The emergence of confused consensus
The industry should see the SFO event as an opportunity to learn, reassess safety boundaries.
‘Drifting into failure’ is a metaphor for the slow, incremental movement of systems operations toward (and eventually across) the boundaries of their safety envelope. Pressures of scarcity and competition typically fuel such movement and uncertain technology and incomplete knowledge about where the boundaries actually are, result in people not stopping the movement or even seeing it.
Recognising that a system is drifting into failure is difficult because the entire protective structure (including suppliers, regulators, managerial hierarchies, etc.) seems to slide along with the operational core toward the boundary. Even if an operational system is ‘borrowing more from safety’ than it was previously or than it is elsewhere by operating with smaller failure margins, this may be considered ‘normal’, as the regulator approved it. Almost everybody inside the system does it, goes along, and agrees, implicitly or not, with what is defined as risky or safe.
Also, the departures from previous practice are seldom quick or large or shocking (and thus difficult to detect): rather, there is a slow succession of tiny incremental deviations from what previously was the ‘norm’. Each departure in itself is hardly noteworthy. In fact, such ‘departures’ are part and parcel of normal adaptive system behaviour, as organizations (and their regulators) continually realign themselves and their operations with current interpretations of the balance between profitability and risk (and have to do so in environments of resource scarcity and competition). As a result, large system accidents of the past few decades have revealed that what is considered ‘normal’, or acceptable risk is highly negotiable and subject to all kinds of local pressures and interpretations.
S. Dekker in 'Resilience Concepts and Precepts'