In the 20th Century, the great Professor James Reason foresaw how 21st Century Safety Management would have to evolve to move us to the next level.
- Two (2) approaches to the problem of human fallibility exist:
- the person and
- the system approaches
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- The person approach focuses on the errors of individuals, blaming them for forgetfulness, inattention, or moral weakness.
- The system approach concentrates on the conditions under which individuals work and tries to build defenses to avert errors or mitigate their effects.
- High-reliability organizations—which have less than their fair share of accidents—recognize that human variability is a force to harness in averting errors. Still, they work hard to focus on that variability and are constantly preoccupied with the possibility of failing.
The basic premise of the SYSTEM APPROACH is that humans are fallible and errors are to be expected, even in the best organizations. Errors are seen as consequences rather than causes, having their origins not so much in the perversity of human nature as in “upstream” systemic factors. These include recurrent error traps in the workplace and the organizational processes that give rise to them. Countermeasures are based on the assumption that though we cannot change the human condition, we can change the conditions under which humans work. The central idea is that of system defenses. All hazardous technologies possess barriers and safeguards. When an adverse event occurs, the critical issue is not who blundered but how and why the defenses failed.
The person approach remains the dominant tradition. From some perspectives, it has much to commend it. Blaming individuals is emotionally more satisfying than targeting institutions. People are viewed as free agents capable of choosing between safe and unsafe modes of behavior. If something goes wrong, it seems evident that an individual (or group of individuals) must have been responsible. Seeking as far as possible to uncouple a person’s unsafe acts from any institutional responsibility is clearly in the interests of managers. It is also legally more convenient.
Although some unsafe acts in any sphere are egregious, the vast majority are not. In aviation maintenance—a hands-on activity similar to medical practice in many respects—some 90% of quality lapses were judged as blameless. Effective risk management depends crucially on establishing a reporting culture. Without a detailed analysis of mishaps, incidents, near misses, and “free lessons,” we cannot uncover recurrent error traps or know where the “edge” is until we fall over it. Trust is a key element of a reporting culture. This, in turn, requires a just culture—a collective understanding of where the line should be drawn between blameless and blameworthy actions. Engineering a just culture is an essential early step in creating a safe culture.
Source: Human Error, 1991