A couple of views of this “disaster waiting for a time and place to happen” situation which is ALL TOO COMMON.
My view from 2008 after meeting Astronaut Mike Mullane
Dave Rebbett’s view:
Even more from Mike:
It’s a stark realization that this is and continues to be a fundamental problem is Safety Management Systems. Blindness to the obvious…
The problem with deviance from the norm is that, some is good. It’s how we learn and evolve. The problem arises where the deviance is no longer seen as the deviance but “the way it is around here.” There becomes a “blindness” to it. The Annual Audit is not likely to be as much of a problem as a solution where the humans inside the system start seeing the deviance as “We’ve always done it that way.”
Identifying “slippage” is a difficult thing when your inside the slippage. Hindsight often gets “arrogant” about their “discovery” of the slippage…easy to do after the “big bang” hard to do when you’re in the eye of the storm. It’s pretty calm in there even though the people inside should be anything BUT calm.
Slippage, scope creep, evolution, they are all natural and predictable errors in live systems. Seeing it, watching for it, then reacting to it is hard to do as so many “all too human” humans find out after it’s too late.