Re: [SystemSafety] Children as a causal factor in major accidents

From: GRAZEBROOK, Alvery N < >
Date: Thu, 2 Oct 2014 10:37:18 +0200

Slightly off to the side, but there are related ethical problems. In medicine, drug testing for children is particularly difficult because of the ethical problems of running drug-safety trials – the children can’t give informed consent.

If I understand the situation correctly, this causes problems to Doctors in their prescribing, because there are many areas of treatment where there are no approved drugs for children under 12. This leaves them in the unenviable position where they have a drug in their hand, that has demonstrated efficacy for adults, and they don’t know whether it is safe to use on a child, what side-effects to look for, or what dose might be effective. If they do go ahead, they can be accused of using the drug “off list”, and if not, of failing to provide effective treatment.

To be clear, I’m not an expert in this, I just know a few GP’s.



From: systemsafety-bounces_at_xxxxxx Sent: 01 October 2014 3:07 PM
To: systemsafety_at_xxxxxx Subject: Re: [SystemSafety] Children as a causal factor in major accidents

Reporting back to the list because a lot of the ideas were sent directly to me. Thank you to Peter, John, Patrick, Philip, Mike, Brian, and Alan. The replies covered a what seems to be an interesting space:

· Child is particularly vulnerable because of their size and body mass. This is important in analysing the effects of exposure, but also with drug safety, medical devices, poisons, and aggressive animals.

· Child is incompatible with personal safety protection provided for adults (seat belts on cars, lap belts on planes, life jackets, air bags). Using the adult safety equipment may be more dangerous than no equipment, with the added concern of providing something appropriate and accessible for children.

· Child equipment incompatible with the system (child leashes stuck in elevator doors, strollers/prams stuck on railway crossings)

· Child security incompatible with safety, or system security incompatible with child safety (mostly involving children locking themselves into spaces or locking adults out of spaces)

· Child incompatible with system safety protection (unable to read warnings, unable to activate alarms, unable to recognise "obvious" danger because it doesn't look dangerous)

· Child as a special case of misuse, because unaware of the consequences of their actions (misuse of alarms, fiddling with controls, disabling autopilot, releasing handbrake)

· Child unable to report danger to themselves or others (secondary drowning, leaving system in an unsafe state)

Fortunately from a safety point of view, only one major accident (Aeroflot 583) was mentioned. I suspect I might find something more once I look at these specific issues.

Have I/we missed anything important? Is anyone interested in collaborating to take this a bit further? I think there'd be something interesting to say by looking at this through a few of the major safety models. All of those issues could be characterised as child-induced control loop failures. Children have different mental models, different capacity for control, different feedback etc. They could also be a scope issue for safety cases. "Have you thought about children" could undercut various types of evidence and argument. Even in a simple barrier model children could distort the effectiveness and side-effects of barriers. Regards,

My safety podcast:<> My mobile (until October 2nd): +44 7783 446 814 My mobile (from October 6th): 0450 161 361

Hi folks,
I've had an interesting request for a DisasterCast episode focussing on children and major accidents. 1) Can anyone suggest a major accident where the presence or behavior of children have been a causal factor? I'm looking specifically for where they increased or determined the likelihood of the accident, not just accidents with large numbers of children. 2) Can anyone suggest (in public-domain terms) ways children have had to be treated as a special case in safety analysis? Off the top of my head I can think of children as a special group in population dose-response modelling for chemical releases, and the debate about child restraints in aircraft. [Didn't want to send a separate email to the whole list, but a public thank you to John and Nancy for help with my last request re Columbia]. Drew

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systemsafety_at_xxxxxx Received on Thu Oct 02 2014 - 10:37:42 CEST

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