you have excessive daytime sleepiness, it correlates with mental health.

About 20% of airline pilots are above the threshold of daytime sleepiness, which suggests they’re at risk of mental health effects. But then I also looked at work-life balance. And again, if you scored high on chronic fatigue, your work-life balance was adversely affected. And I looked at a global measure of mental and physical health now that this thing has been used all around the world, and it’s well established. And again, high chronic fatigue correlates with poor mental health. So, That aspect of fatigue is not addressed in any way by the regulatory framework. It just deals with the sleep side of it. So you’ve got two problems here in aviation and in health care. We try to measure one bit to control it. We ignore the other bit because it’s too difficult. And now, we come back to where we started this conversation. So there’s a big trend at the moment for well-being, peer support, and things like that. And a lot of airlines do give their support to peer support groups within their airlines. I’m going to be a bit radical that’s actually the airline avoiding its responsibility. It’s tokenism.

The people involved are genuinely doing the best job they can. But this is a piece of band-aid. So we’re trying to fix the problem by letting people have access to a support network. What we’re not doing is fixing the problem at source. So, it’s an easy way out. Now, how do you fix the problem at source? Well, that’s the challenge because there is no one size fits all. There’s the age effect, there’s the type of flying, and there are so many variables. It’s difficult. Each individual airline has to recognize the problem and work out a solution that works for them. But never underestimate human nature. So, in the UK, With the introduction of the European Working Time Directive, working hours in health care were capped. A common model is doctors and nurses working three 12-hour shifts a week. And that means they reach their total. A 12-hour shift is frankly crazy, from a safety perspective, in a domain like health care. But if you do customer satisfaction surveys, what you’ll find is a lot of nurses, and I just happened to have looked at a study of nurse attitudes—a lot of nurses like doing three 12-hour shifts. 

Because it gives them four days a week, they can do overtime.

But that keeps you away from your rest.

Something that is trying to limit your effort for beneficial reasons creates a situation where people can do something that they want to do because they want more money. It’s working against itself. And then this is always the problem in all of this: you’ve always got to remember that there is human nature at work. So, there is the perfect world, and there’s the real messy world of human beings. And even when you’re trying to do things in the best interest of human beings, meetings will have other motivations.

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Regarding your aviation example, there was another one you shared with me, which was another Asian carrier as well around fatigue and linked to scheduling. And this had to do with flying over China, airspace being restricted, and how fuel loads would also be impacted.

Yeah, this is where it does start to get messy. There are two aspects there. We’ve also got to remember we’re talking geopolitics to a degree. Chinese airspace, for example, Because the military controls it, and they have a huge tendency to suddenly shut down blocks of airspace because they’re having an exercise of some sort. You might not even know about it until you’re able. Now, that’s going to have an effect on your routing, which means that for all long-haul carriers operating through that airspace, fuel management is an issue and does require crews to properly understand how to manage the fuel on their aircraft. You will find crews arriving at the destination after 12 hours of flying, seriously having to manage the fuel remaining. Then, of course, you’ve got weather effects that could mess up your best plan when you arrive at the destination. That’s one side of it. But then you’ve got another aspect.

On the one hand, you’ve got the effects of fatigue on performance. You’re asking people to manage complex situations that are unpredictable whilst tired. You will see decision-making that is probably not because people think the simplest thing to do is to get the aircraft on the ground.

And in so doing, they sometimes take risks that you wouldn’t expect from a properly rested crew. But the other thing you’ve got is We get back to the business side of it. Aircraft are dispatched with enough fuel to get to the destination with a contingency. And there are computer programs that manage this and build in seasonal variability and the routes flying, et cetera. But you’ll always have pilots who want to take a bit more. I worked for a European airline once, and it was affectionately known as Auntie Betty’s Tun. So, at dispatch, you’d get your planned fuel, and then you’d add a ton for Auntie Betty. All the pilots call it that. Which, of course, you burn fuel to carry fuel, so that’s inefficient. But what I was finding was that as pilots get older, they like a quiet life. So, if I looked at the pilots who carried more than planned fuel, it was typically the older pilots because they wanted a quiet life. They didn’t want to be in a position where they were suddenly presented with a challenge. I would speak to first officers about this, and they’d say, look, I fly with these guys.

Some of them are naked. They don’t want to do anything that will add to that burden. This is where you see that relationship between what’s in the best interest of the airline, what the attitude to the job, and the effects of fatigue all come together in a lack of efficiency. So that’s something that came out of some of the work that I did.

And these are all phenomenal examples because very few organizations are able to track the relationship between these decisions that are part of the system. How do you go about in an organization surfacing these themes, and how do you drive solutions around some of these system impacts?

Right. If I had the answer to that. The first issue, of course, is knowing the scale of the problem. And I return to that cadre of pilots who kindly answered my questionnaire. The number of times people would say to me, well done for trying, but no one will listen. And I said, Yeah, but Management can’t know what it now knows. So, if they don’t understand the scale of the problem, then they’re in a position just to ignore it. So, the first thing you’ve got to do is to reveal the problem. But the real challenge in something like aviation is that it is fundamentally safe without a shadow of a doubt. And pilots, the practitioners, the people who work in those systems, work to keep themselves safe. So, to a degree, the risk that’s inherent in what we’re talking about here is masked because people are pragmatic They work hard. They sort things out in real time. What they don’t necessarily do is share the risks they’re exposed to. So, for example, my study of fatigue. I had more than one pilot would come up to me in class and give me an example of when they fell asleep at the controls of the airplane.

Sure. And I said, did you report that? And they laughed at me and said, you’ve got to be killing. There is no way I would own up to that. And this is where reporting systems don’t really capture the whole problem. I hate to say it, but it’s an area where we need to start thinking about other technological solutions. I mean, trains, for example, have the technology to detect when a train driver might be dosing off.

Sure. Some cars nowadays even have that ability built in.

Yeah. So, although it will be fiercely resisted on airplanes, maybe the time has come to start looking at wearable technology. There are all sorts of things we could start to use now because, at the end of the day, we want to protect the crew as well as the passengers. So, nobody’s more important on that airplane. Everyone’s got to come home safely at the end of the day. But the thing is, first of all, you’ve got to establish the scale of the problem. You’ve got to explore the implications of it. For example, we were talking about how to reduce fatigue. Well, work less. And the answer you get every time is that that would involve spending more money. Well, actually, it doesn’t. So, I was looking at some studies of nurses in another country. They were reducing the working week from five days to four days. What they found was that productivity went up, and sickness absence was reduced. So, the net cost was the same at the end of the day. You ended up with a happier workforce who were there more often than they used to be. So, part of the problem is just resistance to doing something differently.

But we’ve got to look at things like that. On the personal side of it, I talked about nurses who like three-day weeks so they can do overtime. One UK operator I was aware of did offer reduced contracts to some of the older pilots. A colleague told me of a friend who opted for this, and what he found was that because of the UK taxation system, by flying less, he got paid less. But when you took out the reduced tax bill, the net loss was negligible compared to the improved home life, and everything went with it. So, it was a price worth paying. Now, of course, not Everybody can make a salary sacrifice. If you’re younger, you’ve got a family, these things are challenging, which is why one size does not fit all. But it’s a case of exploring. And what I’ve just said there is the answer. I have adaptable contracts according to pilot needs based on where they are in their life cycle. It just requires progressive HR departments. That’s all. It’s not rocket science at the end of the day. The evidence is all out there if people go looking for it.

And part of where you started at the front end is that businesses are financially driven, which is perfectly fine. But we also tend to talk about safety at the operational level. So, in aviation, we’ll talk about safety for the flight crews. But we don’t necessarily talk as much about safety to the finance department or the HR department to understand how they impact a perfect day for a pilot. And there’s an element of awareness in the decision-making that also can have a key impact.

Exactly. And this is why you have to start looking at that bigger systems view. So, we’ve just introduced the equivalent of an air accident investigation branch into health care. And it’s just been reorganized and given a new name. The first report that it published just a couple of months ago was on whether healthcare needs a safety management system. The new interim chief executive announced the report and made a comment that finance directors need to get more involved. Now, that created a furor, and the Health System Finance Directors have their own little Trade Union, and they went public criticizing this comment. So, I wrote a little article, which went out on a blog, and I said that finance Directors do have an effect on safety.


And here’s how. And I developed this systems model. If you think about an organization, it’s a hierarchy of decision-making. I’m at the bottom, and I make decisions about how I’m going to do my job when I turn up for work. I make decisions about things like, am I even going to come to work today because I don’t feel very well? Once I’m at work, I’m part of a team. I’m surrendering some of my autonomy to be a team member. The team, whether it’s the crew on the aircraft or it’s the department I work in, makes decisions about the allocation of responsibilities. What are our goals? How do we apportion tasks and jobs?

There’s a level of decision-making there about the organization of work. And then I’ve already said, the next level up is the organization itself, the airline. And it makes a set of decisions. It’s all decisions that drive outcomes. And then above the airline, of course, you’ve got the regulator. So, the regulator decides how aviation will run within its jurisdiction. So, I was just trying to elaborate on this model and show how decisions made by, in this case, finance directors, as we’ve already alluded to, do have an effect on the front line and will shape safety.

But the problem is, and here, when you start thinking about systems, you’ve got to consider cross-scale effects. An act in one area will have an outcome in another area, but in ways that you possibly couldn’t predict, you couldn’t anticipate, and therefore, you couldn’t manage for. You just have to live with it but recognize that it’s a possibility that your decisions will work in ways you never really intended.

It’s a lot more frequent and common than we think. The complexity as well from a system standpoint, and this in some of the examples that I’ve seen is the impact of a decision doesn’t necessarily manifest itself that day, that week, that month. In the examples you shared, there was proximity. But I’ve seen the impact of decision-making, particularly when you’re talking about hiring, where you have hiring peaks because we talked about seasonality, but sometimes there are good years, and there are bad years financially. And so, there’s big hiring, some years, and then you don’t hire for a couple of years. That can have an impact three or seven years down the road in terms of the level of proficiency skills that people had because they weren’t necessarily properly trained or didn’t have the experiences they needed. And so that becomes easier to abdicate the role of my decision to the impact. But the other element is safety, not the absence of injuries or events. And so, if I take one pound or a dollar for a particular transaction if I take a penny out, probably there’s no impact. If I take two pennies out, there will probably be no impact.

If I take three, maybe not. And so, there’s a complexity there. You don’t know where there’s a trigger. If I cut something, when’s the impact? Could it have an impact 3-7 years down the road?

Yeah, exactly. I worked with an airline once that had a very stable workforce, and they’d all grown old together.

Wow, that’s rare.

Some of them were now getting to the point where it was time to retire and move on to other things. So they had a little recruitment drive, and it was absolute chaos because the workforce that had been there for years had learned to communicate by telepathy. We’re talking about cabin crew. You only had to look down the cabin, and you knew what the other person wanted. All of these new hires that had just come in, young kids, clearly hadn’t had the telepathy chip in schools when they were recruited. The breakdown in the crew functioning was, if it weren’t funny, it would be quite awful. But it was something that we tend not to really think about. The fact that a low churn rate is almost as bad as a high churn rate. We’ve got to reflect on the fact that we need to keep reminding ourselves of how we do the job. And then when someone new comes along, they’re not going to know how we do the job, and therefore, training and communication are all the more important.

Even if you think about 2008, there was very little hiring in the airline industry or most industries in general. The same thing happened around COVID, with very little hiring. All of this has an impact from a system standpoint because there’s less experience. People weren’t flying as much. We weren’t recruiting at the same pace as usual. And then suddenly, you might have the scenario you talked about about the Southern European airline, where you’ve got a huge influx of new talent, and that creates more stretch on the existing resources. Yeah, it’s a problem. Fascinating topics. Any closing thoughts on the system side and encouraging people to really start exploring that side of safety?

It was It is the next frontier. Partly, that’s why I’ve always been interested in how the organization works. So, in the European CRM regulation, there was always this one-line entry about organizational factors. I’m thinking, well, what are those organizational factors? Because it doesn’t tell you anywhere in the curriculum document, it’s just there. And that tacit recognition that the organizational behavior has an effect. And that’s why I became interested in it. But it’s always seemed to me to be, it’s the final frontier. We’re just scraping at the surface of how the business works and the implications of the way it does business. If I was going to say, well, one thing, at the worker level, the natural tendency is to get resentful and to blame the then. Management. Whichever floor they work on, it’s that floor that is the problem. If it’s operational management, the flight Ops Department Is the same as line pilots. They think the same, they act the same, and they have the same problems. The non-operational managers have a different focus, so understand what their different focus is. Don’t get angry with them.

They’re just trying to do a different job from yours, but they’re still trying to make sure that everyone gets paid at the end of the day. So, part of the problem is that people tend to get defensive rather than trying to understand why the other bit of the organization behaves the way it does. And then that’s from the bottom, looking up. From the top, looking down, it’s an awareness of the fact, as we’ve just said, that whatever you do will have an outcome you didn’t anticipate. So, try to understand how that might be and appreciate that the workforce, like you, are just trying to do its job. To the best of its ability. But the fact remains, unless we understand how these factors work and what the relationships between decision-making and outcome are, then we’re never going to make this system as safe as it ought to be. It is safe because people behave in a safe manner. It’s not necessarily safe because of how the organization has designed the work process and equipped the workforce to do its job to the best of its ability. That’s the bit we got to get sorted out.

Thank you, Norman. I really appreciate your insights, and your tangible examples really bring this to life. So, thank you very much for joining us.

You’re more than welcome.

And if somebody wants to get in touch with you, Norman, what’s the best way to do that?

I’m on LinkedIn. I don’t know. Maybe you can post my email address. I’m happy to go out. I’m out there somewhere.

Thank you, Norman. Cheers.

Yes. Bye.

Thank you for listening to The Safety Guru on C-suite Radio. Leave a legacy. Distinguish yourself from the past. Grow your success. Capture the hearts and minds of your teams. Elevate your safety. Like every successful athlete, top leaders continuously invest in their safety leadership with an expert coach to boost safety performance. Begin your journey at Come back in two weeks for the next episode with your host, Eric Michrowski. This podcast is powered by Propulo Consulting.

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Norman MacLeod served in the Royal Air Force for 21 years in the Training and Education specialization. During that time, he was involved in a number of pilot training projects, the most extensive of which was his involvement in C-130 transport aircraft crew training.  On leaving the RAF, he worked for 17 years as a consultant delivering CRM to pilots and cabin crew in over 25 countries around the world. In 2011 he joined Cathay Pacific in Hong Kong as the Human Factors Manager. Returning to the UK in 2019, he is now employed as a Patient Safety Partner in the National Health Service. He has written 2 books on aspects of instructional systems design in aviation, and in 2021, his third book was published, which takes a systems view of aviation and explores what that means in terms of pilot competence.

He can be contacted at [email protected]

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