Ignorance, learning from

The study of case histories is important in the area of safety. To paraphrase G. Santayana, one learns from history or is doomed to repeat it. This is especially true for safety anyone working in the chemical industry can learn from case histories and avoid hazardous situations or ignore history and be involved in potentially life-threatening accidents. 

Many major process safety incidents were preceded by precursor occurrences. These occurrences were unrecognized or ignored because nothing bad actually happened. The lessons learned from such occurrences, typically referred to as near misses, can be extremely valuable in averting disaster. However, this benefit is only realized when they are recognized, reported, and investigation techniques are properly applied. This chapter describes near misses, discusses their importance, and presents the latest methods for helping ensure appropriate near misses are reported. 

Good descriptions of trance states are hard to come by. Because the very name trance has such spookily provocative connotations we are not tempted to learn about it. One consequence is that those of us who are not easily able to enter such altered states tend to be ignorant of what it actually feels like. We may even be fearful of the implied loss of control. The upshot is a tendency to discount the whole story as a fabrication, so we can remain safely and smugly skeptical. But if we continue to ignore trance, we miss the opportunity to learn from it and to better understand it. 

In studies of catalase, much effort has been directed toward a determination of whether or not hydrogen peroxide could be dissociated from the enzyme-substrate intermediates of catalases and peroxidases. It should be pointed out that catalase, as contrasted with cytochrome oxidase, has been studied only at room temperature, and if any lesson is to be learned from the study of cytochrome oxidase 150), it is that the complexes are most likely to be identified at low temperatures, as precursors of the compounds. In this sense, they are of first importance and not to be ignored in our understanding of the mechanism of enzymic reactions. 

To set process conditions successfully in industrial design, it is useful to first determine the optimal conditions and design on a model scale. When applied properly, upscaling and downscaling have immense advantages. One of the important, but often ignored, functions of small-scale research is to learn from blunders. ... 

This more or less deliberate obscurity served two unfortunate purposes. First, it retarded progress since each worker in the field was kept in ignorance, or at least in uncertainty, as to what others were doing, so that no man could profit by another s mistakes or learn from another s brilliance. Secondly, it made it possible for any quack and faker to present himself, provided he spoke obscurely enough, as a serious worker. The knave could not be distinguished from the scholar. 

These ethical tenets are literally written in blood in the blood of millions of victims of the Holocaust of hundreds of African-American syphilitic men in Tuskegee, Alabama, unjustly sentenced to death through non-treatment of syphilis when treatment was available of millions of AIDS victims sentenced to death through an early purposeful avoidance of study and treatment of thousands of women and ethnic minorities excluded from clinical studies because gender and ethnic differences made studies more difficult, expensive, and involved. In many, perhaps most, of these cases, a disdain for the omitted or ignored constituency has played a role in the mistakes or deficiencies of clinical studies. In ethics, including biomedical and bioengineering ethics, we learn from the mistakes and sins of the past. 

The model of the ideal gas ignores intermolecular interactions. Given some intermolecular interactions, statistical mechanics must be employed to obtain the equation of state of the real fluid. For fluids of high density, approximations are necessary, but these naturally evolve from the formal, general statistical mechanical framework. For polymers in bulk, the present theories are of the kinetic theory variety since they do not, in principle, relate all macroscopic properties to the constituent molecular properties. In approaching a statistical mechanical theory of polymers in bulk, we can first ask if we can learn from these successes in the statistical mechanics of gases. One way to accomplish this is to consider a bulk polymer situation whicli simulates as closely as possible ideal gas situations. This model illustrates the following ... 

We have learned, from the example given at the beginning of this chapter, that the genetic defect of the mean field methods is that they describe electrons that ignore the fact that they are close to or far from each other. For instance, in the two-electron case previously considered, where we established the coordinates of electron 1, electron 2 has a certain distribution of the probability density. This distribution does not change when electron 1 moves to a different position. This means that the electrons are not afraid to get close to each other, although they should, since when electrons are close, the energy increases (Fig.l0.1a,b). 

It is obvious that often the standards of analysis are lowered. This does not always have to be a problem. Much depends on what one wants to learn from the data. Static experiments for accurate determinations of the morphology is a minority class of experiments performed with SR beamlines. When kinetics are studied, it often suffices to concentrate on a small part of the data range and study the development of the scattered intensity in this region as a fiinction of time and ignore, for instance, elaborate background subtraction routines that might be only second-order effects. 

Learning from Ignorance A Brief History of Pressure Vessel Integrity and Failures... 

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