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Old 2nd Apr 2012, 13:47
  #4 (permalink)  
safetypee
 
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With continuing interests and without challenge to the categories in #1 (nor any supporting evidence of them being the norm), I have found an alternative view. This involves ideas of surprise within the concept of resilience.

Surprise can be divided into situational and fundamental. (Ref)
Situational surprise is what we normally define as a surprising, unexpected situation. We know how things work, what might fail, and thus what the consequences might be. Thus even when a sudden event occurs - a surprise - we have sufficient background knowledge to enable understanding and the selection of a course of action, e.g. engine failure. Also we can anticipate, monitor and provide defenses/responses to these unexpected but foreseeable situations.

Fundamental surprise involves those situations which refute our basic beliefs about how things work, and thus are “inconceivable”. These situations either cannot be foreseen (comprehended), or we choose not to see them beforehand, i.e. a rare, obscure, or multiple system failure (AF447, 737 AMS).
The lack of foresight or understanding depends on an individual’s level of knowledge and experience (how to use that knowledge). Due to these limitations, situations involving fundamental surprise cannot be defined in advance and thus cannot be monitored or have preplanned actions (SOPs).

The deficiencies are not in a system design or circumstance, but with the level knowledge which is available for use before and during an event. Could we have foreseen a triple speed sensor failure in an aircraft which has a triple redundant control philosophy – we are naturally biased to conclude that such failures (or the result) are unforeseeable (not the same as impossible, cf Black Swans).

The ideas above appear to be very similar to the categories in #1. An inexperienced pilot (case 2) might be more likely to interpret a surprising situation as one of fundamental surprise; opposed to an experienced pilot (case 3) who manages to comprehend the surprising situation due to greater knowledge / experience.

These ideas may enable some defensive aspects for the inexperienced. Whilst we cannot anticipate or monitor all situational conditions, we can be prepared for surprise by monitoring our resources of workload and capacity to respond – open mindedness, questioning, and considering other alternatives.

The reference also provides interesting views on how we learn from surprise – in our post-accident analysis do we inadvertently convert fundamental surprise to situational surprise, and thus the learning is not as good as it should be - cf discussion on recent accidents – the effect of hindsight bias.

Ref – intro: http://www.resilience-engineering-as.../Papers/33.pdf
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