The growth of large, complex technology systems in recent decades, such as nuclear power plants, commercial aviation, the petrochemical industry, chemical process plants, and marine and rail transport, has spawned rare but often catastrophic events such as organizational or system accidents. The Three Mile Island nuclear accident, the Exxon Valdez oil spill, the Bhopal India gas leak, the Challenger disaster, and numerous airline accidents, among others, caused growing public concern over the terrible costs, loss of life, the risk to the public, and threat to the environment. In most instances, human error was cited as the cause of these incidents.
Dr. James Reason studied human error for years (as did several others) and published his first book by that title in 1990. A central thesis of his work is that the relatively limited number of error types and ways in which errors manifest themselves are conceptually tied to underlying (non-error-producing) normal cognitive processes. He advocates that errors result from normal cognitive processes, the same origin as success. Another thesis is that disasters are rarely the product of a single monumental error. Usually, they involve the collaboration of several, often quite minor, errors committed either by one person or, more often, by a number of people.
In 1997, Reason published Managing the Risks of Organizational Accidents. Reason maintained that understanding how organizational accidents occur requires we look deeper into the system. Unsafe acts by individuals may trigger an event. However, latent conditions within the organization, aligned with local workplace and task factors, contribute to accidents in the form of process errors or error-likely situations. Thus, the combination of these latent conditions in conjunction with an active error more correctly accounts for events. From this perspective, errors are the consequences, not the causes, of disturbances in the organization.
Accidents are the result of failed controls and barriers. People are fallible; even the best make mistakes. It is human nature to err. However, events can be eliminated or controlled by changing the conditions in which people work. Managing the risks of organizational accidents requires managers, supervisors, and staff to work to eliminate latent organizational weaknesses.
Reason proposes three (3) compelling reasons why latent conditions must be eliminated.
- They combine with local factors to breach controls. In many cases, they are weakened or absent controls.
- They are like “resident pathogens” within the workplace that can be identified and removed before the event.
- Local triggers and unsafe acts are hard to anticipate, and some proximal factors are almost impossible to defend against (for example, forgetfulness, inattention, and the like).
The challenge is great for organizations trying to change the conditions in which people work to improve the operating system and lower the risk of accidents. However, the risks associated with not accepting the challenge are enormous. Accidents cost lives, and they are also economically disastrous. Very few organizations can sustain levels of financial loss associated with product and materials damage, plant damage, building damage, tool and equipment damage, legal costs, and similar losses, plus the loss of business, recruitment difficulties, and loss of morale.
Dr. Reason’s work is the foundation for the human performance improvement model.