Delft University of Technology Securing safety Resilience time as a hidden critical factor Beukenkamp, Wim DOI 10.4233/uuid:3dec02ac-c659-4741-980f-85619f2c4da6 Publication date 2016 Document Version Final published version Citation (APA) Beukenkamp, W. (2016). Securing safety: Resilience time as a hidden critical factor. TRAIL Research School. https://doi.org/10.4233/uuid:3dec02ac-c659-4741-980f-85619f2c4da6 Important note To cite this publication, please use the final published version (if applicable). Please check the document version above. Copyright Other than for strictly personal use, it is not permitted to download, forward or distribute the text or part of it, without the consent of the author(s) and/or copyright holder(s), unless the work is under an open content license such as Creative Commons. Takedown policy Please contact us and provide details if you believe this document breaches copyrights. We will remove access to the work immediately and investigate your claim. This work is downloaded from Delft University of Technology. For technical reasons the number of authors shown on this cover page is limited to a maximum of 10. SECURING SAFETY Resilience time as a hidden critical factor Willem R. Beukenkamp Cover illustration by W.R. Beukenkamp September 24, 2009 two freight trains and a passenger train collided at Barendrecht, south of Rotterdam. Time was an important safety critical factor in this fatal accident. Note that the loco 6514 was named ‘Wim’, same as the author of this thesis. SECURING SAFETY Resilience time as a hidden critical factor Proefschrift ter verkrijging van de graad van doctor aan de Technische Universiteit Delft, op gezag van de Rector Magnificus prof.ir. K.C.A.M. Luyben; voorzitter van het College voor Promoties, in het openbaar te verdedigen op maandag 3 oktober 2016 om 10:00 uur door Willem R. BEUKENKAMP, Technisch-bestuurskundig ingenieur geboren te Rotterdam, Nederland Dit proefschrift is goedgekeurd door de promotoren: Prof. dr. ir. J. A. Stoop Prof. dr. ir. S.P. Hoogendoorn Samenstelling promotiecommissie: Rector magnificus Voorzitter Prof. dr.ir. J.A. Stoop Lund University, promotor Prof.d r.ir. S.P. Hoogendoorn Technische Universiteit Delft, promotor Onafhankelijke leden: Prof. dr. ir. R. Benedictus Technische Universiteit Delft Prof. dr. ir. R.P.B.J. Dollevoet Technische Universiteit Delft Prof. dr. ir. M.J.C.M. Hertogh Technische Universiteit Delft Prof. dr. C. Johnson University of Glasgow Dr. P.C.J. Neuteboom Inspectie Leefomgeving en Transport TRAIL Thesis Series no. T2016/18, the Netherlands Research School TRAIL TRAIL P.O. Box 5017 2600 GA Delft The Netherlands E-mail: [email protected] ISBN: 978-90-5584-210-0 Copyright © 2016 by W.R. Beukenkamp All rights reserved. No part of the material protected by this copyright notice may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, without written permission from the author. Printed in the Netherlands Preface As always when you start a PhD study you have no idea what it is going to be and what will result from it. What is clear is what caught your attention, what it is that you want to research in detail. It requires tenacity to continue the research and bring it to a successful ending. There are inevitable moments that you are seriously questioning yourself if it is worthwhile to continue. Those are the moments that the support of others is very important. It is almost cynical when doing research about how to deal with calamities and catastrophes that a year ago I myself was confronted with a life threatening physical problem. I experienced some of the aspects as written down in this thesis, not as an onlooker but as a core actor, a casualty. I observed the actions of professionals when the specialists in my local hospital were working out what was wrong with me and could not find the cause of my physical problems until it was almost too late. I nearly lost my life because of a diagnostic process that got derailed through communication problems between expert professionals. I thank my life to the knowledge and skills of the emergency surgical team at the Amsterdam Medical Centre where I arrived late in the evening just in time. Having survived that critical situation I became more than ever motivated to complete this research and publish the results as shown in this thesis. I would like to express my gratitude to my wife Josina van der Horst for supporting me during this long research. The successful ending of it could not have been possible without the guidance of prof. dr. ir. John Stoop of Delft University of Technology, my scientific mentor for many years now. We had many discussions usually starting with both of us having a certain view and disagreeing on each other’s opinion, ending up agreeing on a third view, having discovered new insights. Also I would like to thank prof. dr. ir. Serge Hoogendoorn of Delft University of Technology who guided me through the final stages of this research, prof. dr. ir. Rinze Benedictus, prof. dr. ir. Rolf Dollevoet, prof. dr.ir. Marcel Hertogh, prof. dr. Chris Johnson and dr. Peter Neuteboom for examining this thesis and making valuable recommendations to further improve it. Furthermore I would like to thank the Dutch Environment and Transport Inspectorate (ILT) and ir. Marnix van der Heijde, manager of the rail enforcement section in particular. He recognised the importance of this study for the work of the inspectorate and allocated sufficient resources for me to finish it. My final acknowledgement is to the thousands of victims of transport and other accidents Worldwide over the years. Although each fatal accident is one too many, often their lives were not lost in vain. We have learned from fatal accidents and we are still learning from them, although unfortunately in some cases over time lessons are lost or worse: ignored. Haarlem, September 2016. 1 2 Securing Safety Content Preface ....................................................................................................................................... 1 Content ...................................................................................................................................... 3 1. Security and safety, what fails? ........................................................................................ 7 1.1 INTRODUCTION .............................................................................................................. 7 1.2 SAFETY, SECURITY AND RISKS ....................................................................................... 7 1.3 RISK POLICIES IN THE NETHERLANDS ............................................................................. 9 1.4 LESSONS LEARNED AND CHALLENGES FOR THE FUTURE .............................................. 11 1.4.1 Control variables .................................................................................................. 11 1.4.2 First lesson: the George dilemma ........................................................................ 11 1.4.3 Second lesson: media and design and control of systems .................................... 11 1.4.4 Third lesson: methodical approach ...................................................................... 12 1.4.5 Symptom management .......................................................................................... 12 1.5 NEED FOR A DIFFERENT APPROACH .............................................................................. 12 1.6 SCOPE, RESEARCH QUESTIONS AND APPROACHES ........................................................ 13 1.7 SCIENTIFIC CONTRIBUTIONS OF THIS RESEARCH ........................................................... 15 1.8 OUTLINE OF THIS THESIS .............................................................................................. 15 2. Risk management of transportation systems ............................................................. 21 2.1 INTRODUCTION ............................................................................................................ 21 2.2 RISK MANAGEMENT IN A HISTORICAL PERSPECTIVE ..................................................... 21 2.3 CONFLICT IN DECISION MAKING: THE GEORGE DILEMMA ............................................. 22 2.4 THEORY OF RISK MANAGEMENT: SLOVIC, STIRLING AND OTHERS ............................... 23 2.4.1 Slovic .................................................................................................................... 24 2.4.2 Stirling .................................................................................................................. 25 2.4.3 Perrow .................................................................................................................. 27 2.4.4 Petroski ................................................................................................................. 28 2.4.5 Stoop ..................................................................................................................... 30 2.4.6 Rosmuller ............................................................................................................. 32 2.4.7 Van Poortvliet ...................................................................................................... 33 2.5 CONCEPTUAL MODELS ................................................................................................. 34 2.5.1 Behaviour of a risk sensitive system ....................................................................