[SystemSafety] NTSB report on Boeing 787 APU battery fire at Boston Logan

[Matthew Squair]

John Downer (whose on the list I think) coined the phrase 'epistemic
accident' to cover accidents which are due to our knowledge being
contingent as much on on theories, and assumptions, as facts. Said theories
which may then prove to be not quite good enough. Apologies if I mangle the
definition a bit.

I also noticed the NTSB homed in on the need to surface assumptions and
make them explicit. Assumptions of course being the epistemic equivalent of
 whoopy cushions in engineering. :)

Matthew Squair

MIEAust, CPEng
Mob: +61 488770655
Email; Mattsquair at gmail.com
Web: http://criticaluncertainties.com

Matthew Squair

MIEAust, CPEng
Mob: +61 488770655
Email; Mattsquair at gmail.com
Web: http://criticaluncertainties.com
On 6 Dec 2014, at 2:30 am, Mike Ellims <michael.ellims at tesco.net> wrote:

In the Guardian Gawande states..

" There was an essay that I read two decades ago that I think has influenced
almost every bit of writing and research I've done ever since. It was by two
philosophers - Samuel Gorovitz and Alasdair MacIntyre - and their subject
was the nature of human fallibility. They wondered why human beings fail at
anything that we set out to do. Why, for example, would a meteorologist fail
to correctly predict where a hurricane was going to make landfall, or why
might a doctor fail to figure out what was going on inside my son and fix
it? They argued that there are two primary reasons why we might fail. The
first is ignorance: we have only a limited understanding of all of the
relevant physical laws and conditions that apply to any given problem or
circumstance. The second reason, however, they called "ineptitude", meaning
that the knowledge exists but an individual or a group of individuals fail
to apply that knowledge correctly."



However I think that Gorovitz and MacIntyre argue something very different,
the following is I believe the essence of their argument. I have edited it
because the paper is very long and not the easiest of reads.

  {First they discuss where our traditional views of error come from i.e.
the natural sciences}

For  on  this  view  all  scientific  error  will  arise  either from  the
limitations  of  the  present  state  of  natural  science-that  is,  from
ignorance or  from  the  willfulness  or  negligence  of  the  natural
scientist-that is, from ineptitude. This classification is treated as
exhaustive.
   <snip>
This view of ignorance and ineptitude as the only  sources of error has been
transmitted  from  the pure to the applied  sciences, and hence, more
specifically, from  medical  science  to  medical  practice  viewed  as  the
application  of what  is learned  by  medical  science.
   <snip>

   {they then go on to look at the issue that doctors - and engineers face
dealing }
   { with particular situations, EMPHISIS ADDED below }

Precisely  because  our  understanding  and  expectations  of particulars
cannot  be  fully  spelled  out  merely  in  terms  of  law like
generalizations  and initial  conditions,  the  best  possible judgment  may
always  turn  out  to  be erroneous,  and  erroneous  not  merely  because
our  science  has  not  yet progressed  far  enough  or  because  the
scientist  has been  either  willful  or negligent,  but  because  of  the
necessary  fallibility  of  our  knowledge  of particulars.
  <snip>
The  recognition  of  this  element  of  necessary  fallibility  IMMEDIATELY
DISPOSES OF THAT TWOFOLD CLASSIFICATION  of  the  sources  of  error  which
we have  seen  both  to  inform  natural  scientists'  understanding  of
their  own practices  and  to  be  rooted  in  the  epistemology  that
underlies  that  understanding.  Error  may  indeed  arise  from  the
present  state  of  scientific ignorance  or  from  willfulness  or
negligence.  But  it  may  also  arise  precisely from  this third factor,
which  we have called  necessary  fallibility  in respect  to particulars.

-----Original Message-----
From: systemsafety-bounces at lists.techfak.uni-bielefeld.de
[mailto:systemsafety-bounces at lists.techfak.uni-bielefeld.de
<systemsafety-bounces at lists.techfak.uni-bielefeld.de>] On Behalf Of
Peter Bernard Ladkin
Sent: 05 December 2014 11:58
To: systemsafety at lists.techfak.uni-bielefeld.de
Subject: Re: [SystemSafety] NTSB report on Boeing 787 APU battery fire at
Boston Logan

On 2014-12-05 12:36 , Martin Lloyd wrote:


On 05/12/2014 10:52, Mike Ellims wrote:

Interestingly research suggests surgeons who expect things to go

wrong and plan for failure have much higher success rates.


Does anyone have a reference to these research results?


Atul Gawande is giving the Reith Lectures at the moment on a closely related
topic, namely how to improve the success rate of/avoid avoidable failures in
medicine. A summary of the first is
http://www.theguardian.com/news/2014/dec/02/-sp-why-doctors-fail-reith-lectu
re-atul-gawande  The BBC page is
http://www.bbc.co.uk/programmes/articles/6F2X8TpsxrJpnsq82hggHW/dr-atul-gawa
nde-2014-reith-lectures

PBL

Prof. Peter Bernard Ladkin, Faculty of Technology, University of Bielefeld,
33594 Bielefeld, Germany
Tel+msg +49 (0)521 880 7319  www.rvs.uni-bielefeld.de




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