Decades of efforts aimed at understanding what safety is and why accidents happen have led to several significant insights. One is that untoward events more often are due to an unfortunate combination of a number of conditions, than to the failure of a single function or component. Another is that failures are the flip side of successes, meaning that there is no need to evoke special failure mechanisms to explain the former. Instead, they both have their origin in performance variability on the individual and systemic levels, the difference being how well the system was controlled.
It follows that successes, rather than being the result of careful planning, also owe their occurrence to a combination of a number of conditions. While we ...
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