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.

The Secret to Joy of Heart and Mind

“To serve is beautiful, but only if it is done with joy and a whole heart and a free mind.”

— Pearl S. Buck

Many people know that a fundamental happiness exists in a state of humility. Somehow we are blessed with spiritual blessings when we think of others more and ourselves less. This is not thinking of ourselves as less than others, but just thinking less of our problems, uncertainties, and conflicts, or our gains and pleasures. Accepting our problems as they are, not coveting our pleasures, we move on into a bigger world; a world full of others. This is a world we can contribute to in loving ways. This is a world that God seeks to use us in.

The secret to joy of heart and mind is a genius of simplicity.

When we grasp that service with a purpose has gaping measures of awe about it, that we are serving the living God, we feel privileged to be called and to enact such a creative endeavour.

When God Makes Life Beautiful

We all tend to notice a beautiful sunny day, the majesty of a dark and stormy evening, a sunrise or sunset, but we may not often notice the beauty that can be experienced through serving others.

This is a very personal gift that God gives us. It is a joy with such integrity we have to pinch ourselves to believe it. “What, by giving to others, in intentional ways, because I want to, you (God) make me feel never more wonderful?”

This is a secret that God keeps from all those too selfish to serve.

But for those who are prepared to throw their hats into the ring of life, and give not only their time and resources and energy, but give their very selves in whatever way they are called in the moment, these are blessed with a joy surpassing understanding.

Notwithstanding the beauty in nature, and other visible beauties, this beauty of joy is a breathtaking reality. It truly is one of the seven wonders of life.

When God makes things beautiful, because without him we cannot, we cannot help but appreciate that life, at once, has made more infinite sense in one moment than ever before. Only one experience like this is enough to convert us to the power of God for an abundant life we always dreams of.

But we must continue to give of ourselves, or we slink back into the old joyless way.

***

It is more blessed to give than receive. Those who bless by their service of a wholehearted and free-minded joy find the secret to life. God gives never more than to the willing servant wanting to bless others.

© 2012 S. J. Wickham.

Pride and Privilege – A Male Problem?

It’s not really a man’s fault that he is favoured in society. Indeed, it actually even works to his detriment. But the phenomenon of white male privilege, or more generally male privilege, works just as much against women as it does against men. When a male complains about the things that should be done for him, or the special considerations he is due because ‘he works so hard’, he feels unfairly treated and she just wishes he would get over himself.

Neither male nor female is actually privileged from this context.

It’s a societal problem, and it has ramifications as far as domestic abuse, even murder. Male privilege is a phenomenon known within psychological science as a socio-cultural factor that has swept our globe for hundreds if not thousands of years.

But anyone—male or female—serious about relational life and venturing forward within the workings of love and respect has opportunities of awareness and action.

The Opportunities of Awareness

It was only relatively recently that I recognised how much I had bought in to my own sense of male privilege. I cherished and protected my time—harbouring it, even, you could say, worshipping time. I could surrender anything just about, but time. The cause: male privilege. I felt I deserved my time, to spend as I wished. And besides the fact that I quarried this time in useful pursuits, like writing, my heart wasn’t right.

The opportunity of awareness, for me, occurred through some timely counselling research and study. The penny dropped, and the light went on within me.

With other things transforming within me already in train, I finally saw the truth regarding my coveting of time. Having become aware, and almost without the need for prayer, I felt my carnal grip on time loosen. I became more available, and surrender became easier.

As a result, I was blessed with a sense of pervading peace for no longer needing to covet time. (But if I’m honest, I may continue to be vulnerable regarding the manipulation of ‘my’ time.)

Other men may not struggle so much with surrendering their time, but I believe men more than women struggle to surrender because of this issue of male privilege. And, as above, my belief is backed up by socio-cultural science.

The Opportunities For Action

There are opportunities for both men and women regarding how we effectively deal with male privilege.

Women should continue to gracefully accede to their men, within the bounds of fairness—whatever would be fair for both sexes. It takes a good deal of strength to be assertive—to watch for both people’s needs—but that is the opportunity for action for women.

Men, on the other hand, have an opportunity—emerging (hopefully) from their heightened awareness—to consider the negative role male privilege plays in their relationships, particularly with their partners. It is possible to have a level playing field between the genders, certainly from the viewpoint of how we treat each other. When a man can work on his surrender, especially within the difficult things he wants to control, he challenges his sense of male privilege.

Opportunities for action need to be acted upon. It is no good promising without delivering.

***

Male privilege is a problem for both genders, and it is not caused by men, but by society as a whole. When both men and women can agree their relationships transcend typical gender boundaries—both genders deserving equal privilege—trust and respect soars and love ascends to beautiful heights.

© 2012 S. J. Wickham.

Postscript: Male privilege is defined as “one of the many power structures that may exist within a given society... [it] describes one of many systemic power structures that are interdependent and interlinked throughout societies and cultures.” (Source: Wikipedia)

Care, Advocacy and Action for the Defenceless

Outlier (definition: noun): a person excluded from a group; an outsider.

Those that are particularly vulnerable to feeling rejected are likely to feel like outliers when rejected. But that would be all of us. None of us like to be rejected. Likewise, none of us like to be feel excluded by reason of prejudice, which is very often delivered silently, where the body language communicates volumes. Much more bullying takes place covertly than overtly.

The good thing about having felt like an outlier is we get to feel how unacceptable it is that people would treat other people like this—especially those who should know better—those who believe in love, supposedly—but don’t make the effort, or don’t have conscience enough, to create opportunities for inclusiveness.

People who espouse to be loving, yet don’t act that way reveal a fearful level of hypocrisy, based in pride or greed. But the focus of this article is about the daring of the outlier toward advocacy for other outliers.

A Poignant Biblical Example of Prejudice

Jesus struggled with prejudice and was treated like an outlier at his hometown of Nazareth. Such was the effect of the negativity of the people against him he could not do any miracles there. It wasn’t as though he didn’t want to. He couldn’t!

Well, he did cure a few sick people there, but his divine powers were rendered almost perfectly ineffective, because he was so amazed at their unbelief. Their unbelief had quenched the spiritual power within Jesus.

Likewise, the effect of prejudice quenches our spiritual power when we encounter it; when we feel like an outlier. We feel awkward, self-conscious, and unable to draw on the confidence that God so effectively speaks into our lives at other times.

But the outlier has a special purpose: to become an advocate for other outliers.

The Caring of Advocacy

Why is it so people choose to exclude,

When to love, it’s simple, we must include,

But the experience of an outlier is preciously rare,

Because by their exclusion they know how to care.

                                                                  ***      

When an outlier converts their shame for having been rejected into anger against the injustice for being rejected, and they are then able to save that stored indignant energy to advocate for others, they are a powerful weapon for God.

There is no shortage of outliers in our world. When we empathise with other outliers, particularly the ones who have special disadvantages, God speaks to us about how we can defend the defenceless and speak up for those who cannot speak for themselves.

***

When we are rejected, and we feel like outliers, we have a special duty. We feel what it feels like to be discriminated against, and then we convert the prejudice against us into a force for advocacy for outsiders with special disadvantages. We turn the force for evil against us into a force for good for the disadvantaged.

When good fights good, good always wins! Injustice is merely fuel for action.

Those who know injustice know most why it’s important to care.

© 2012 S. J. Wickham.

The Tragic Truth About Time

“Life is not measured in time, but in love, contribution, and grace.”

— Carly Fiorina

Life is the learning ground. But we only realise this when we are plunged into the darkness of things like a terminal sickness or of a loss incalculable. Suddenly a heinous road opens up before us, and those material things and things of achievement we placed much stock in pale in comparison. Perhaps only those who have weathered these dark roads can attest to the strength-of-wisdom learned in having their souls stripped away.

When we have become barely human, the immaterial things rise in prominence, and we find our essential humanness. When we have come alive spiritually, we have only then truly come alive.

Life Is Deeper Than Time

We very truly live a short time.

Whilst that is such a simple and obvious statement it bears conscious recognition. We have less control than we think we do. Even with all the health choices we make we don’t have the final say. We exist in this life because of one thing: the unfathomable measure of God’s grace handed to us on a golden platter.

This life, mine and yours and everyone else’s, belongs to God.

Yet we rally against the Divine, even Christians, in ways to suggest that our time is ours, and that we have either oodles of it or we never have enough. Time is too abstract to understand, and this is proven by how jaded we feel when the biggest of life’s events happen.

This life that belongs to God is deeper than time.

Transforming Our Life Focus

The moment we can conceptualise that life is much more than time—that it’s about love, making a contribution in others’ lives, and epitomising grace—we find the perspective and the peace we have always looked for in life.

Transforming our life focus is about challenging our ideas about time. Time is an illusion; we hoard it at our peril. The more time-hungry we are, the more selfish we get, and our contentedness evaporates.

The more we can debunk traditional ideas about time, the more we invest in the eternal processes of life. We fall in love with people generally, and we see the gifts beyond every bad thing that occurs to us.

***

Time is not something we can save; it’s something we have to spend.

The more generous we are with our time the more content we’ll be. Peace exists in surrendering our time-god to the living God of glory. Then we learn life is about love, making a contribution, and grace.

© 2012 S. J. Wickham.

Special acknowledgement to: Pranitha Timothy, for partly inspiring this article.

Being Single and ‘Recovering’ from Love

It wasn’t that long ago I was single. And although the past half decade of matrimony has seen a blossoming occur within my soul, I still retain memory of the pain I felt in being single.

Being single, having been married, or partnered with a significant other person, especially when we are the ones who have been jilted, is a hard road to travel. A whole new identity needs to be formed, and this (obviously) takes time.

Being single and recovering from love is an arduous process if we are to do it right. I have to admit, if I’d have had my own way—without relying on obeying God—I would have ‘moved on’ into another relationship quicker than I did. But, alas, I was not ready. (For 13 years of previous marriage it worked out that I needed three years of being single in order to adequately recover and rebuild.)

Most, if not all, people who are recently separated are not ready for a new relationship until they have done the work of personal reformation.

There are that least two factors involved in this personal reformation process:

1.      The dealing with the personal faults that came to the fore in the broken relationship; and,

2.      The jettisoning of partnered identity and the rebuilding of a new self.

Dealing with the Personal Faults That Have Been Exposed

In any broken relationship, as we look back, there was fault on both sides, but often not equal fault. In fact, in all relationships faults are brought to bear. Having endured a broken relationship we have the opportunity to identify the faults we brought to the relationship in order that they would not affect (so much) a future relationship.

This requires honesty and openness, as well as courage and humility.

Entering into our personal faults, without blaming the ex-partner for everything that went wrong, abides to the truth; nobody is perfect. We can only ready ourselves for the next relationship if we are open and honest, and courageous and humble, in recognising our opportunities for growth.

Rebuilding the New Self

Having done the work of repentance, through having gone to God to have certain character traits refined, the next opportunity is to embrace the new life of singleness. This in itself is a difficult journey; to accept we are no longer part of the partnership.

But we cannot advance into the land of mutuality—of caring for another person and having another person care for us—without having become ourselves again. This may sound silly. But it is crucial to the future relationship that we can first hold our own as single persons.

Rebuilding the new self is an awesome opportunity, if we can get beyond the fears of being alone. Having loving friends helps, but we also have opportunities at doing many things alone that we wouldn’t otherwise. We develop our sense for autonomy and we nurture a safe base that isn’t dependent on another person.

***

Having suffered a relationship breakdown we need time to recover. We need time to deal with the faults exposed by the previous relationship. We need time also for rebuilding identity, where we would invite God to nurture within us a safe sense of self. Only having done this work are we ready for a new relationship.

© 2012 S. J. Wickham.

The Intimacy of Overlapping Imaginations

Relationships need mutuality.

The intimacy of overlapping imaginations is what happens when our minds meet with another person’s mind and there is that special connection between two. This sort of connection is saved for the superlative marriage, for best-friends-forever, and for those relationships where teams come to endure great and tumultuous conquests together.

The intimacy in overlapping imaginations is that crazy sort of connection we serendipitously arrive at; both amazed at the wonder that is felt in the inter-psychic space between them. A bond that transcends time and space occurs.

Halcyon Relationships Are Symbolised by Fleeting Moments of Connection

Whenever a loved one has died, the mind recalls memories of split instances in time where something special was said or done. We retain that fleeting moment as an enduring memory that symbolises what the relationship meant to us.

This, and many other examples of the best of times, is proof that the best of relationships are harnessed in the heavenly moment that transcends every self-conscious barrier. In the moment, from the spiritual viewpoint, two become one.

In a flash there is the overlapping of the imagination. The meeting of minds and the heralding of hearts brings a transformation of purpose to both, or all concerned.

All it took was a moment of mutual openness.

When such a moment arrives, many other previously regrettable moments are swept from the memory. This is the moment of redemption!

If we would believe, falsely I might add, that there is no basis for redemption in certain relationships, we may stand to be corrected to experience such a heavenly moment. No relationship is beyond repair, so long as there is the possibility of having a moment of mutual openness with the other.

Opening Up Into Another

Our opportunities to love are myriad every day. As we open up into another person, through a gentle curiosity to understand their world, without the slightest sense of intrusion, we expand the likelihood of engaging in the overlapping imagination—where two minds combine, for a moment, into oneness.

In the moment, the transaction of loving affinity is made—a fusion of souls. This is relationship.

Opening up into another person is one soul’s availability for another. Preferring another person’s agenda over our own creates space for the overlapping of their imagination with ours. All it takes is the desire to enter into service for another.

***

Relationships are blessed because of the overlapping of imaginations—where two people share a moment of oneness. Establishing the overlapping of imaginations requires the enjoining of one person’s curiosity with another person’s receptivity.

Love is a two-way street, but love starts when one reaches toward another in ways that the other person welcomes.

© 2012 S. J. Wickham.

Enjoying People the Way They Are

To live an abundant life of peace, love, and joy we must connect with our world spiritually. And such connectedness occurs in and through people; the people God has chosen to put in our lives and around us. The abundant life is this: to truly enjoy the company of others. To do this we need to accept people unconditionally.

This seems impossible. How would we achieve this? Let’s start this way:

It’s a message we can never really hear enough of: the awareness and the will to appreciate the beauty all around us, especially in people. Appreciating the beauty in people is an internal and an external thing. Where people are concerned, there are four things we can appreciate: other people’s external and internal beauty, as well as our own external and internal beauty.

Other People’s External and Internal Beauty

It’s a natural for our humanity to pick and prod at another person’s personality, behaviours, and character. We clearly see the differences we don’t like. But this default human position is not the way to the abundant life. We need to take a U-turn.

God is made all people beautiful in their time. Externally each is adorned with bodily splendour; a symphony of billions of continuous biophysical, physiological, and psychological transactions at once. Our organisms are cities in their own right. How could we not see this beauty in another person—in the person we have struggled to forgive, for instance?

Then there is the internal beauty. They, like we, have been made in the image of God, as thinking, feeling, and acting persons of divine worth. Others, internally and externally, have been made in the same general blueprint. If our biology and experiences were of these people we would act pretty much as they do.

All people are beautiful—our task, interpersonally, is to find it within each other person.

Our External and Internal Beauty

We can’t truly appreciate other people’s external and internal beauty until we can appreciate our own. At this point we must appreciate our beauty; what we’re made of; the value that God places on us as individuals; the fact that we are living, breathing human beings with histories and futures.

Our external beauty is manifest in physical form, just like others’ is. We have been God-moulded and God-shaped. Not one of us is short on physical beauty, and no one has a world title on it.

Our internal beauty is magnificent. Our spirits are eternal, and therefore we cannot begin to contemplate the value that God has placed on us from before the time we were born.

All people are beautiful—our task, personally, is to find it within us.

***

Appreciating the beauty in people provides us joy in our relationships, and joy in our lives. The more we can see people, including ourselves, as God sees us the more we will be filled with joy projected toward love and peace.

© 2012 S. J. Wickham.