TakeawayA method for finding the deviation that your control framework is structurally unable to see.
Every serious organisation has a control framework that would survive an audit. That is not the problem. The problem is that control frameworks are designed against the normal case, and the normal case is not when they are needed.
The argument
Under pressure, the documented system and the observed system separate. The separation is not random. It follows the path of least consequence: whichever behaviour is cheapest at that moment for the person doing it. If the thorough handover takes forty minutes and nobody notices either way, and the fast one takes five and gets you off site, the system has already chosen.
What the room leaves with
Where to look for the deviation your framework cannot see, because the framework is what defines what counts as a deviation.
Why near-miss reporting rates go down for two entirely different reasons, and how to tell which one you are looking at.
What a control looks like when it is designed against the pressured case rather than the normal one.
