Can the perfect safety system be dangerous?
This company genuinely strives to “live, eat and breathe safety” in everything they do, and they have comprehensive safety policies and procedures for virtually everything.
Without question the safety system had responses for every certification requirement and thoroughly covered every topic.
So we might presume this company is very safe and everyone follows the procedures, per their comprehensive training program co-ordinated by their professional learning and development team?
What we did find was hundreds and possibly thousands of documents located in different storage systems of various ages with a wide range of titles and descriptions.
Further the company documents; overlapped each other, had some inconsistent instructions, were too complex and “wordy”, used different terminology and lacked a consistent glossary, and not all related documents were identified or cross referenced.
In practice it would be impossible for any normal person to find everything they need, let alone be aware of all of the stated requirements, and be able to accommodate the vagaries inherent in such a complex system.
Sidney Dekker famously stated in his book Drift into Failure that “complexity is the enemy of safety”, and Professor Dennis Else, formerly of Ballarat University, supports this with research he says shows a reasonable (but imperfect) procedure that is followed by everyone provides a higher level of safety than a supposedly perfect, but incomprehensible system that few if any people follow.
I therefore conclude that the “perfect safety system” can be dangerous and that our goal must be to build practical safety procedures.