3 replies to this topic

[Saml]

Dear all, 

 

After seeing several investigations both in house and from public access (most notably the U.S. Chemical Safety Board, CSB) I found a pattern of causation.  Most of the time they are defined as counterfactuals.

 

Normally one would expect the form:

Because A happened, B happened. That is a direct causation in the Hume definition of cause.

 

But it is very common to see:

"Because A did not happen, B happened" or the "Had A happened, B would not have occurred"

 

While it is generally accepted  that omissions are causes there is no clear cut between an omission or something that just did not happen.  In a mundane example, if I travel and ask my daughter to water my plants, she said yes, and when I come back the plants are bone dry then, is is correct to say that her "not watering the plants" is the cause of the plants dying. However, my neighbour did not water the plants either. She saw my plants not being watered and did nothing.  But her not taking action it is not a cause. Neither the mail man that also saw the plants dying.  

 

One example where I see this pattern, is the Chevron Richmond refinery fire (http://www.csb.gov/a..._2015-01-28.pdf), where one of the causes listed is " Despite the known risks of unmonitored sulfidation corrosion rates in potentially low-silicon carbon steel piping components, the CSB found that API RP 939-C specifically refrained from requiring companies to search for low-silicon piping components in their facilities"

 

Apart from the strange use of "found", as if it was hidden before, it seems that this case is more like the case of my neighbor than the case of my daughter and the CSB is over reaching, taking a self righteous stand, playing politics, playing a blame game or just using flawed logic (or any combination of the preceding).

 

My request to the forum is the following:

 

¿Have you come across any work that is written to a layman about this topics of causation by omission or counterfactuals? ¿Can you recommend any reading on this issue?

 

I've searched for philosophical work starting from Hume to the counterfactual theories of Lewis, but generally they are full of a academic jargon that is difficult to translate to action in concrete situations like an incident investigation.

Edited by Art Montemayor, 10 February 2017 - 02:31 PM.
include Reference source

[Art Montemayor]

Luciano:

 

This is a very interesting and, I believe, necessary safety concern.  I hope our Forum members take the opportunity to contribute with their valued and experienced comments.

 

Please accept my editing of your initial post in order to identify your source by name and also cite their webpage where the mentioned document can be found and downloaded.

 

I join our members in appreciation to you for sharing your thoughts and comments on this specific subject that seek to find answers for improving our on-going efforts for more effective safety programs and guidelines.

 

Thank you.

[Zauberberg]

Apologize for late kicking in, I have missed the thread.

 

Without going too deep in the terminology and phrasing, if certain activity is a part of one's duties and that same person fails to perform his or her duties, then he or she should be held responsible for any event or incident arising from not performing the required tasks. Speaking of the example with the flowers in your garden and your neighbor, if there was an arrangement between the two of you according to which he was supposed to water the plants during your absence, then yes - he is absolutely responsible for the withered flowers and plants (unless some force majeure happened during your absence and rendered his presence completely useless).

 

Think of a plant, where a dangerous leak occurs in the pump transporting fluid above its autoignition temperature. And a field operator, who is responsible to perform 6 walk-downs during his shift, and yet he deliberately fails to do so, and the leak goes unnoticed. Now, imagine the leak causing the fire to spread and cause major consequences. Whose fault is that? Certainly the operator's, along with other factors that would be investigated and revealed later on.

 

I would think the same applies for the design stage. If an engineering company designs an unsafe facility, even if they gave the maximum effort to design the plant up to their best knowledge, that does not excuse them from responsibility if a failure occurs as a result of incorrect design (not because of poor operation or maintenance). And we have seen such and similar cases in the CPI industry. Our failure to recognize and mitigate such problems (they are typically a consequence of short-term, profit-driven, non-technically educated management) will cause these and similar events to keep reoccurring in future.

 

This is a quite broad subject and it would require lot more space for discussion than just a single forum thread. And, even more important, each case would have to be accessed and examined on its own. There are no universal conclusions, neither in terms of "always-blame-someone-policy" nor in washing the responsibility off of any party. For everything, every time, there is a cause (or causes) and initiators.

[Saml]

Agree with you. Let's take your example:

 

" And a field operator, who is responsible to perform 6 walk-downs during his shift, and yet he deliberately fails to do so". 

Sure: is his responsibility that him not doing the walk-downs is a cause. Moreover, if this is a chronic issue, the foreman not enforcing the walk downs is also a cause.

 

I this case, before the incident, there were a clear duties (do the walk-down, supervise and correct behaviour) that were omitted.

 

But that is not always the case about things that are defined as causes in incident reports. Specially in the counterfactual form "had (something that did not happen) happened, the incident would have been prevented" .

 

Let's make a progression from cause to non cause.

1) Had my son watered the plants they would not have died.

2) Had my neighbour....

3) Had the mailman....

4) Had Barack Obama....

 

They are all true. And although there is a tendency to blame politicians for everything bad that happen, number 4 is clearly not a cause.

 

Regarding number 3, probably the mailman was in position to detect the problem and even do something. But that does not mean that him not watering the plants is a cause.

 

Number 1 and 2, may be, dependent on what arrangement I have with the other party.

 

My original question is that in this kind of progressions from cause to non cause, I have not seen any formal criteria to set causes and non causes apart other than "common sense".  

 

However, in several report, there are "causes" that seem stretched. I my original post I refer to the 100% inspection in API 939-C. Can this be stated as a cause? Was the API committee that redacted API 939-C supposed to include the requirements of 100% inspection? Or are they are just building a "cause" in the form of  "lack of my proposed solution" . It seems to me more the case of the mailman that may even noticed something wrong with the plants but did nothing, rather than the case of my son that agreed to water my plants, and did not. 

 

There is obviously a limit, probably broad and not very sharp. Philosophers have talked about this quite a bit. However, bringing philosophical essay to actual criteria to use in investigation of events, is not something I've seen in the literature and that was what I was asking about. 

However, in several report, there are "causes" that don't seem to respect this. I my original post I refer to the 100% inspection in API 939-C. Can this be stated as a cause? Was the API committee that redacted API 939-C supposed to include the requirements of 100% inspection? Or are they are just building a "cause" in the form of  "lack of my proposed solution" . It seems to me more the case of the mailman that may even noticed something wrong with the plants but did nothing, rather than the case of my son that agreed to water my plants, and did not. 

 

There is obviously a limit, probably broad and not very sharp. Philosophers have talked about this quite a bit. However, bringing philosophical text to actual investigation of events, is not something I've seen in the literature.