This week on Safe As, we unpacked two types of the ‘same same, but different’ systemic blind-spots: a hazardous gap between work-as-imagined/prescribed/designed and work-as-done.
1. Dangerous software: In Dekker & Woods article ‘Strong, Silent, and Wrong’ on automation failure, they use the 838 MAX MCAS accidents to show what happens when high-authority automated systems operate on a flawed internal model of reality, without giving operators clear observability or easy ways to intervene.
2. Successful work: Ashraf et al.’s study used their Skip-Order-Action (SOA) framework. They tracked 1,400 procedural steps in petrochemical operations, finding that ~30% of steps departed from prescribed methods. Yet all tasks were successful, showing that context and changing conditions drive adaptations more than a simple “non-compliance” narrative.
So whether it’s rigid automation or rigid paperwork, systems break down when they fail to represent operational reality.
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