In particular when you are doing something for the first time, uncertainty creates a space for a safety culture to operate.

Design, process and safety emphasis lead to operational success.

Over time the original designers and engineers leave, new staff join. Field experience shows that most of the safety problems that were anticipated in design never happen. The organisation starts to become complacent.

All the safety features and procedures start to be considered, psychologically, as a “safety margin” or a kind of budget that can now be spent by taking more risks. Triple or quadruple redundancy just starts looking like extra weight.

Within the org, pressures to lower costs and deliver faster start to win out...