Workplace injuries and illness and the associated costs are a problem of epidemic proportion adversely impacting workers and employers. While workplace safety systems appear to offer the potential for effectively reducing workplace injury and illness, rates of injury in many jurisdictions remain unacceptably high. The purpose of this study was to understand the process of leaders’ apparent perspective transformation associated with a record of high injury rates to making safety a corporate priority, how that impacts the organization, and how that experience might inform others. Using the lens of transformative learning this case study, informed by ethnography, examined the experience of a long term seniors’ living facility which had dramatically reduced injury rates and costs. Interviews were conducted with influential managers at the facility and corporate level plus one non-management person. Document review, observation and artefacts provided additional data. Findings indicated that organizations with high injury rates have the potential to change their safety perspective and that perceived realities, or frames of reference serve to direct actions taken by leaders. Disorienting dilemmas, discourse and critical reflection were seen as contributing to changes in leaders’ frames of reference leading to action to create a safer workplace. Compassion, commitment and respect for employees by leaders were seen as underpinning the change, while engagement of workers was seen as an important part of effecting a culture change within the workplace. Leadership commitment was seen as critical to effecting the change in safety priority and the workplace culture relative to safety. Transformative learning was seen both as a way of understanding the change within the case study, and potentially as a means of effecting change in leaders’ frames of reference more broadly.