Safety by Design Under Strain: A Case Study in System Convergence

Abstract

Safety by Design (SbD) is increasingly embedded in high-risk industries to promote alignment with the hierarchy of controls by eliminating or minimising risk through engineering and system design rather than reliance on administrative or personal protective equipment controls (Safe Work Australia, nd).

In practice, however, applying SbD is not straightforward. Complexity emerges where engineering, organisational systems, human factors, contractor delivery models, commercial pressures, and regulatory frameworks intersect within dynamic operating environments.

This paper presents an abstract case study based on a significant network event within a New Zealand electricity distribution context involving excavation works, repeated asset interactions, and eventual exposure to a live high-voltage asset. The event resulted in unplanned network disruption and elevated risk to both workers and the public, requiring rapid decision-making across multiple organisational boundaries, including local authority-led contracting environments where no direct commercial relationship existed with the asset owner.

Using a qualitative, reflective approach, this study examines how SbD principles were applied, adapted, or constrained in practice. The concept of System Convergence Strain is introduced to describe how overlapping duties, fragmented contracting chains, and competing priorities create ambiguity and shift risk control away from engineered systems toward frontline judgement under uncertainty. The findings challenge the assumption that safety can be effectively managed within organisational boundaries and instead position safety as an emergent property of interacting systems.