Investigations of accidents in a number of hazardous domains suggest that a cluster of organizational pathologies—the “vulnerable system syndrome” (VSS)—render some systems more liable to adverse events. This syndrome has three (3) interacting and self-perpetuating elements:
- Blaming front-line individuals,
- Denying the existence of systemic error provoking weaknesses and
- Blinkered pursuit of productive and financial indicators of safety
VSS is present to some degree in all organizations, and the ability to recognize its symptoms is an essential skill in the progress towards improved safety performance.
