Despite the increased frequency and scale of wildfire-related catastrophes, there has been little or no effective and coordinated international policy to address their highly negative impact. Possibly a generalized approach to respond to such major events could be modeled on existing international safety investigation policies and agreements that already have proved successful. The International Civil Aviation Organization (ICAO) outlines safety investigations after international fatal aviation accidents. Although this well-established safety investigation protocol cannot be directly applied in acute wildfire-related accidents, it can offer a useful framework for establishing international guidelines to reduce risk of future wildfire catastrophes. The co-operation between safety investigation authorities has been shown to be fruitful especially for those less developed countries that have limited resources and experience related to accident investigations. While primarily an adaptive measure that can set practices to reduce vulnerability and fragility of ecosystems and human societies, the same policies could be seen as a climate change mitigation measure, as wildfires can contribute significantly to global CO₂ emissions. Finally, the concept of independent and qualified safety investigations represents the principle of serendipity: disclosing by accident something that has not been foreseen. Feedback from reality compensates assumptions and limitations of feedforward analysis of complex systems that can only reveal their dynamics and performance in reality and over time.

@en

Recently, several major events in various high tech industries have revealed deficiencies in assessing safety at a systems level. Conventional analytic approaches in the operational phase suffer from paradigmatic limitations. In non-plus, ultra-safe and complex, dynamic systems, such as Air Traffic Management systems, safety requires a new approach in which: - Safety is a strategic value in decision making and business modeling.- Safety is a system property, represented by state/space vectors.- Safety assessment focuses on quantifiable dissimilarities between various system states and operating conditions throughout their life cycle phases. In order to cope with non-linear interactions and interventions, firstly, safety has to be integrally designed into the system and assessed as an inherent property before it can manifest itself in practice as an emergent property. Secondly, engineering design methods have to be mobilized, such as forensic engineering, value and knowledge based engineering and resilience engineering. The design of safer systems should apply a non-linear design methodology, with an integral assessment of all values and performance requirements, including safety. Such a predictive, quantifiable assessment includes simulation, prototyping and dissimilarity measurements. Finally, system adaptation should focus on the functional level, inherent system properties and synchronization of event vectors and system state vectors.@en

Since 1988, the Dutch flatfish fisheries are dealing with sustainability aspects in the vessel design process. In the first place at a time when social and political trends call for more attention to personal safety and working conditions and later extended with emphasis on a greener image and the triple P aspects (People, Planet, Profit). Nowadays due to the Paris climate agreement, every country has set their goals for radical emission reductions, even zero-emissions in 2050. This means that the CO2 targets are also becoming a (scientific) challenge developing new fishing vessel design methodologies including eco-technical solutions (B-design), personal safety and working conditions(a-design) and socio-technical strategies (a-design). An effective combined B-a design methodology does not exist yet, let alone also integrating the new circular economy (-) requirements. For such a new fishing vessel design process the evolving circular economy, principles (CE) are challenging with the ultimate sustainability goals: zero-emissions, zero-waste, zero-accidents on-board. The design experiences of the safety-integrated Beamer 2000 redesign (1990) and the sustainability-integrated MDV-1 new design (2015) are stimulating starting points.@en

The Bhopal pesticide accident triggered a number of responses from the companies involved from the Indian government as well as reforms in the United States. These initiatives reached a range of different conclusions that arguably failed to provide a coherent framework for action around the globe. In other domains, organisations such as the International Civil Aviation Organisation (ICAO), provide a common point of reference for the many different investigations that may be conducted in the aftermath of an accident. The early origin of the international aircraft safety investigation process can be traced back more than 70 years and has developed in the course of time to be useful in improving aviation safety. Despite these practices can't applied directly to other industry they may help to develop good practices. Even today, the international chemical industry lacks international guidelines for safety investigations. There are, however, initiatives to support investigations within individual nations. Without greater consistency, we argue that there is little prospect of ensuring international cooperation in mitigating the consequences or reducing the likelihood of future accidents across increasingly globalized chemical industries. This contribution elaborates on the engines for change, taking into account system inherent properties and safety management concepts that serve as barriers for implementation. Such barriers are of a methodological nature, originating from differences in goals and perspectives between accident investigation in aviation and risk management strategies in nuclear and chemical industries. We also identify opportunities to overcome these barriers through the exchange of good practice across these industries.

@en

Aviation has been recognized as one of the ultimate safe socio-technical systems. This contribution discusses the conditions and context that moulded the system safety to its present level by applying integral safety, a sectoral approach and safety as a strategic value. At present the aviation system consists of institutional arrangements at the global level, a shared repository of knowledge and operational experiences, feedback from reality, the notion of Good Airmanship, together with the choice of technology as the flywheel for progress. This architecture made aviation a Non-Plus Ultra-Safe system characterized by a safety performance level of beyond 10-7 accident rate. To cross this mythical boundary in legacy systems like aviation, it is imperative to apply game changers such as socio-technical systems engineering, disruptive technologies and innovation transition management. In such a transition, a shift in focus occurs from performance to properties, from hindsight to foresight, highlighted by the case study of the stall recovery device, the Kestrel concept.@en

In August 2014, a special issue of Safety Science contested the foundations of safety science as a scientific domain on methodological, theoretical and philosophical grounds. Safety specialists in social, behavioural and organisational sciences discussed what seems to be an identity crisis in occupational safety and social sciences. A tension between scientific and societal relevance of the notion of safety was noted, raising doubts about the scientific validity of safety science (Safety Science, 2014). As three of the founding fathers of the Safety Science Group (SSG) at Delft University of Technology (DUT) in 1978, we were challenged by this debate to reflect on our ambitions and mission that were expressed during the inception of safety science at DUT. In addition to what has already been described by Hale and De Kroes (1997) and Hale (2014), we elaborate also on personal experiences and insights, gained over a period of some 40 years of work. These additional experiences were gained in particular by the first two authors in the transport domain from a technological and engineering design methodological perspective. They provide a more encompassing scope on the development of safety science in general as a scientific activity at DUT. Parallel developments in other domains have been described in other papers (Hale, 1985, 2006, 2014; Hale and de Kroes, 1997). First, we have to correct a long term omission by translating the founding documents for safety science at DUT into English to make them accessible for non-Dutch experts. Second, we highlight the development of three basic notions that were identified in 1978, at the inception of the SSG, as the cornerstones for safety science as a scientific discipline, no matter what domain it is related to: interdisciplinarity, problem-solving orientation and systems approach. We document in this paper their development and use in the transport domain in the DUT as a whole, i.e. more broadly than the SSG. Third, we discuss more in general the observations, particularly of the first two authors on the value and unique role of safety investigation methodology and systems engineering as powerful feedback loops with learning potential and drivers of change through their potential to address safety in complex, dynamic and open transport systems. Fourth, we elaborate on three additional basic notions that are needed as extra building blocks for a paradigm shift in safety thinking, irrespective of disciplines and domains – a full information supply, engineering design methodology and multiple intervention strategies. Finally, we advocate a mutual recognition of the value and validity of scientific paradigms as developed in the various disciplines, that in conjunction constitute safety science as a distinct, multidisciplinary activity in the academic community. @en

The European Safety Reliability and Data Association (ESReDA) has since 1993 set up a series of Project Groups dealing with the different angles of ‘accident investigation’ and ‘learning from events’. With the 25th Anniversary of ESReDA now in 2016, the core of this group is still active, and has just initiated a new phase with its latest Project Group on ‘Foresight on Safety’. With the objective of improving the quality of accident investigation and the efficiency of learning from experience process and ultimately raising safety performance, the successive groups tasked themselves at two levels: the first one, at a societal, institutional and legal level, on the public accident investigation and societal learning; the second one, at a methodologicaland organisational level, on the conduct of accident investigation, the enablers and barriers to learning. This article summarises the Project Groups' achievements (reports, books, papers and ESReDA seminars) on the various aspects of of accident investigations and dynamic learning from events. This article presents a synthesis of the approach and main results, the lessons learned, some dilemmas and conflicts, future challenges, recommendations and suggestions for action. Although varying in composition over time, the main participants remained involved in the development of the issue: participants from the European and member state authorities, industries, research centres and universities and professional practitioners represent a unique, voluntary cooperation across sectors, actors and disciplines that has lasted for almost 23 years now. At last, with the rise of ‘big data’ it is valuable to recall the interest of single case investigation and address the complementarity of the two approaches to learning.@en

Safety is frequently addressed as an emergent property of complex and dynamic systems. This contribution advocates the validity and importance of incorporating intrinsic technological hazards and systemic interrelations from a multi-actor perspective in the early phases of design and development. This perspective creates inherent properties in various system states, which may manifest themselves as emergent properties during operations. These safety properties are based on their business models, selectively focusing on primary system components such as infrastructure, vehicles or traffic management. Experiences with major aviation and railway projects highlight the potential of engineering design approaches such as multidisciplinary design optimization, value engineering and vectorial state/space modelling. Such an approach has high change potential for a specific category of high energy density complex socio-technical systems @en