Safety alchemy: false assurance by converting operational risks into milestone documents

For many organisations, managing safety also encompasses managing a system of safety documents. These documents are ‘enabling devices’: they function as institutional passports that allow work to commence or advance. Previous work indicates that such documents can contribute to safety beliefs and practices becoming decoupled from operational risks. In this project we analysed reports from seven major accidents to identify how this decoupling occurs. The analysis revealed a recurring process we term ‘safety alchemy’: the conversion of unresolved uncertainty and operational risk into perceived certainty and organisational assurance through the creation, completion, revision, or acceptance of safety artefacts, without a corresponding improvement in the underlying control of risk. The process was fuelled by documentation displacing attention from underlying problems and becoming authoritative accounts of safety. These findings identify specific ways in which safety management system processes can create false risk assurance. These mechanisms offer practical opportunities for improved review and audit of safety management systems.