Complexity for complexity-How advanced modeling may limit its applicability for decision-makers.

As today's engineering systems have become increasingly sophisticated, assessing the efficacy of their safety-critical systems has become much more challenging. The more classical methods of "failure" analysis by decomposition into components related by logic trees, such as fault and event trees, root cause analysis, and failure mode and effects analysis lead to models that do not necessarily behave like the real systems they are meant to represent. These models need to display similar emergent and unpredictable behaviors to sociotechnical systems in the real world. The question then arises as to whether a return to a simpler whole system model is necessary to understand better the behavior of real systems and to build confidence in the results. This question is more prescient when one considers that the causal chain in many serious accidents is not as deep-rooted as is sometimes claimed. If these more obvious causes are not taken away, why would the more intricate scenarios that emanate from more sophisticated models be acted upon. The paper highlights the advantages of modeling and analyzing these "normal" deviations from ideality, so called weak signals, versus just system failures and near misses as well as catastrophes. In this paper we explore this question.

The ethical dilemmas of risky decisions.

Even in a pandemic there seem to be inherent conflicts of interest between the individual and societal consequences of remedial actions and strategies. Actions taken in the sole interests of patients, as required by the Hippocratic oath, can have broadly inconvenient economic implications for the State. ("Average" benefits for a population can impose individual inconveniences for the vulnerable.). Understandably these decisions are not normally made explicitly and transparently by governments. This leads to seemingly illogical and inhumane strategies which are not understood and hence mistrusted and often ignored by the public. Vaccination sentiments on social media are often an unwanted symptom of this dilemma. This article outlines and discusses a number of examples of such situations with a focus on ethical aspects. It concludes that each case must be considered individually as to the issues that need to be weighed in these difficult decisions; and that there are no clear and universally acceptable ethical solutions. What can be learned from the COVID-19 crisis is that short term utilitarianism has consequences that in the eyes of the population are unacceptable. This lesson seems equally valid for cost benefit evaluations regarding other risks, such as from hazardous industries, flood defenses, and air transport. Decisionmakers and politicians can learn that persuasion only goes so far. In the end the people appear to prioritize in terms of deontology.

Dragons, black swans and decisions.

Since Nassim Taleb coined black swan as an event that occurred as a complete surprise for everybody, the metaphor of the black swan has been applied to a much wider variety of events. Black swan events now comprise events that are a surprise for some but not for others, events that have a low likelihood, events that were not believed to be possible but still proved to be possible, events that were dismissed as being too improbable to worry about but happened anyway. For a decision maker the black swan problem is choosing where to put effort to prevent, or mitigate events for which there are warnings, or for which the possibility has been put forward. Does the fact that there are thousands of books written about fire breathing dragons warrant the development of an Anti-Dragon Defense Shield? The black swan may have been a surprise for Willem de Vlamingh in 1697, it was not a surprise for the inhabitants of Australia, for which the appearance of tall white humans was their "black swan event". In this paper we explore the options available to decision makers when confronted with the various sorts of swan (or dragon) events.

Language issues, an underestimated danger in major hazard control?

Language issues are problems with communication via speech, signs, gestures or their written equivalents. They may result from poor reading and writing skills, a mix of foreign languages and other circumstances. Language issues are not picked up as a safety risk on the shop floor by current safety management systems. These safety risks need to be identified, acknowledged, quantified and prioritized in order to allow risk reducing measures to be taken. This study investigates the nature of language issues related danger in literature, by experiment and by a survey among the Seveso II companies in the Netherlands. Based on human error frequencies, and on the contents of accident investigation reports, the risks associated with language issues were ranked. Accident investigation method causal factor categories were found not to be sufficiently representative for the type and magnitude of these risks. Readability of safety related documents used by the companies was investigated and found to be poor in many cases. Interviews among regulators and a survey among Seveso II companies were used to identify the gap between the language issue related dangers found in literature and current best practices. This study demonstrates by means of triangulation with different investigative methods that language issue related risks are indeed underestimated. A recommended coarse of action in order to arrive at appropriate measures is presented.