[SystemSafety] Historical Questions

Peter Bernard Ladkin ladkin at causalis.com
Thu Mar 9 06:16:00 CET 2017



On 2017-03-09 05:59 , DREW Rae wrote:
> ....
> My question is not about when investigation was invented, but specifically when did people start
> explaining accidents in terms of failed safety processes. 

I think it is hard to be precise about what you're after.

I would think that people have been saying "don't do that; you're going to lose it all" for
millenia. I imagine the first time a ship went out in weather when some people thought it shouldn't
sail, and sunk. People would surely say "he shouldn't have sailed and we said so". That's a failed
safety process. Still happens all the time in general aviation. There's a saying: "better down here
wishing you were up there than up there wishing you were down here".

Or the first time somebody took a band of traders into a known dangerous place, and lost them all in
a fight with the locals.

> Formal investigation for the purpose of safety, and formal regulation of safety through
> Inspectorates is a 19th century invention. 

Maybe, but what's your trigger? What constitutes "formal"? What constitutes "regulation"? You seem
to suggest: state involvement. So, at some point a state decides "we are going to adjudicate
accident-events formally". The process by which they do that doesn't come out of nowhere. It comes
out of existing patterns of judgement concerning those events.

PBL

Prof. i.R. Peter Bernard Ladkin, Bielefeld, Germany
MoreInCommon
Je suis Charlie
Tel+msg +49 (0)521 880 7319  www.rvs-bi.de





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