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The Parable of the Boiled System Safety Professional: Drift to FailureRecall from the Parable of the Boiled Frog, that tossing a frog into boiling water causes the frog to jump out and hop away while placing a frog in suitable temperature water and slowly bringing the water to a boil results in the frog boiling due to not being aware of the slowly increasing danger, theoretically, of course. System safety professionals must guard against allowing dangers to creep unnoticed into their projects and be ever alert to notice signs of impending problems. People have used various phrases related to the idea, most notably, latent conditions, James Reason in Managing the Risks of Organizational Accidents (1, pp 10-11), Drift to Failure, Sydney Dekker (2, pp 82-86) in Resilience Engineering: Chronicling the Emergence of Confused Consensus in Resilience Engineering: Concepts and Precepts, Hollnagel, Woods and Leveson, and normalization of deviance, Diane Vaughan in The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA (3). Reason also said, If eternal vigilance is the price of liberty, then chronic unease is the price of safety (1, p 37). Our challenge as system safety professionals is to be aware of the emergence of signals that warn us of slowly eroding safety margins. This paper will discuss how system safety professionals might better perform in that regard.
Document ID
20110015770
Document Type
Conference Paper
Authors
Shivers, C. Herbert (NASA Marshall Space Flight Center Huntsville, AL, United States)
Date Acquired
August 25, 2013
Publication Date
August 8, 2011
Subject Category
Quality Assurance and Reliability
Report/Patent Number
M11-0481
Meeting Information
29th International System Safety Conference (ISSC)(Las Vegas, NV)
Distribution Limits
Public
Copyright
Work of the US Gov. Public Use Permitted.

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