Foundations of Safety Science

A Century of Understanding Accidents and Disasters

Sidney Dekker

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781351059770
• Edition: 1
• Topic: Technology & Engineering
• Subtopic: Industrial Health & Safety
• Index: Technology & Engineering

How are today's 'hearts and minds' programs linked to a late-19th century definition of human factors as people's moral and mental deficits? What do Heinrich's 'unsafe acts' from the 1930's have in common with the Swiss cheese model of the early 1990's? Why was the reinvention of human factors in the 1940's such an important event in the development of safety thinking? What makes many of our current systems so complex and impervious to Tayloristic safety interventions? 'Foundations of Safety Science' covers the origins of major schools of safety thinking, and traces the heritage and interlinkages of the ideas that make up safety science today.

Features

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• Offers a comprehensive overview of the theoretical foundations of safety science
• Provides balanced treatment of approaches since the early 20th century, showing interlinkages and cross-connections
• Includes an overview and key points at the beginning of each chapter and study questions at the end to support teaching use
• Uses an accessible style, using technical language where necessary
• Concentrates on the philosophical and historical traditions and assumptions that underlie all safety approaches

1 The 1900s and Onward

Beginnings

Drew Rae and Sidney Dekker

Key Points

• Safety science is the interdisciplinary study of accidents and accident prevention. It contains theories inspired by engineering, physical sciences, epidemiology, sociology, psychology, anthropology, and more.
• Most of the theories that guide current safety practices were developed during the 20th century. The same principles of scientific experimentation, theorizing, and logical reasoning—which had increasingly shown their value during the 18th and 19th centuries—could be brought to bear on the problem of safety.
• This accompanied a shift toward believing that the causes of accidents could be scientifically understood, and that there was a moral responsibility to engineer or organize preventative measures.
• It laid the basis for the emergence of new institutions for the creation and maintenance of safety rules and practice, including regulators, inspectorates, and investigative bodies that directly represented the government. Other institutions represented the common interests of employers or workers (standard bodies, professional associations), and still others combined the two, as in the case of government-mandated private insurance schemes.
• The first political concern for safety grew from the mines, factories, railroads, and steamships of the Industrial Revolution. The interplay between concerned citizens and scientists, government regulators, and insurers would continue to drive the creation of safety theories and their practical applications into the 20th and 21st centuries.

1.1 Introduction

Safety Science is the interdisciplinary study of accidents and accident prevention.

• As a social science discipline, Safety Science describes how society makes sense of and responds to the possibility of accidents.
• As a psychology discipline, Safety Science examines how humans behave as individuals, teams, and organizations during the incubation and aftermath of accidents.
• As a discipline in population health, Safety Science describes trends and patterns in the occurrence of accidents.
• As a multitude of physical sciences disciplines, it describes the physical processes by which accidents occur.
• As an engineering discipline, it seeks to identify and suggest practices and other interventions that can reduce the likelihood and consequences of accidents.

Most of the theories that guide current safety practices were developed during the 20th century, which is why this book concentrates on this time period. In this first chapter, however, we briefly consider the social and intellectual roots from which these theories have grown. These roots were planted in the 18th and 19th centuries: the historical germination and appearance of “modernity.” It is not surprising that much of the origins of safety thinking can be found there. One of the defining characteristics of modernity was a widespread faith in human-engineered progress. People began to believe that the same principles of scientific experimentation and logical reasoning—which had harnessed lightning, predicted the movement of the planets, and supported the invention of steam engines—could be brought to bear on problems such as poverty, famine, and war. Under modernity, accidents came to be seen as problems that were caused by human failings, and that were fixable by human efforts. Through engineering, social, and legislative efforts, humans were held to have the capacity—and the responsibility—to make their world safer.

This chapter traces two themes that dominated safety in the 19th century, and still shape the way we see safety today.

1. A shift toward believing that the causes of accidents could be scientifically studied, and that there was a moral responsibility to engineer or organize preventative measures.
2. The emergence of new institutions for the creation and maintenance of safety rules and practice. Some of these institutions were regulators who directly represented the government. Other institutions represented the common interests of employers or workers, and still others combined the two, as in the case of government-mandated private insurance schemes.

Together, these changes created a social system in which governments had the right and responsibility to create or endorse rules for safe design and operation, and to enforce those rules through inspection, licensing, or punishment. They also created an individual right, if not to be protected from harm at work, then at least to be compensated and taken care of when injury occurred. This right in turn placed an obligation on employers to fund insurance schemes for workers’ compensation.

1.2 Safety and Risk: Divine or Human?

The history of safety thought can be charted by examining the flurry of social, political, and intellectual activities following major accidents or ‘crises’ arising from large numbers of smaller accidents. From newspaper articles, letters, official reports, and academic papers, we can see how people at the time tried to make sense of catastrophic events. How people explained accidents determined the types of actions they took to prevent future accidents:

• An act of divine retribution demanded repentance and prayer;
• A chance event beyond human control created a need for insurance;
• An engineering failure suggested engineered solutions.

Throughout every country and industry, almost every change to safety law or practice can be linked to one or more accidents.

To find an exact beginning for Safety Science, it would be necessary to artificially divide history into an era when accidents were seen as divine or random acts, versus an era when accidents were seen as preventable or insurable. There is indeed broad support for the gradual shift from divine to engineering views of risk and accidents during the modern era, with an acceleration toward the end of the 19th century (Green, 1997). Yet in a sense these worldviews have always been contested, with movement back and forth and a gradual shift in dominance from one view to the other.

Early hints of what we might term modern thinking, for example, can be seen in ancient texts. Some trace safety back to the Code of Hammurabi (Hollnagel, 2009; Noy, 2009), a set of 282 Babylonian laws recorded around 1754 BCE. Five of these laws dealt with shoddy construction, promising severe retribution for those found at fault (The Avalon Project, n.d.):

229 If a builder builds a house for someone, and does not construct it properly, and the house which he built falls in and kills its owner, then that builder shall be put to death.

230 If it kills the son of the owner, the son of that builder shall be put to death.

231 If it kills a slave of the owner, then he shall pay, slave for slave, to the owner of the house.

232 If it ruins goods, he shall make compensation for all that has been ruined, and inasmuch as he did not construct properly this house which he built and it fell, he shall re-erect the house from his own means.

233 If a builder builds a house for someone, even though he has not yet completed it; if then the walls seem toppling, the builder must make the walls solid from his own means.

Parts of the Pentateuch referenced safety and negligence. Deuteronomy (22:8 NIV), written around 1400 BCE, includes the safety-through-design rule, with the understanding that flat roofs were (and are) used for more than just covering a house. At night, they offer escape from the heat and are even slept on:

When you build a new house, make a parapet around your roof so that you may not bring the guilt of bloodshed on your house if someone falls from the roof.

Exodus (21:28–29), written between 600 and 400 BCE, draws a distinction between accident and negligence:

If a bull gores a man or woman to death, the bull is to be stoned to death, and its meat must not be eaten. But the owner of the bull will not be held responsible.

If, however, the bull has had the habit of goring and the owner has been warned but has not kept it penned up and it kills a man or woman, the bull is to be stoned and its owner also is to be put to death.

These passages hint at a world where the future can be predicted by studying the past, and where individuals hold responsibility for the safety of those around them. There are numerous examples of court rulings that upheld human responsibility for injury and property damage, but these notions stood alongside the idea that the divine acted in daily life, and that sickness and misfortune were the wages of sin (Hall, 1993; Loimer & Guarnieri, 1996).

The Lawyer’s Logic, endorsed by the Bishop of London, opined that the use of profane words like ‘fortune,’ or ‘chance,’ or ‘haphazard’ was evidence that people did not understand the “first cause: God’s providence” (Loimer & Guarnieri, 1996, p. 105). In 1615, a boy of seven or eight “was drowned in Goodmans ffeilds in a Pond, playing with other Boyes there and swymming” (Forbes, 1979). The boy’s death was ruled the result of a “Visitation of God,” or “Act of God” (Burnham, 2009, p. 7).

A few decades after the drowning of the boy at Goodman’s, however, we can find stirrings of a modern view. Consider the Bills of Mortality, published in London in 1647, for example. Over 13,000 “premature” deaths were recorded that year, with epidemic diseases (smallpox, measles, bubonic plague, malaria, tuberculosis, and enteric diseases) as their overwhelming cause (Loimer & Guarnieri, 1996). But 27 additional deaths resulted from “accidents.” Drowning killed another 47 and burning killed 3 (today these categories might be labeled as accidents too).

Reflecting on the Bills, an early amateur demographer by the name of John Graunt noted that deaths from accidents were ‘chronical.’ Their number, he observed in his 1662 Natural and Political Observations Made upon the Bills of Mortality, was rather constant from year to year, like that of homicide or suicide. This was in sharp contrast with the bursts of deaths from epidemic diseases. It suggested a different etiology, or set of causes. Though a devout man, Graunt connected these deaths to people’s occupations and suggested divine intervention might say

…nothing of the numbers of those that have been drowned, killed by falls from scaffolds, or by carts running over them, etc. because [this] depends upon the casual trade, and employment of men.

Loimer and Guarnieri (1996, p. 102)

The naturalist, or human-made view of accidents, however, would have another couple of centuries of contest with divine views ahead of it. Like in many other spheres of life (everything from the divine right of kings to an understanding of pathogens), these were heady and unsettled centuries where secular interpretations of how to understand, govern and order life slowly gained ground. The Scientific Revolution, the Enlightenment, and the Industrial Revolution would all contribute, as would the many developments and disasters during the 20th century.

1.3 Modernity and Humankind’s Control of Nature

Francis Bacon was arguably the most influential scientist never to make any original scientific discoveries. In his 1620 masterpiece, The New Organon, he explicitly set out to tear down the reputations of the ancient philosophers whose writings—along with biblical studies—formed the basis of medieval scholarship. Bacon believed that reliance on logical thought was a certain pathway to self-deception:

The mental operation which follows the act of sense I for the most part reject; and instead of it I open and lay out a new and certain path for the mind to proceed in, starting directly from the simple sensuous perception. The necessity of this was felt, no doubt, by those who attributed so much importance to logic, showing thereby that they were in search of helps for the understanding, and had no confidence in the native and spontaneous process of the mind. But this remedy comes too late to do any good, when the mind is already, through the daily intercourse and conversation of life, occupied with unsound doctrines and beset on all sides by vain imaginations. And therefore that art of logic, coming (as I said) too late to the rescue, and no way able to set matters right again, has had the effect of fixing errors rather than disclosing truth. There remains but one course for the recovery of a sound and healthy condition—namely, that the entire work of the understanding be commenced afresh, and the mind itself be from the very outset not left to take its own course, but guided at every step; and the business be done as if by machinery.

Bacon (1620, p. 8)

Bacon’s approach was based on a form of inductive reasoning, and bears little resemblance to the hypothetico-deductive ‘scientific method’ taught today. But his core argument that logic and argument led to self-deception, and that experiment and observation guided by strict methods led to fundamental truths, formed the heart of a new empirical approach to science.

Bacon’s work was (and in the history of philosophy, still is) contrasted with René Descartes. On the surface, Bacon and Descartes held very different ideas about science. Bacon argued that human reason was too fallible to result in reliable knowledge; Descartes believed that reason could be used to extend knowledge beyond direct observation, so long as strict rules of logic were followed. Bacon and Descartes agreed on something more important and long-lasting than either of their methods. They were both spiritual men who believed in God, but they were engaged in the same grand project of developing systems of scientific enquiry to understand nature—and by understanding, to control it.

In 1637, Descartes published his Discourse on the Method of Rightly Conducting One’s Reason and of Seeking Truth in the Sciences. Observing the tribulations of Galileo, he was originally not eager to have his own work printed and distributed, but reasoned:

But as soon as I had acquired some general notions respecting physics, and beginning to make trial of them in various particular difficulties, had observed how far they can carry us, and how much they differ from the principles that have been employed up to the present time, I believed that I could not keep them concealed without sinning grievously against the law by which we are bound to promote, as far as in us lies, the general good of mankind. For by them I perceived it to be possible to arrive at knowledge highly useful in life; and in room of the speculative philosophy usually taught in the schools, to discover a practical, by means of which, knowing the force and action of fire, water, air the stars, the heavens, and all the other bodies that surround us, as distinctly as we know the various crafts of our artisans, we might also apply them in the same way to all the uses to which they are adapted, and thus render ourselves the lords and possessors of ...