This is a great synopsis of how serious accidents build within an organization over time because of the lack of a functioning SMS. When reading this, think “swiss cheese model” from Reason and the “domino model” from Heinrich.
Disasters are essentially organized events. To occur, they typically require the systemic and prolonged neglect of varying signs and signals of danger, creating deep pockets of organizational ignorance, organizational silence, and organizational blindness. When signals of risk are not noticed or are misunderstood in organizations, then safeguards against those risks can be allowed to degrade – or may never be created in the first place.
