2009 Spring Meeting & 5th Global Congress on Process Safety

(63f) The Ignorance of Bliss

Author

Ward, R. - Presenter, University of New South Wales


In a previous paper, over a decade ago, this author presented two situations which ended in accidents, fortunately at a minor level, but which were caused by both client and contractor being involved in work of which each knew very little, if anything, of the hazards caused by what the client wanted, and what the contractor performed. As a title for these situations the author borrowed the legal term ?double jeopardy?; the situations were not, of course, even partially analogous to the term's use in law, but it suited pointing out that if one of the parties had known the hazards that would have been ?single jeopardy?, risking disaster by the other's ignorance, and the risk was increased to ?double? by both being ignorant.

In a book published after this author's paper above, Kletz referred to ?knowledge of what we don't know?, remarking that although what we don't know can hurt us, what we don't know we don't know can hurt us even more (paraphrased), and that lack of knowledge, the blissful state of being ignorant of the potential for disaster, is what this paper is all about.