Organizational accidents revisited

158 Pages·2016·2.1 MB·English

by  James Reason

OrganizatiOnal accidents revisited
To Thomas Augustus Reason (1879–1958).
My grandfather to whom I owe much more than my existence.
Organizational Accidents
Revisited
JAmes ReAsOn
Professor Emeritus, University of Manchester, UK
CRC Press
Taylor & Francis Group
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© 2016 by James Reason
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Version Date: 20160223
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Contents
List of Figures and Tables vii
About the Author ix
Chapter 1 Introduction   1
ParT 1 refreshers
Chapter 2 The ‘Anatomy’ of an Organizational Accident   9
Chapter 3 Error-Enforcing Conditions   13
ParT 2 aDDiTions sinCe 1997
Chapter 4 Safety Management Systems   23
Chapter 5 Resident Pathogens   27
Chapter 6 Ten Case Studies of Organizational Accidents   41
Chapter 7 Foresight Training   87
Chapter 8 Alternative Views   99
Chapter 9 Retrospect and Prospect   111
Chapter 10 Taking Stock   123
Chapter 11 Heroic Recoveries   131
Index 137
Page Intentionally Left Blank
List of figures and Tables
figures
1.1 The ‘Swiss cheese’ model of accident causation   2
2.1 summarizing the stages involved in an organizational accident 10
7.1 The three-bucket model for assessing risky situations   90
7.2 How the buckets might be ‘read’ by junior staff working alone 91
7.3 Balancing the person and the system   92
9.1 The cyclical progression of stages   115
9.2 Reduction in variability on each successive cycle   120
Tables
3.1 The principal sources of latent conditions related to specific
case studies 13
3.2 Error-enforcing conditions and their relative effects   18
3.3 Error-producing situations   18
6.1 summarizing the active failures and latent conditions that
undermined or breached the aircraft maintenance system’s
defences   58
Page Intentionally Left Blank
about the author
James Reason is Professor emeritus of Psychology at the
University of manchester, england. He is consultant to numerous
organizations throughout the world, sought after as a keynote
speaker at international conferences and author of several
renowned books including Human Error (CUP, 1990), Managing
the Risks of Organizational Accidents (Ashgate, 1997), The Human
Contribution (Ashgate, 2008) and A Life in Error (Ashgate, 2013).