Finishing up writing a couple of papers and thought these references may be of interest.
The first image is taken from Peter Ladkin’s re-evaluation of Andrew Hopkin’s analysis of the 1999 Glenbrook rail accident (source below).
Hopkins and the official investigation revealed some interesting facets of rule following – the governing system was complex, voluminous, didn’t necessary match with operational reality in parts and didn’t necessarily guide safe operations.
Similarly, image two is one of my favourite extracts from the Esso Longford plant accident investigation. Here it’s noted that their OIMS (Operations Integrity Management System) was complex, repetitive, circular and was at times “impenetrable”.
Importantly, it was seen to have taken on a life of its own, where people managed the system and documents rather than the operational issues.
We identified multiple examples of these effects in previous published papers or accident reports (“Fantasy planning: the gap between systems of safety and safety of systems” and “Writing plans instead of eliminating risks: How can written safety artefacts reduce safety?” – both available through my Researchgate page, link below).
Moreover, we also more recently identified evidence of this effect in safety auditing (papers in draft/review).
Note: This isn’t a criticism on rules, nor saying we shouldn’t have rules and management systems. It’s more around understanding how/when these systems may not help us to manage the issues we expect.
Image 1 source: Ladkin, P. (2005). Why-Because Analysis of the Glenbrook, NSW Rail Accident and Comparison with Hopkins’s Accimap
Image 2 source: Dawson, M. The Esso Longford Gas Plant Accident. Report of the Longford Royal Commission
Link to my Researchgate papers: https://www.researchgate.net/profile/Ben-Hutchinson-4
Link to the LinkedIn post: https://www.linkedin.com/posts/benhutchinson2_finishing-up-writing-a-couple-of-papers-and-activity-7057108071730307072-uvhk?utm_source=share&utm_medium=member_desktop
SafetyInsights.org 
Can’t wait to read your new research when it comes out. I really enjoyed reading “Fantasy planning: the gap between systems of safety and safety of systems” and “Writing plans instead of eliminating risks: How can written safety artefacts reduce safety?” and regularly refer back to them or refer collegues to them to read.
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