Managing the Risks of Organizational Accidents

by James Reason

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.

Genres: Aviation, Nonfiction

252 pages, Paperback

First published December 15, 1997

About the author

James Tootle Reason was a professor of psychology at the University of Manchester, from where he graduated in 1962 and where he was a tenured professor from 1977 until 2001. He wrote books on human error, including such aspects as absent-mindedness, aviation human factors, maintenance errors, and risk management for organizational accidents. In 2003, he was awarded an honorary DSc by the University of Aberdeen. He was a Fellow of the British Academy, the British Psychological Society, the Royal Aeronautical Society, and the Royal College of General Practitioners. He received a CBE in 2003 for his services in the reduction of the risks in health care. In 2011 he was elected an honorary fellow of the Safety and Reliability Society.
Among his many contributions is the introduction of the Swiss cheese model, a conceptual framework for the description of accidents based on the notion that accidents will happen only if multiple barriers fail, thus creating a path from an initiating cause all the way to the ultimate, unwanted consequences, such as harm to people, assets, the environment, etc. Reason also described the first fully developed theory of a just culture in his 1997 book, Managing the Risks of Organizational Accidents.

Reviews

[Eric Mesa · Rating 3 out of 5]

I had to read this book as part of my graduate work and I'm glad I did. It is an important look at how we can better work on reducing industrial accidents like oil rig explosions, airline crashes, and nuclear power plant explosions. A large part of the problem, in the author's studied opinion, is the way we assign blame. We blame the person who had an accident rather than the system that created the situation for the accident. Except for extreme cases of negligence or criminal activity, this shouldn't be the case and causes us to learn the wrong lessons; preventing a chance at stopping it from happening again.

I got deep into this book before my recent business trip - not a good idea. Most of the examples are about the aviation industry. You know how sometimes you're waiting for a plane and they delay it for maintenance? According to this book you should not want to get on that plane afterwards - messed up maintenance is one of the biggest sources of airline accidents now. That's right - maintaining the aircraft is, because of errors, ending up worse than letting the aircraft naturally fail.

The book is also smart about talking about theory and then talking about how to apply it in the real world. Too often management books (and self-help books on a personal level) talk about things in the ideal world, but life isn't like that. Reason tries to give some examples of how you could take the research he's aggregated and apply it in the real world.

I'd recommend first to anyone working in a hazardous field - energy, aviation, etc and second to anyone who's an OSHA representative.

[Rolf Häsänen · Rating 5 out of 5]

This book is the perfect companion to J.Reasons Human Error.
There is some overlap between the books but they complement each other nicely.

The strenghts of this book is that it will give you insights, mental models, methods and principles for working with risks/Organizational Accidents/Human Error

I just wish that the chapter "Practical Guide to Error Management" and "Engineering a safety culture" would contain a bit more examples and information.

[Joe Kopacz · Rating 5 out of 5]

I found this book referenced frequently in others about human and organizational performance. I found it easy to read and what I was looking for at the time (i.e., how to better understand complex systems and how they failed).

There's a balance between stories about accidents and investigative concepts arising from their analysis. If you're a manager or have to do root causes analysis with any frequency, this is well worth the read.

[Vincent Saint-Cyr · Rating 3 out of 5]

A bit out of dated but with a lot of real case which make the book easy to read.

[Sriram · Rating 5 out of 5]

An excellent book and a must read for all those involved in hazardous industries/work

[Melsene G · Rating 3 out of 5]

Before I get to the substance, I must point out that the quality of this paperback was awful-one of the worst I've seen for a major author. The side margins were too wide and the words were lost in the crease, so it was very difficult to read. I had to hold the center of the book down to see the last word in each sentence-for the entire book. The publisher needs to fix this as it's disgraceful-thus I downgraded the book.

This is a theoretical and technical book with lots of good information, case studies,etc., regarding organizational accidents in high reliability organizations like aviation and nuclear power. It will take some time to get through as there are charts and tables and lots to digest. The book is broken down into 10 chapters: Hazards, Defenses and Losses; Defeating the Defenses; Dangerous Defenses; The Human Contribution; Maintenance can Seriously Damage your System; Navigating the Safety Space; Practical Guide to Error Management; The Regulator's Unhappy Lot, Engineering a Safety Culture, and a summary.

Each chapter contains helpful information for those in large organizations. In sum, more emphasis needs to be placed on organizational factors, not human factors. The human condition will always be with us and people will always make mistakes. Focus on your systems and processes-and fix those if you can.

[Angela · Rating 4 out of 5]

It took a lot of time for me to swim through this book, but it was rewarding. At the time I worked at an airline; the discovery from this book that the best and brightest are often the perpetrators of the gravest errors was eye-opening! There are many other gems of knowledge in this book, including a very rich bibliography that I want to get to this year. :) The best information to be gleaned from James Reason's book is that "engineering a safety culture" is the only way for businesses, governments, and institutions to avoid catastrophe, and it includes placing barriers to human error and acts of God in the process. It's fascinating to read about large-scale failures of the system...

[Gallottino · Rating 4 out of 5]

A cornerstone of risk management and a useful toolbox for whoever is interested in this field. Identification of human error is not the conclusion of an investigation after an adverse event but is the starting point for understand what you can change in workplace's organization. The book gives useful classifications (the noteworthy slip, lap, mistake for example) and describes how to implement a safety culture. Too many examples of aviation disasters and none of adverse events in healthcare. In spite of this, a great book

[Dave · Rating 3 out of 5]

This book provides some very good insight and food for thought.

I would only recommend it to someone very interested in safety. It is not a light read, and takes some wading through it. But it is interesting to a safety professional.

I think that he goes overboard on trying to depict some things with graphics. Maybe it is because I had trouble in getting what he was trying to show that he couldn't do with words, and I just didn't "get" some of them.

[Garwin · Rating 5 out of 5]

This book has become a staple and a core to the safety profession. Its concepts are solid and are still highly relevant to the current day and age. It is well known for the introduction of the "Swiss cheese" concept where he likens safety defenses to layers of Swiss cheese. Accidents occur when an accident projectile defeats all the holes in the defenses. A worthwhile read for anyone looking to understand safety

[Bharata Satria · Rating 5 out of 5]

The premier ... Harus dibaca oleh novice dan expert alike. Buku yang sangat bagus untuk pendamping buku teks kuliahan... Kalau buku teks menyajikan teori dan metode K3, buku ini membuat kita waspada di mana saja teori dan metode itu bisa salah dan gagal.