The environment, organization, economics, capabilities, technology, and regulatory context all change over time. This backdrop of continuous systemic change ensures that hazards and how they are managed are constantly changing.
Progress on safety concerns anticipating how these kinds of changes will create new vulnerabilities and paths to failure even as they provide benefits on other scores. The general lesson is that as capabilities, tools, organizations and economics change, vulnerabilities to failure change as well – some decay, new forms appear. The state of safety in any system is always dynamic, and stakeholder beliefs about safety and hazard also change.
Another reason to focus on change is that systems usually are under severe resource and performance pressures from stakeholders (pressures to become faster, better, and cheaper all at the same time). First, change under these circumstances tends to increase coupling, that is, the interconnections between parts and activities, in order to achieve greater efficiency and productivity. However, research has found that increasing coupling also increases operational complexity and increases the difficulty of the problems practitioners can face. Second, when change is undertaken to improve systems under pressure, the benefits of change may be consumed in the form of increased productivity and efficiency and not in the form of a more resilient, robust and therefore safer system.
It is the complexity of operations that contributes to human performance problems, incidents, and failures. This means that changes, however well-intended, that increase or create new forms of complexity will produce new forms of failure (in addition to other effects). New capabilities and improvements become a new baseline of comparison for potential or actual paths to failure. The public doesn’t see the general course of improvement; they see dreadful failure against a background normalized by usual success.
Future success depends on the ability to anticipate and assess how unintended effects of economic, organizational and technological change can produce new systemic vulnerabilities and paths to failure. Learning about the impact of change leads to adaptations to forestall new potential paths to and forms of failure.
Source: Behind Human Error; Second Edition; David D. Woods, Sidney Dekker, Richard Cook, Leila Johannesen & Nadine Sarter, 2010
