Major accidents are rare events due to the many barriers, safeguards and defences developed by modern technologies. But they continue to happen with saddening regularity and their human and financial consequences are all too often unacceptably catastrophic. One of the greatest challenges we face is to develop more effective ways of both understanding and limiting their occurrence. This lucid book presents a set of common principles to further our knowledge of the causes of major accidents ...

Human Error, published in 1991, is a major theoretical integration of several previously isolated literatures. Particularly important is the identification of cognitive processes common to a wide variety of error types. Technology has now reached a point where improved safety can only be achieved on the basis of a better understanding of human error mechanisms. In its treatment of major accidents, the book spans the disciplinary gulf between psychological theory and those concerned with ma...

This succinct but absorbing book covers the main way stations on James Reason’s 40-year journey in pursuit of the nature and varieties of human error. In it he presents an engrossing and very personal perspective, offering the reader exceptional insights, wisdom and wit as only James Reason can. The journey begins with a bizarre absent-minded action slip committed by Professor Reason in the early 1970s - putting cat food into the teapot - and continues up to the present day, conveying his ...

Managing the Risks of Organizational Accidents introduced the notion of an ’organizational accident’. These are rare but often calamitous events that occur in complex technological systems operating in hazardous circumstances. They stand in sharp contrast to ’individual accidents’ whose damaging consequences are limited to relatively few people or assets. Although they share some common causal factors, they mostly have quite different causal pathways. The frequency of individual accidents ...

Situations and systems are easier to change than the human condition - particularly when people are well-trained and well-motivated, as they usually are in maintenance organisations. This is a down-to-earth practitioner’s guide to managing maintenance error, written in Dr. Reason’s highly readable style. It deals with human risks generally and the special human performance problems arising in maintenance, as well as providing an engineer’s guide for their understanding and the solution. Af...

This book explores the human contribution to the reliability and resilience of complex, well-defended systems. Usually the human is considered a hazard - a system component whose unsafe acts are implicated in the majority of catastrophic breakdowns. However there is another perspective that has been relatively little studied in its own right - the human as hero, whose adaptations and compensations bring troubled systems back from the brink of disaster time and again. What, if anything, did...

The authors believe that a systematic organizational approach to aviation safety must replace the piecemeal approaches largely favoured in the past, but this change needs to be preceded by information to explain why a new approach is necessary. Accident records show a flattening of the safety curve since the early Seventies: instead of new kinds of accident, similar safety deficiencies have become recurrent features in accident reports. This suggests the need to review traditional accident...

Resilience engineering has since 2004 attracted widespread interest from industry as well as academia. Practitioners from various fields, such as aviation and air traffic management, patient safety, off-shore exploration and production, have quickly realised the potential of resilience engineering and have became early adopters. The continued development of resilience engineering has focused on four abilities that are essential for resilience. These are the ability a) to respond to what ha...

The Blame Machine describes how disasters and serious accidents result from recurring, but potentially avoidable, human errors. It shows how such errors are preventable because they result from defective systems within a company. From real incidents, you will be able to identify common causes of human error and typical system deficiencies that have led to these errors. On a larger scale, you will be able to see where, in the organisational or management systems, failure oc...

The U.S. healthcare system is now spending many millions of dollars to improve "patient safety" and "inter-professional practice." Nevertheless, an estimated 100,000 patients still succumb to preventable medical errors or infections every year. How can health care providers reduce the terrible financial and human toll of medical errors and injuries that harm rather than heal? Beyond the Checklist argues that lives could be saved and patient care enhanced by adapting the re...

Dynamic Risk Assessment is the key tool to support a holistic risk management framework. This book aims to help employers, managers and staff alike to understand how they can effectively integrate dynamic risk assessment into business management processes and systems to improve safety.With tips, examples and solutions throughout, this multi-disciplinary text delivers an effective and comprehensive approach to help you to understand how dynamic risk assessment (DRA) can be integrate...

The International Civil Aviation Organization’s (ICAO) decision to require aviation organizations to adopt Safety Management Systems poses a major problem especially for small and medium sized aviation companies. The complexity of regulations overstrains the aviation stakeholders who seek to fully advantage from them but have no clear guidance. The aim of the book is to show the implementation of such a new system with pragmatic effort in order to gain a gradation for smaller operators. Th...