“By their nature, accidents are not directly controllable”, so says James Reason in this 1993 article.
Just a single extract from the article’s conclusion:
· “Safety has two faces: a positive one relating to an organization’s intrinsic resistance to chance conjunctions of unsafe acts and hazards, and a negative one, revealed by accident and incident data, that reflects moments of past vulnerability”
· “Positive safety, like good health, is a difficult notion to pin down. By comparison, unsafe states, like diseases, are all too clearly signaled by fatalities, lost time injuries, physical damage and financial losses. Each of these negative aspects translates readily into numbers, and many organizations use them to assess the relative safety of their various activities”
· “But the data supplied by accident and incident reporting systems are too little and too late to support effective safety management”
· Though they provide essential information, negative outcome data (i.e., fatalities, lost time injuries, etc.) are poor indicators of an organization’s general safety health”
· “Only if an organization has complete control over all accident-causing factors could its accident history provide a valid measure of intrinsic safety. But no organization engaged in hazardous operations can ever achieve this total control”
· “The probability of their [latent conditions[ adverse conjunction is always greater than zero. The large stochastic component in accident causation means that “safe” organizations can still have bad accidents, while relatively “unsafe” ones can escape them for lengthy periods”
· “Safety management is essentially an organizational control problem. Given limited resources, the trick is to know what is manageable and what is not”
· “By their nature, accidents are not directly controllable”
Ref: Reason, J. (1993). The identification of latent organizational failures in complex systems. In Verification and validation of complex systems: Human factors issues (pp. 223-237). Berlin, Heidelberg: Springer Berlin Heidelberg.
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