Safety Accidents in Risky Industries

Black Swans, Gray Rhinos and Other Adverse Events

Sasho Andonov

• Publisher: CRC Press
• Year: 2021
• ISBN:
  9781000486155
• Edition: 1
• Topic: Technology & Engineering
• Subtopic: Industrial Health & Safety
• Index: Technology & Engineering

This text introduces bad events (incidents and accidents) named as metaphors. The metaphors, called as "safety animals, " are named as black swan, gray rhino, gray swans, and invisible gorilla.

The book analyzes incidents and accidents from the context of the safety management system in the risky industries including aviation, nuclear, chemical, oil, and petroleum. It further uses mathematical analysis of these events (through statistics and probabilities) and presents preventive and corrective measures in dealing with the same.

It comprehensively covers important topics including real-time monitoring, reverse stress testing, change management, predictive maintenance, management system, contingency plans, human factors, behavioral safety, anticipatory failure determination, resilience engineering (RE), resilience management (RM), Swiss cheese model, and probability distribution.

Aimed at professionals working in the fields of health and safety, quality engineering, compliance engineering, aerospace engineering, occupational health and safety, and industrial engineering, this text:

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• Provides an insight to safety managers in analyzing bad events and the ways to deal with them

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• Covers randomness, uncertainty, and predictability in detail

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• Explains concepts including reverse stress testing, real-time monitoring, and predictive maintenance in a comprehensive manner

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• Presents mathematical analysis of incidents and accidents using statistics and probability theories

1 Philosophy of Science As Introduction

DOI: 10.1201/9781003230298-1

1.1 Introduction

Science is something that has contributed the most to human well-being. Whatever you think about science and the scientists, turn around and you can notice things that are products of the efforts of the scientists: Your laptop, mobile, car, food, clothes, home, etc. In everything, scientists have put their knowledge, experience, and strange and good ideas, and it resulted in all these things that we use today.

Not always was this fact recognized by the humans…

At the beginning of human journey throughout the centuries, the functioning of the nature was not so obvious to them. The mystic force in our brains was looking for the explanation of the things around us that we could not explain. Very often, the gathered knowledge showed benefit, so people tried to use it to improve their lives. But not always was the gathered knowledge describing the true nature of the world around us. Unfortunately, not all people were able to understand the things as they were, and many of them were prone to accept some other understandings about the nature and the world around them. They tried to pursue their ideas about functioning of the nature and the world to others.

I would not speak about the bad and the good things of the philosophy of general science in this chapter, but I would speak about the development paths of today’s achievements and how the ideas of understanding the nature and the world were evolving in our history. Of course, everything in this chapter should be seen through the aspect of “safety animals”.

1.2 History of Human Scientific Thinking

The tremendous change in the human understanding of the nature and the world around us was achieved in the 15th century. The new geographic discoveries at the end of that century and at the beginning of the next century showed to the people that, even in this planet, there are different worlds and the things are not the same everywhere. This caused an emergence of the critical understanding of the nature and the world around us by the cleverest people and they started to do and publish their researches. These publications were a new dawn of new ideas. I would not like to take a side in the history, but I found very important for Renaissance in Europe, the fall of Emirate of Granada in Spain. Queen Isabel I of Castile and her husband King Ferdinand II of Aragon defeated the Muslim forces in Granada and Spain was Catholic again. In that time, the Islamic libraries in Granada and Alhambra were full with the saved works of old Greek philosophers. All these works became available to European scientists and all these erudite people recovered the already lost knowledge of old Greek philosophers and spread them to the European public.

These Arabic translations of the Greek philosophers had a profound effect in Europe. The period of Renaissance started, and some other views of the nature and the world (never seen before) were presented to the people. The step forward from metaphysics to physics (or from religion to science) was done. In the next few centuries, the development of science offered the knowledge that brought benefit to most people, and this period is lasting even today.

The development of physics, which happened after Renaissance, contributed very much in building the machines that were reason for the first industrial revolution. This affected the social development also, but the pace of scientific and technological development was (unfortunately) faster than that of social development. The problem, which is present even today, was lack of development of the social and industrial skills of the humans compared to the development of the technology. Even today, when we are surrounded by all these engineering and technological marvels, our social development is still behind. The effect of engineering and technology made changes to our lives, but for plenty of us, it is just contribution to the Human Factors¹ (HF). And these HF will be also considered in this book from the aspect of the “safety animals”.

In the time of Renaissance, the first changes of the mind and understandings were connected by the critics of the religious thinking.² The deterministic (causal) nature of the world was established later. It is not my intention to go deeply into the philosophical explanation of the Determinism because there are even different definitions depending on the context of the investigations or its use.

I will just explain Determinism as a way of understanding our world as governed by particular cause for every event and particular consequence for every cause. Of course, it is valid if the natural laws are causal. By using them, we can determine what will happen in the future by knowing the situation today and by using the data about situations from the past. It means that we can predict future events by knowing the deterministic laws of nature and by having data from the past and the present state of things. In mathematics this means: Having a formula and knowing the initial conditions, we can find the state of the system in the future.

Of course, that it is not so simple…

For example, the cause of an apple falling from the tree is Newton’s Gravitational Law, but it will happen only if the weight of the apple (the force of gravity) becomes bigger than the force of keeping the apple by stalk connected to the branch of the apple tree. So, the cause of the apple’s falling is connected not only to the Gravitational Law but also by the imbalance of forces in nature. This interconnection and additional “meddling” of the laws shapes our world even today. If we do not recognize these things on time, later, it can make our life harder. Anyway, life is not easy at all…

¹ Human Factors are outcomes of scientific approach to the aspects of human behaviors which is contributing to adverse events (­incidents and accidents). ² Even religious view of the world was deterministic. In the Middle Age’s religious dogma there were four types of causes: Material, Formal, Final and Efficient. Scientists just inherited this view and accepted it because their results of experiments showed correctness with the behavior of nature.

In the past (and even today), Determinism could not explain all events as people notice that there are things that happen randomly. By random events, we speak about events that happen by chance or, compared with Determinism, there is maybe a particular cause for this event to happen, but the outcome (consequence) cannot be predicted. The random event can be explained by throwing a dice. If the dice is well balanced, all six sides of a dice can show up equally and we cannot predict which one will happen with accuracy. Scientifically, I can say that, the probability of each of them to happen is equal and that is the reason why I cannot predict which one of them will show up after tossing.

In general, the random events are events of guessing and the cause of happening as these cannot say anything that will predict the future events by knowing the past and the present events. If I throw a coin and I get a “tail”, throwing a coin one more time will produce a result I can only guess. Simply, the “tail” from the previous throw will not contribute to my understanding of the process, it will not help me predict whether I get a “head” or a “tail” in the next throw.

Approximately around 1960s, the world was deterministic and random, but in the second half of the last century, slowly, another “view of the world” was discovered: The Chaos!

At the beginning, the Chaos was discovered only in complex systems. Complex systems, in the general meaning of the word,³ are systems that consist of many parts. The system functioning depends on the functioning of the parts, individually and in combination, with other parts, in the scope of the system. Actually, the system does not necessarily need to be complex (made by many parts). It could be also very simple, but it is enough if the interactions between the parts are complex. Most of the complex systems have interactions between the parts inside which are nonlinear, and as such, it is not easy to (scientifically) find the solutions of the equations that describe the system. In general, the Chaos can show up if the description of the functioning of the system can be described by three or more variables. If there are only two variables, the Chaos cannot happen.

The evident example of the complex system, where the Chaos can be registered, is the weather. Other examples are the turbulence in the air, the flowing of liquid through the pipes, the predator-prey model in nature, etc.

Usually, the complexity of the systems is connected by uncertainty of the prediction of how the system will behave: More nonlinearity – more uncertainty. And more uncertainty – more unpredictability.

The Chaos was noticed by the humans around 1960s as a purely mathematical concept and, as such, it was not accepted immediately by the physicists. Although there was some research dedicated to the nonlinear dynamics of the complex systems, during those times, the physicists mostly dealt with the theory of relativity and the quantum mechanics. But thanks to some of the “stubborn” scientists, the Chaos found its “place under the sun”. At the beginning, it was not so revolutionary due to its abstract nature, but having in mind that it was dealing with nonlinear system’s behavior, it developed very fast.

³ There are also complex systems in regard to the equipment (­machinery!), which may differ from this general meaning.

Later researches showed that the Chaos can be noticed even in simple systems with nonlinear structure. Of course, if the structure of the systems is more complex, the Chaos will bring more unpredictability. Today, there are Chaos researches in the fields of meteorology, physics, biology, chemistry, cardiology, economy, etc.

1.3 Determinism, Randomness, and Chaos

The Determinism was the pillar of the science for many centuries in the past, and it is still present today, simply because it works very well. Whatever we think about the combination of nonlinearity in our world and Determinism, do not forget that nevertheless universe is ruled by the theories of Einstein’s Relativity and the Randomness of the Quantum Mechanics; the space travels of many spacecraft (with or without humans) are made through application of Newton’s Gravity Law, which is strongly deterministic.

Usually, scientists dedicate the particular phenomenon in the reality to a system, explaining that a system is a closed entity where this phenomenon showed up, moved, or worked. So, scientists investigate the phenomena in closed systems. Usually, there is a particular mathematical expression (equation) that is dedicated to each phenomenon as its explanation and the equation is used for prediction of what will happen with the system (phenomenon) in the future. This explanation of Determinism is like a recipe: You have a recipe for a cake and you cook the cake following the recipe. All further cooking of the cakes will produce the same cake, if you follow the recipe. So, if we are sure that you will follow the recipe, you can predict how the cake will be.

This example brings us to another characteristic of the Determinism: The events there are also repeatable: The cooking of the cake by use of the same recipe provides repeating of the same cake.

That is the reason that we say: Determinism is connected with predictability and repeatability. We know the initial condition of the movement (position, velocity, direction, environment, etc.), we know the equation (the law, the formula, etc.) describing the movement, so we can predict where the body will be in next few minutes, few hours, few days, etc. That is the actual mode of how our spacecraft navigates in our Solar system.

The problem with Determinism is that it applies only to linear systems or linear processes. The linear system (or linear process) can be described mathematically by a simple equation:

$$y=a\cdot x+b$$

where y is the output (outcome) of the system, x is input into the system (variable) and a and b are parameters that define the system. Graphically presented, this equation will result in a straight line in the graph and that is the reason for the name “linear system”. If other equations for describing the system or the process are used, the graph is a curve (different than a straight line), then this equation describes a nonlinear system (process)

But applying the same linear equations for...