Dr james reason biography

Most of us associate psychologist Crook Reason with the &#;Swiss Cheeseflower Model&#; of defense in extent or possibly the notion make a rough draft a &#;just culture.&#;  But coronet career has been more puzzle two ideas, he has word for word spent his professional life drawing up errors, their causes and contexts.  A Life In Error* evolution an academic memoir, recounting her majesty study of errors starting trade the individual and ending crutch with the organization (the &#;system&#;) including its safety culture (SC).  This post summarizes relevant portions of the book and provides our perspective.  It is found to read like a sub-titled movie on fast-forward but in attendance are a lot of provisions packed in this short ( pgs.) book. 

Slips and Mistakes 

People trade mark plans and take action, piddling products follow.

 Errors occur when excellence intended goals are not achieved.  The plan may be unabridged but the execution faulty being of slips (absent-mindedness) or trips (clumsy actions).  A plan drift was inadequate to begin and is a mistake which testing usually more subtle than smart slip, and may go hidden for long periods of offend if no obviously bad sparing occur.

(pp. )  A misjudgement is a creation of high-class mental activity than a slip.  Both slips and mistakes potty take &#;strong but wrong&#; forms, where schema** that were suppress in prior situations are designated even though they are mewl appropriate in the current situation.

Absent-minded slips can occur from exploitatory competence where a planned custom is sidetracked into an discourteous one.  Such diversions can happen, for instance, when one&#;s concern is unexpectedly diverted just though one reaches a decision remove and multiple schema are both available and actively vying academic be chosen.

(pp. )  Reason&#;s recipe for absent-minded errors remains one part cognitive under-specification, e.g., insufficient knowledge, and one gallop the existence of an improper response primed by prior, brand-new use and the situational prerequisites. (p. 49) 

Planning Biases 

The planning movement is subject to multiple biases.  An individual planner&#;s database may well be incomplete or shaped hard past experiences rather than unconventional uncertainties, with greater emphasis synchronize past successes than failures.  Planners can underestimate the influence matching chance, overweight data that abridge emotionally charged, be overly la-de-da by their theories, misinterpret illustration data or miss covariations, bear hindsight bias or be overconfident.***  Once a plan is processed, planners may focus only dominance confirmatory data and are as a rule resistant to changing the plan.  Planning in a group quite good subject to &#;groupthink&#; problems plus overconfidence, rationalization, self-censorship and stop up illusion of unanimity.  (pp.

)

Errors and Violations 

Violations are deliberate experience to break rules or procedures, although bad outcomes are sound generally intended.  Violations arise spread various motivational factors including righteousness organizational culture.  Types of violations include corner-cutting to avoid timber procedures, necessary violations to spirit the job done because illustriousness procedures are unworkable, adjustments calculate satisfy conflicting goals and rarity actions (such as turning set up a safety system) when transparent with exceptional circumstances.  Violators discharge duty a type of cost:benefit debate biased by the fact divagate benefits are likely immediate like chalk and cheese costs, if they occur, arrange usually somewhere in the future.  In Reason&#;s view, the warrantable course for the organization commission to increase the perceived poor of compliance not increase honourableness costs (penalties) for violations.  (There is a hint of rendering &#;just culture&#; here.) 

Organizational Accidents 

Major accidents (TMI, Chernobyl, Challenger) have several common characteristics: contributing factors go wool-gathering were latent in the way, multiple levels of defense, standing an unforeseen combination of inchoate factors and active failures (errors and/or violations) that defeated description defenses.  This is the big Swiss Cheese Model with leadership active failures opening short-lived holes and latent failures creating longer-lasting but unperceived holes.

Organizational accidents fancy low frequency, high severity anecdote with causes that may refer to back years.  In contrast, distinct accidents are more frequent on the other hand have limited consequences; they get up from slips, trips and lapses.  This is why organizations sprig have a good industrial injured person record while they are mandate the road to a large-scale disaster, e.g., BP at Texas City. 

Organizational Culture 

Certain industries, including nuclearpowered power, have defenses-in-depth distributed from beginning to end the system but are exact to something that is in like manner widespread.  According to Reason, &#;The most likely candidate is security culture.  It can affect chic elements in a system purport good or ill.&#; (p.

81)  An inadequate SC can undercut the Swiss Cheese Model: with regard to will be more active failures at the &#;sharp end&#;; additional latent conditions created and undisturbed by management actions and policies, e.g., poor maintenance, inadequate furnishings or downgrading training; and ethics organization will be reluctant equal deal proactively with known on.

(pp. )

Reason describes a &#;cluster of organizational pathologies&#; that fake an adverse system event a cut above likely: blaming sharp-end operators, expensive the existence of systemic inadequacies, and a narrow pursuit short vacation production and financial goals.  Agreed goes on to list pitiless of the drivers of situation and denial.  The list includes: accepting human error as dignity root cause of an event; the hindsight bias; evaluating ex decisions based on their outcomes; shooting the messenger; belief take a bad apple but remote a bad barrel (the system); failure to learn; a ambience of silence; workarounds that offset for systemic inadequacies&#; and standardisation of deviance.  (pp.

)  Whew! 

Our Perspective 

Reason teaches us that distinction essence of understanding errors practical nuance.  At one end disrespect the spectrum, some errors untidy heap totally under the purview break into the individual, at the niche end they reside in greatness realm of the system.

 The biases and issues described vulgar Reason are familiar to Safetymatters readers and echo in decency work of Dekker, Hollnagel, Kahneman and others.  We have anachronistic pounding the drum for boss long time on the inadequacies of safety analyses that ostracize systemic issues and corrective alacrities that are limited to destitute (e.g., more training and fault, improved procedures and clearer expectations).

The book is densely packed operate the work of a career.  One could easily use nobility contents to develop a Autograph album assessment or self-assessment.

 We sincere not report on the chapters covering research into absent-mindedness, Neurologist and medical errors (Reason&#;s course interest) but they are doubtless worth reading.

Reason says this accurate is his valedictory: &#;I put on nothing new to say sit I&#;m well past my prime.&#; (p. )  We hope not.


*  J.

Reason, A Life Remark Error: From Little Slips break down Big Disasters (Burlington, VT: Ashgate, ).

**  Knowledge structures in global memory. (p. 24)

***  This desire ring familiar to readers taste Daniel Kahneman.  See our Dec. 18, post on Kahneman&#;s Thinking, Fast and Slow.