Over the past several years, I have focused on my SMS/HF postings rather than the traditional technical postings. Being a safety pro means we wear many hats. I break these down into just two (2) main categories: 1) Technical and 2) Management Systems, including the soft skills we need to possess. Those who have followed me over the years know I love the technical side. But those who have worked with me outside the process safety arena know my love for Safety Management Systems and the softer/empathetic side of safety. Last year, I created two new sections for my blog posts: SMS and HF. I moved all my articles which had resided in the Chemical Process Safety section, to their rightful place so they could be more easily found.
As you may have figured out, I am a disciple of James Reason and his approach to human behavior. I am also a huge E Scott Geller disciple. I believe joining these two men’s work is the near-perfect blend for taking a business to the next level, above and beyond the OSHA compliance approach to OSH. This passage from one of the many writings of Dr. James Reason is one of my favorites. Suppose you are involved in incident investigations, or you’re worried about how investigations in your workplace are influencing your culture in a negative way rather than creating a LEARNING opportunity. In that case, I highly recommend Reason’s books, even though many are written for the Health Care sector. Here is what he had to say in 1990 after several significant industrial events worldwide. (emphasis by me)
Close examination of several recent disasters (especially Bhopal, Challenger, Chernobyl, Zeebrugge and King’s Cross) shows the need to distinguish two ways in which human beings contribute to the breakdown of complex systems (see also Rasmussen & Pedersen (1984)).
(i) Active failures: those errors and violations having an immediate adverse effect. These are generally associated with the activities of ‘front-line’ operators: control room personnel, ships’ crews, train drivers, signalmen, pilots, air traffic controllers, etc.
(ii) Latent failures: these are decisions or actions, the damaging consequences of which may lie dormant for a long time, only becoming evident when they combine with local triggering factors (that is, active failures, technical faults, atypical system conditions, etc.) to breach the system’s defenses. Their defining feature is that they were present within the system well before the onset of a recognizable accident sequence. They are most likely to be spawned by those whose activities are removed in both time and space from the direct human-machine interface: designers, high-level decision-makers, regulators, managers and maintenance staff.
Two recent accident investigations, in particular, have dramatically reversed the usual practice of focusing upon the actions of the ‘front-line’ operators (Sheen, 1987; Fennell 1988).
Both the Zeebrugge and King’s Cross inquiries concluded that rather than being the main instigators of these disasters, those at the human-machine interface were the inheritors of system defects created by poor design, conflicting goals, defective organization and bad management decisions. Their part, in effect, was simply that of creating the conditions under which these latent failures could reveal themselves.
Source: The contribution of latent human failures to the breakdown of complex systems, James Reason, 1990