I found these three extracts from major accident reports pretty apt – they featured in our latest study on audit failures in high hazard industries.
The first two examples came from coronial reports in mining. It’s a shame that such important findings are so frequently ‘written in blood’.
1.
2.
They highlight the false assurance that our risk management systems and practices may entice us into believing, even though critical risks may remain ill-managed.
The third extract comes from one of the (many) Macondo investigation reports. It highlights the misplaced understanding that the CEO had about internal system reviews – believing it to be a function for the consultants (or safety people), rather than an activity that leaders must own and drive.
If you’re interested in reading more about this type of false assurance in auditing, check out our paper linked here. The link to our previous papers on false assurance and risk decoupling are also linked in comments.
Sources:
- Queensland Courts. Inquest into the Death of Peter Whitoria Marshall; 2006.
- Queensland Courts. Inquest into the Death of Scott Meho Karajic; 2006.
- Mitchell A. In the Matter of DEEPWATER HORIZON. Report Regarding Transocean’s Safety Management System and the ISM Code. Published online 2011.
Links:
Major accident audit failures: https://aiche.onlinelibrary.wiley.com/doi/epdf/10.1002/prs.12579
OHS audit failures: https://www.sciencedirect.com/science/article/pii/S0925753523002904/pdfft?md5=a08fa66f34e788c3b5d314a44319a8f0&pid=1-s2.0-S0925753523002904-main.pdf
Writing plans instead of eliminating risks: https://www.researchgate.net/publication/359237387_Writing_plans_instead_of_eliminating_risks_How_can_written_safety_artefacts_reduce_safety
SafetyInsights.org 
One thought on “The false safety of interlocking management systems of audits, reports and rules”