Customer Reviews

Managing the Risks of Organizational Accidents

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Professor James Reason of Manchester University, is a giant in dealing with the human error. His famous book "HUMAN ERROR", first published in 1990, was an instant hit with the safety professionals and until today, remains an authoritative reference for anyone who wants to know more about human errors and human failings.

In 1997, Reason published yet another hit - "MANAGING THE RISKS OF ORGANIZATIONAL ACCIDENTS". This book, as Reason puts it, ... aimed at the "real people" and especially those whose daily business is to think about, and manage or regulate, the risk of hazardous technologies - like commercial aviation - our business.

Yes, this book is meant for the bosses, the Chairman, the CEO, all the Presidents, Executive Vice Presidents, Senior Vice Presidents and last but not least --- (if you are in the air transport business) --- the pilots in the flight deck - as the "Sharp End Operators" and the "Last Line Defenders" to fight against of all the possible latent errors and threats made long before we step into the flightdeck, but expect us to put a stop to any possible mishap from happening when the situation arises!

Professor Reason uses his now popular "Swiss Cheese" Model of Defence to explain the nature of those "latent threats" or "latent errors" lurking in our air transport organization (and others), waiting to spring on us when the time and opportunity present themselves.

Reason argues that highly hazardous technological industry like the air transport industry, (nuclear and chemical plants as well etc.) are usually protected with layers of strong defences..

Let me try to illustrate; let's say we have a lot of hazards to contain on the left hand side of this page, and the losses (if the hazards are not contained and causing accidents) are on the right hand side of this same page. Our defences are like layers of steel plates erected between the hazards and losses to protect them from meeting (liken to be like a light beam shining through).

In real life, these steel plates are both "hardware" and "software". Hardware are, for example better designed modern airplanes with many safety features incorporated from experiences gained over the last few decades of air transport operations, better human-engineering to prevent human factor related errors from being committed. Having better equipment to forecast weather better, better equipment to detect and forewarn the pilots of impending collision with other traffic or terrain etc.

Software, on the other hand, are people themselves, plus philosophy, policy and enforcing procedures to promote safety, implementing safety rules and regulations and practices to guard against accidents from happening.

Well and good, to be fair, all these work pretty well most of the time. That's why you don't get to see many air disasters, nuclear plant accidents, or offshore oil rig disasters very often. Reason, however, argues these "steel plates" are not hole-proof, there are in fact, full of "holes", caused by latent threats and errors, such as company pressure, tight schedules, awkward rules that are hard to follow, long working hours, inadequate rest, lack of on-going trainings, or lack of safety awareness practices, impractical fuel policy etc.

These "holes" in the steel plates expand or shrink depend on prevailing conditions. The holes are "latent threats and errors" built-in to the system, they alone will not cause accidents (not all the plates) but when coupled with some "active failures", (the remaining plates) such as human errors, lapses or slips in the system, in the right place and at the right time, the imaginary light from the left hand "hazards" side, will shine through these porous steel plates and light up the right hand "losses" side, an accident happens! But when it does happen, it is certainly a "Big Bang" headline news, which is usually coupled with heavy human death toll and colossal hardware losses.

Professor Reason deals specifically with the latent threats rather than the active failures, because, as in the Swiss Cheese Model, all you need to do is to make one of the steel plate hole-proof and the error chain is broken, thus preventing a disaster from occurring. Simple as that. Active failures will be dealt with elsewhere..

To sum up, this book covers hazards, defences and losses in all the hazardous high technology industries, it also points out reasons why sometimes these defences are penetrated and defeated. In fact Reason says some of these defences are themselves dangerous! He also talks of the human contribution to the breakdown in the defences, even maintenance, the very reason for maintenance is to ensure safety and reliability of the systems we built, itself can cause accidents if negligence seeps in. He offers practical guides to error management, and finally, how to engineer a safety culture to prevent "Big Bangs" from happening.

A highly recommended reference for those who take flight safety business seriously.

Eddie

This book examines the issues involved in managing safety in complex technologies such as aviation, chemical process plants, and nuclear power. Mr. Reason leads the reader through the complex web of forces which interact to shape human performance. He builds on his earlier works, such as Human Error, to produce a comprehensive examination of difficulties in managing human performance. This book is a "must have" if you are seeking to understand human performance management or reducing human error.

This book is a must for anyone who is interested in understanding the organizational factors involved in accidents. It presents a clear picture of what the basic issue is with safety. It helps significantly in the understanding of what must be done in order to manage safety appropriatley. It presents principles that are applicable to all type of industries. I think the fact that an effective book on safety can be written by a psychologist emphasises the role people play in the safety process.

A novice in this area, I found this book easy to read and very enlightening. The challenge for automation engineers, designers and safety professionals is not what needs to be done, but how to translate these concepts into your company's culture.

This is a landmark book by the renowned expert and guru on human error, Professor James Reason. The author methodically, step-by-step, explains how the various defenses erected to prevent accidents can be breached in the highly technologically advanced and hazardous industries. Using the famous "Swiss Cheese" model to illustrate his point, he outlines how latent defects can conspire with active failures to result in accidents. Professor Reason's arguments, proposals and conclusions are persuasive and logical and are presented in an easy to follow and understand format.

According to Reason, error management includes measure to reduce the error susceptibility of particular tasks or task elements; determine, assess and then remove error-producing factors within the workplace; identify organisational issues that generate error-producing factors within the individual, the team, the task or the workplace; improve error detection; increase the error tolerance of the workplace or system; make latent conditions more visible to those who operate and manage the system; improve the organisation's intrinsic resistance to human fallibility.

It is important that organisations balance profit and costs, and try to ensure that the defences which are put in place are the most cost-effective in terms of trapping errors and preventing catastrophic outcomes.

It is hard to remember what the safety world was like before this book. Over 10 years on, while Ch 7 has dated, the rest remains essential reading. My personal best 'swiss cheese conference' was one in which 5 presenters referenced Reason's most famous model.

Pages started falling out of this book as soon as I opened it. It's a shame because it's a good book. Amazon sent me a replacement.

Book has excellent final points and analysis of system design, but it is exceedingly a challenge to follow the tortured writing style (too many details and hard-to-follow examples). I wish someone would make a Reader's Digest version and then it would be a great book! By the way, descriptions of accidents in this book transpired exactly in recent tragic events in Japan.

I did recieve it in time but barely. I wish it would have come a little earlier like the other books I ordered that same day. But over all good service. Book was great even though it was used!

A classic elaborated on in the context of quality in health care - an MBA class. Reason's principles can be applied to reduce the errors which contribute considerably to soaring medical costs and sub-par results from our otherwise topnotch medical staff and equipment.