THE GAP THAT KEEPS US SAFE
Why the goal isn’t to eliminate work-as-done—but to support it.
- The plan was solid.
- The procedure was approved.
- The task was rehearsed.
BUT
- Then the component is 20 feet off the ground
- Wind picked up.
- The scissor lift will not fit
Nothing failed. The environment changed.
That moment—when work stops matching the plan—is the gap between work as imagined and work as done. And it’s where safety is either won or lost.
THE MYTH WE KEEP CHASING
Most systems are built on a quiet assumption: If we define work clearly enough, reality will cooperate. It won’t. Real work lives in complex systems, shaped by uncertainty, pressure, and interaction effects, as Donella Meadows describes. Add human judgment under time pressure—what Daniel Kahneman calls fast thinking—and variability is not a defect. It’s inevitable.
Trying to eliminate the gap creates brittle systems
- They look good on paper.
- They fail in the field.
WHY THE GAP EXISTS
The gap exists because:
- Conditions change faster than procedures
- Hazards emerge from combinations, not checklists
- People must adapt to keep work moving
As Nassim Nicholas Taleb reminds us, rare and unexpected conditions dominate outcomes. No rulebook can anticipate them all
INFORMATION ISN’T ENOUGH
Organizations are excellent at pushing information:
- Procedures
- Training
- Rules
But information does not equal capability. Competency comes from knowledge:
- Why a control matters
- What signals indicate rising risk
- When stopping is the right call
- How to adapt without breaking the system
WHAT GOOD SYSTEMS DO
Strong systems don’t try to close the gap. They support the people inside it. They:
- Make changing risk visible
- Encourage questioning and escalation
- Reward speaking up, not silent compliance
- Trust skilled workers with bounded autonomy
People don’t follow reality—they interpret it, moment by moment
THE CORE MESSAGE
Safety is not created by tighter control. It’s created by better support for human judgment. The goal is not to eliminate the gap between work as imagined and work as done—the goal is to design systems that help people navigate that gap safely when reality refuses to match the plan.
That’s not a weakness. That’s how work actually succeeds?
REFERENCES
- Taleb, N. N. (2007). The Black Swan: The Impact of the Highly Improbable. New York, NY: Random House.
- Syed, M. (2015). Black Box Thinking: Why Most People Never Learn from Their Mistakes—but Some Do. London, UK: John Murray.
- Meadows, D. H. (2008). Thinking in Systems: A Primer. White River Junction, VT: Chelsea Green Publishing.
- Kahneman, D. (2011). Thinking, Fast and Slow. New York, NY: Farrar, Straus and Giroux.
- Ariely, D. (2008). Predictably Irrational: The Hidden Forces That Shape Our Decisions. New York, NY: HarperCollins.
- Madsbjerg, C. (2014). Sensemaking: The Power of the Humanities in the Age of the Algorithm. New York, NY: Hachette Book Group.
- Hollnagel, E. (2014). Safety-I and Safety-II: The Past and Future of Safety Management. Farnham, UK: Ashgate.
- Dekker, S. (2014). The Field Guide to Understanding ‘Human Error’ (3rd ed.). Farnham, UK: Ashgat