This article was originally published on LinkedIn on 27 May 2025. It has been moved to the riskfacilitator Insights library so the website remains the permanent source.[1]
A legal decision in New Zealand involving the former CEO of Ports of Auckland has sent a strong and lasting message to leaders across every high-risk sector:
You can’t delegate your way out of accountability. You must verify that risk is being managed in practice, not just on paper.
The CEO was found guilty under New Zealand’s Health and Safety at Work Act, not because he directly caused harm, but because he failed to exercise due diligence as an officer. A worker died after entering a known exclusion zone. The zone existed in policy, but was poorly enforced in reality.
It wasn’t a one-off. It was a pattern. And leadership missed it.
When “Work-as-Imagined” Doesn’t Match “Work-as-Done”
One of the most persistent blind spots in risk governance is the assumption that because a procedure exists, it is followed. That because training was delivered, it was absorbed. That because a risk control is written down, it is operating effectively.
Professor Erik Hollnagel captured this disconnect in his concept of “Work-as-Imagined” versus “Work-as-Done.”Leaders often imagine work through reports, procedures, or flowcharts, but that version of work is almost always cleaner, more compliant, and more linear than what actually happens on the ground.
In the Gibson case, exclusion zones were clearly documented. But operational drift meant those zones were routinely entered, not as a breach, but as business-as-usual. The rules existed, but the reality diverged. And no one at the executive level was verifying the difference.
This isn’t just a compliance gap, it’s a systems gap. One that widens every time leadership assumes a document reflects reality, rather than checking whether it does.
In dynamic environments, this gap can be fatal. Risk isn’t managed by policy alone. It’s managed through the daily adjustments, trade-offs, and decisions made under real-world pressures.
And unless leaders are engaging with the lived experience of work, they will continue managing the imagined and missing the emerging.
Drifting Into Failure
This wasn’t about one worker making a bad decision. It was about a system slowly, quietly drifting into failure, a term Professor Sidney Dekker uses to describe how organisations incrementally move toward catastrophe, all while appearing normal on the surface.
At Ports of Auckland, exclusion zones weren’t just poorly enforced, they had become routinely ignored. A breach wasn’t the exception; it was the norm. Leadership either didn’t see it, or didn’t ask the right questions to uncover it.
This kind of cultural drift doesn’t appear in a dashboard. It shows up in behaviours, conversations, shortcuts, and ultimately, consequences.
Real safety leadership requires more than believing the system works. It requires getting close enough to see where it doesn’t.
What Officers Must Learn
Regardless of your industry or environment, the core message holds:
- Leadership must be operationally curious.
- Verification is a duty, not a courtesy.
- Systems must be validated, not assumed.
- Culture is not what’s written, it’s what’s tolerated.
“Due diligence is not the compliance of the organisation. It is the compliance of the individual officer.” , Michael Tooma, Due Diligence: Duty of Officers
This is not about paperwork. It's about presence, foresight, and a refusal to be passive. Due diligence, as Tooma frames it, is a personal discipline, not a collective excuse.
References
- Paul Chivers, When Leadership Fails to Look: Lessons from the Gibson Judgment, LinkedIn, originally published 27 May 2025.
- Maritime New Zealand, High Court dismisses Tony Gibson appeal, accessed 10 August 2026.