[SystemSafety] Historical Questions

[Peter Bernard Ladkin]

On 2017-03-09 07:18 , Drew Rae wrote:
> When was the first accident report that found explicitly that failure to conduct a *risk assessment*
> was a cause of the accident? 

I would say that that is, in general, mistaken causal reasoning.

When an operator fails to perform a necessary action, that is a reified non-event in WBA.  For
example, failure to brake was a cause of the Berajondo derailment.

But how can there be a causal connection, according to the Counterfactual Test, from failure to
perform an analysis to an accident event?

Try it. The CT statement: In the closest possible world to ours, had a risk analysis been performed,
the accident would not have happened.

Generally not passed. Had a risk analysis been performed, *and been acted upon*, and *had all
subsequent actions been conformant with the risk analysis*, then *maybe* the accident would not have
happened. But, after all, a risk is a risk and it is consistent with any non-zero risk and
concomitant action that the risk is realised, that is, the accident happened.

> When was the first regulation that required explicitly that *risk assessment* should be conducted?

Very interesting question!

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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