Inherent safety, ethics and human error

A patient is to have the damaged left kidney removed. To safeguard correctness of action several layers of expert checks have been performed prior to the operation, which results in the removal of the fully functional right kidney. Nobody asked the patient. The patient did not volunteer providing "unnecessary" information. The experts know everything ... An untidy house made out of flammable materials. A careless smoker left his lit cigarette unattended. A blow of wind and the house comes in flames. Would better construction materials have prevented the accident in spite of the carelessness of the inhabitant? A tricky medical condition which is expected to provoke a patient's fast health deterioration and their slow death. The doctor takes the initiative and responsibility of performing a risky operation. The patient's life is saved and their health is re-established. This work is not, as initially intended, the result of a thorough investigation of accidents, neither contains a systematic collection of data that can support the conclusions or the suggestions made. It is in the main a compilation of personal views. These views have been established from the correlation of the results of numerous accident investigation reports with the causes of small and insignificant incidents. These incidents are related with the education of university students, regulations within an academic environment and from independent personal experience working in different countries and with people of different cultures. The analysis that follows, however, should not be perceived as a mere reference to university students and/or to a university environment. University is the place where the fundamental scientific and engineering principles are germinated while current and past university students are the future and current production and design engineers, respectively. The places where the presented incidents have occurred are not always relevant with the conclusions, thus they are not stated. The reason this article is presented here is that I believe that often, complex accidents, similarly to insignificant ones, often demonstrate an attitude which can be characterized as "inherently unsafe". I take the view that the enormous human potential and the human ability to minimize accidents needs to become a focal point towards inherent safety. Restricting ourselves to human limitations and how we could "treat" or prevent humans from not making accidents needs to be re-addressed. The purpose of this presentation is to highlight observations and provoke a discussion on how we could possibly improve the understanding of safety related issues. I do not intent to reject or criticize existing methodologies. (The entire presentation is strongly influenced by Trevor Kletz's work although our views are often different.).