Dr. Reason is recognized as a world-leading expert on human error, with a distinguished career spanning industry, healthcare, and academia. He is a graduate of the University of Manchester and held the position of Professor of Psychology from 1977 to 2001. Professor Reason is probably best known for his “Swiss Cheese” Accident Causation Model which he published in 1990. While attending Murray State Univesity in the early 1990’s, the causation model was all the rage and it is still very popular today, especially in process safety when discussing “Layers of Protection”. But Professor Reason is also known, albeit to a much lesser degree than his swiss cheese model, for his 12 Principles of Error Management.
Here are his 12 Principles of Error Management:
- Human error is both universal & inevitable: Human error is not a moral issue. Human fallibility can be moderated but it can never be eliminated.
- Errors are not intrinsically bad: Success and failure spring from the same psychological roots. Without them, we could neither learn nor acquire the skills that are essential to safe and efficient work.
- You cannot change the human condition, but you can change the conditions in which humans work: Situations vary enormously in their capacity for provoking unwanted actions. Identifying these error traps and recognizing their characteristics are essential preliminaries to effective error management.
- The best people can make the worst mistakes: No one is immune! The best people often occupy the most responsible positions so that their errors can have the greatest impact…
- People cannot easily avoid those actions they did not intend to commit: Blaming people for their errors is emotionally satisfying but remedially useless. We should not, however, confuse blame with accountability. Everyone ought to be accountable for his or her errors [and] acknowledge the errors and strive to be mindful to avoid recurrence.
- Errors are consequences not causes: …errors have a history. Discovering an error is the beginning of a search for causes, not the end. Only be understanding the circumstances…can we hope to limit the chances of their recurrence.
- Many errors fall into recurrent patterns: Targeting those recurrent error types is the most effective way of deploying limited Error Management resources.
- Safety significant errors can occur at all levels of the system: Making errors is not the monopoly of those who get their hands dirty. …the higher up an organization an individual is, the more dangerous are his or her errors. Error management techniques need to be applied across the whole system.
- Error management is about managing the manageable: Situations and even systems are manageable if we are mindful. Human nature – in the broadest sense – is not. Most of the enduring solutions…involve technical, procedural and organizational measures rather than purely psychological ones.
- Error management is about making good people excellent: Excellent performers routinely prepare themselves for potentially challenging activities by mentally rehearsing their responses to a variety of imagined situations. Improving the skills of error detection is at least as important as making people aware of how errors arise in the first place.
- There is no one best way: Different types of human factors problems occur at different levels of the organization and require different management techniques. Different organizational cultures require different ‘mixing and matching’….of techniques. People are more likely to buy into homegrown measures…
- Effective error management aims as continuous reform, not local fixes: There is always a strong temptation to focus upon the last few errors …but trying to prevent individual errors is like swatting mosquitoes…the only way to solve the mosquito problem is to drain the swamps in which they breed. Reform of the system as a whole must be a continuous process whose aim is to contain whole groups of errors rather than single blunders.