Managing the Risks of Organizational
Accidents by James T. Reason
Dealing With Human Error
This is a practical book aimed at those whose daily task it is to think about
and manage or regulate the risks of hazardous technologies. The book is
not targeted at any one domain, but attempts to identify general tools and
principles that are applicable to all organizations facing dangers of one sort
or another. This could include banks and building societies just as much as
nuclear power plants, oil exploration and production, chemical process
plants, and air, sea and rail transport. The emphasis is placed upon the
principles and practicalities of defenses against accidents, and how to
meet the challenges and minimize risk.
Personal Review: Managing the Risks of Organizational
Accidents by James T. Reason
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
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