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Wednesday, October 31, 2012

Managing Human Error with Professor James Reason

Meeting Professor James Reason CBE was the realisation of something significant personally. Professor Reason was engaged by Shell globally in 1988 and as a result Tripod Delta Proactive Approach to Safety (“Tripod”) was developed to understand and explain incident causality. It revolutionised approaches to incident investigation and ventured explanations regarding the elephant-in-the-room of human error. I worked for Shell during 2002-2003 and was trained extensively in Tripod. Tripod is the basis of modern Incident Causal Analysis Method (ICAM).
Professor Reason authored Managing the Risks of Organizational Accidents (1997), which includes the original Just Culture Model, and this had a profound impact on my early career in safety (I started as a safety professional in 1997) and continues today.
The following are the noteworthy quotes (verbatim, or as close to verbatim as possible):
Foresight is a very tricky trap.
There aren’t enough trees in the rainforest to cover the procedures needed.
You can measure safety by the absence of something.
A falling or zero LTIFR is the road to hell.
Personal injury rates do not measure process rates.
The real data of safety are stories.
You don’t make absent-minded slips crossing a busy road.
Business is the delicate balance between production and protection.
There are always more errors putting things back together than taking things apart, because there is more than one way to put something back together.
Extroverts are not more error-prone.
Young men violate, old women don’t.
People last less time than the task, hence the need for procedures.
Opinions of close others are what shapes potential violators most.
Young lads violate when they are endorsed by other young lads.
Human beings are such good pattern-matchers.
The brain abhors a vacuum. We would prefer to align with the wrong theory than choose no theory.
A virtuoso is not someone who never makes an error, but someone who detects and recovers from the error.
100,000 Americans die annually because of medical and health care mistakes. The moral to the story: don’t go to hospital.
Roads are wonderful laboratories for violations.
90% of errors are honest errors.
I (Professor Reason) never called the Swiss Cheese Model the Swiss Cheese Model. Rob Lee from Canberra first coined the phrase. I am indebted to him, because I love the name.
I (Professor Reason) regret inventing the term “Latent Failures/Errors.” It should have been “Latent Conditions.” (e.g. the oxygen state in a fire is not a failure, but a condition)
Lawyers are typically into billiard ball causality. It is better to be probabilistic about causality.
The first question to be asked post-incident is, “Which defence failed and why did it fail?”
Many political structures in the 1980s (the lean and mean age) caused many accidents.
The same situations cause different errors in different people.
It’s not always easy to develop good lead indicators.
Air Canada pilots had three words about their culture. They were, “very boring, very proceduralised, and very safe.”
After a textbook landing and Air Canada pilot remarked, “That was a very boring landing...” Professor Reason interjected, “No, it was a very safe landing.”
Every time a human being touches something it’s likely to go wrong.
Tripod was named after a three-legged dog.
Of the General Failure Types (GFT) in Tripod, Professor Reason would no longer include “defences” or “error-enforcing conditions,” reducing the GFTs to 9 in total.
When British Airways stopped using tripod they drifted back into Jurassic Park.
There’s a big difference between safety management and error management.
We need to think not in terms of human as hazard, but in terms of human as hero.
What is needed along with ALARP (as low as reasonably practicable) is ASSIB (and still stay in business).
Production pays for safety.
Air-traffic control is not about safety, but revenue... to push more planes through the sky.
The safety war cannot be won like Waterloo was.
Entropy [the lack of order or predictability; a gradual decline into disorder] gets you all.
Zero harm and target zero misunderstand the nature of the safety war.
“History is a race between education and catastrophe.” (H.G. Wells)
Culture should be CEO-proof. Long after the CEO has left should the culture remain. The trouble with most CEOs is they leave after a year or two.
The Nazi military in 1940 and 1941 were the very best High Reliability Organisation (HRO). They knew what needed to be done without being told.
Human error is a system failure.
In reality, a good safety record is no such thing.
Bad outcomes, just like good outcomes, are a team effort.
No accidents is a cause for concern. (Commenting on the idea of “chronic unease”)
Chernobyl operators had never learned to be afraid.
There is a natural tendency for things to go wrong.
The pursuit of excellence is wrong. Excellence is only manifested by the pursuit of the right kind of excellence.
Human Error Reduction Operation (HERO) is about harnessing what we have, doing what we need to do, and doing what we should.
Safety is a dynamic non-event; we have to work very hard so nothing will happen.
Either we will manage human error or it will manage us.
For Professor Reason’s presentation click here.
© 2012 S. J. Wickham.

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