I am updating my SMS/HF course for a course in October. This may be helpful to some. This is the James Reason HF model. I have shared other graphics of his model over the years, but this one and the one from our friend at the UK’s HSE are my favorites.
I hope that some organizations will begin to lean in this direction regarding “unsafe workers” as a root cause in our incident investigations. We need to lean more towards LATENT ORGANIZATIONAL FAILURES, creating ACTIVE FAILURES. So many factors influence our workers’ behaviors, and the vast majority of them can be managed to reduce the unsafe behaviors we observe in our workers.
I am in NO WAY saying that all unsafe acts are a management system failure. But let’s agree to go down the path of identifying the LATENT ORGANIZATIONAL FAILURES involved in the event that may have influenced the behaviors and decision-making that led to the event BEFORE we begin to examine the worker(s) ACTIVE FAILURES during the chain of events. This approach WILL INCREASE TRUST and CREDIBILITY in our causal analysis process AND INCREASE incident reporting, which everyone should want.
