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This succinct but absorbing book covers the main way stations on James Reason’s 40-year journey in pursuit of the nature and varieties of human error. In it he presents an engrossing and very personal perspective, offering the reader exceptional insights, wisdom and wit as only James Reason can. The journey begins with a bizarre absent-minded action slip committed by Professor Reason in the early 1970s - putting cat food into the teapot - and continues up to the present day, conveying his unique perceptions into a variety of major accidents that have shaped his thinking about unsafe acts and latent conditions. A Life in Error charts the development of his seminal and hugely influential work from its original focus into individual cognitive psychology through the broadening of scope to embrace social, organizational and systemic issues. The voyage recounted is both hugely entertaining and educational, imparting a real sense of how James Reason’s ground-breaking theories changed the way we think about human error, and why he is held in such esteem around the world wherever humans interact with technological systems. This book is essential reading for students, academics and safety professionals of all kinds who are interested in avoiding breakdowns that can cause serious damage to people, assets and the environment.
This 1991 book is a major theoretical integration of several previously isolated literatures looking at human error in major accidents.
Safety has traditionally been defined as a condition where the number of adverse outcomes was as low as possible (Safety-I). From a Safety-I perspective, the purpose of safety management is to make sure that the number of accidents and incidents is kept as low as possible, or as low as is reasonably practicable. This means that safety management must start from the manifestations of the absence of safety and that - paradoxically - safety is measured by counting the number of cases where it fails rather than by the number of cases where it succeeds. This unavoidably leads to a reactive approach based on responding to what goes wrong or what is identified as a risk - as something that could go wrong. Focusing on what goes right, rather than on what goes wrong, changes the definition of safety from ‘avoiding that something goes wrong’ to ‘ensuring that everything goes right’. More precisely, Safety-II is the ability to succeed under varying conditions, so that the number of intended and acceptable outcomes is as high as possible. From a Safety-II perspective, the purpose of safety management is to ensure that as much as possible goes right, in the sense that everyday work achieves its objectives. This means that safety is managed by what it achieves (successes, things that go right), and that likewise it is measured by counting the number of cases where things go right. In order to do this, safety management cannot only be reactive, it must also be proactive. But it must be proactive with regard to how actions succeed, to everyday acceptable performance, rather than with regard to how they can fail, as traditional risk analysis does. This book analyses and explains the principles behind both approaches and uses this to consider the past and future of safety management practices. The analysis makes use of common examples and cases from domains such as aviation, nuclear power production, process management and health care. The final chapters explain the theoretical and practical consequences of the new perspective on the level of day-to-day operations as well as on the level of strategic management (safety culture). Safety-I and Safety-II is written for all professionals responsible for their organisation's safety, from strategic planning on the executive level to day-to-day operations in the field. It presents the detailed and tested arguments for a transformation from protective to productive safety management.
Major accidents are rare events due to the many barriers, safeguards and defences developed by modern technologies. But they continue to happen with saddening regularity and their human and financial consequences are all too often unacceptably catastrophic. One of the greatest challenges we face is to develop more effective ways of both understanding and limiting their occurrence. This lucid book presents a set of common principles to further our knowledge of the causes of major accidents in a wide variety of high-technology systems. It also describes tools and techniques for managing the risks of such organizational accidents that go beyond those currently available to system managers and safety professionals. James Reason deals comprehensively with the prevention of major accidents arising from human and organizational causes. He argues that the same general principles and management techniques are appropriate for many different domains. These include banks and insurance companies just as much as nuclear power plants, oil exploration and production companies, chemical process installations and air, sea and rail transport. Its unique combination of principles and practicalities make this seminal book essential reading for all whose daily business is to manage, audit and regulate hazardous technologies of all kinds. It is relevant to those concerned with understanding and controlling human and organizational factors and will also interest academic readers and those working in industrial and government agencies.
The Human Contribution is vital reading for all professionals in high-consequence environments and for managers of any complex system. The book draws its illustrative material from a wide variety of hazardous domains, with the emphasis on healthcare reflecting the author's focus on patient safety over the last decade. All students of human factors - however seasoned - will also find it an invaluable and thought-provoking read.
On April 14, 1994, two U.S. Air Force F-15 fighters accidentally shot down two U.S. Army Black Hawk Helicopters over Northern Iraq, killing all twenty-six peacekeepers onboard. In response to this disaster the complete array of military and civilian investigative and judicial procedures ran their course. After almost two years of investigation with virtually unlimited resources, no culprit emerged, no bad guy showed himself, no smoking gun was found. This book attempts to make sense of this tragedy--a tragedy that on its surface makes no sense at all. With almost twenty years in uniform and a Ph.D. in organizational behavior, Lieutenant Colonel Snook writes from a unique perspective. A victim of friendly fire himself, he develops individual, group, organizational, and cross-level accounts of the accident and applies a rigorous analysis based on behavioral science theory to account for critical links in the causal chain of events. By explaining separate pieces of the puzzle, and analyzing each at a different level, the author removes much of the mystery surrounding the shootdown. Based on a grounded theory analysis, Snook offers a dynamic, cross-level mechanism he calls "practical drift"--the slow, steady uncoupling of practice from written procedure--to complete his explanation. His conclusion is disturbing. This accident happened because, or perhaps in spite of everyone behaving just the way we would expect them to behave, just the way theory would predict. The shootdown was a normal accident in a highly reliable organization.
In Occupational Risk Control you will find Derek Viner's wealth of experience used to its fullest. He presents a coherent and scientific theoretical basis for, and a practical understanding of, the prediction and management of accidents in the industrial and commercial worlds. The author spans ideas formed between the industrial revolution and the present day, but focuses on more recent theoretical developments specifically in defence and petro-chemical systems. He argues that the consequences of the absence of a holistic approach is the tendency for regulators to form (misinformed) theory on which to base legislation and the prevalence of commercial systems leading to disparate efforts by different industries. The net effect of this is seen in disasters of the magnitude of the Gulf of Mexico explosion and oil spill.