PJ2
"The key to understanding this is the question always asked by "production-minded" managers, "so if you think we're not safe to operate, where are the accidents to prove your point?" In other words, precursors to accidents are not taken as "real", nor are near misses. The notion of "luck" and "skill" are often invoked in such a mentality."
Wise words indeed. I recently encountered exactly that in questioning the design of an intravenous pump which is capable of delivering a lethal amount of moprhine. The problem was so simple, the casing had a hinge mechanism which was insecure. Once the casing was open then it would be very easy for a confused patient to inadvertently depress the driver button and inject a lethal dose. It was reported on an incident reporting mechanism but the "management" adopted exactly that defensive approach. No one has died so whats the problem?