Prógono is the Manufacturing Director in charge of four Manufacturing Sites of a multinational company in South America. The significant injury rate chart is showing an alarming increase after several years of continuous improvement. The situation makes him very uncomfortable, as he thought he had solved the Safety issue once and for all. He is preparing for the monthly Management Review Meeting and does not find words to explain what is happening so that he could persuade his bosses that Safety in South America region is under control. The improvement seen in previous years had been achieved by following the strategies defined by his Company's Global Sustainability Board, and a tool that was developed and implemented to engage Supervisors in Safety issues in an unprecedented way. In parallel with the Safety issue, Prógono is implementing the Shingo Lean Manufacturing model in the region. The Shingo Model was developed by the Shingo Institute after researching recipients of the Shingo Prize that face periods of declining results after cycles of improvement. His understanding of the Shingo Model literature was that only companies that base their strategy on Principles or Values are able to improve performance year on year in a sustainable fashion. A strategy that is based on Benchmarking, Best Practices, Projects, Initiatives, and the like is bound to encounter cycles of decline after cycles of improvement. The Shingo Model states that Safety must come first, but unfortunately
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