SafetyInsights.org

Seems fitting to cover some work from James Reason and to reflect on his enduring impact on our professional work, thinking and models.

I’ve focused more on articles I’ve summarised or posted an image extract of, or could find a full-text article for. It’s NOT systematic. I’ve also included articles not from Reason but whom have leveraged his work.

James Reason and his bitter refusal around “error”

12 varieties of rule-following behaviour

Diagnosing “vulnerable system syndrome”: an essential prerequisite to effective risk management

Coronial inquiry: Not hard to find human ‘culprits’ and “we must beware of falling prey to the fundamental attribution error (i.e. blaming people and ignoring situational factors)”

Coronial inquiry: fatal drill rig design, poor machine interface and numerous error traps

Has the pendulum swung too far in investigations and safety?

Too little and too late: A commentary on accident and incident reporting systems

Risks of automation and removing people

The blame cycle

Beyond the organisational accident: the need for ‘‘error wisdom’’ on the frontline

Safety paradoxes and safety culture

Of heroes, villains, error traps and accidents

Safety paradoxes

Safety as a dynamic non-event

Reliability and safety are “dynamic non-events” and “dynamic inputs create stable outcome”

https://doi.org/10.1098/rstb.1990.0090

https://www.academia.edu/22355239/Errors_and_violations_on_the_roads_a_real_distinction

Click to access qualhc00016-0008.pdf

Click to access v014p00056.pdf

https://pmc.ncbi.nlm.nih.gov/articles/PMC1117770/?

Click to access 017_Swiss_Cheese_Model.pdf

https://doi.org/10.1016/j.ssci.2020.104660

https://www.researchgate.net/publication/374471149_A_comprehensive_review_of_the_Swiss_cheese_model_in_risk_management

https://www.tandfonline.com/doi/pdf/10.1080/18811248.1999.9726296

Click to access TeamError9.1.92.pdf

https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=fdb6951c36574023c59171cc79ce1963e52181ec

https://library.oapen.org/bitstream/handle/20.500.12657/27820/1/1002185.pdf#page=258

Click to access Failure-Analysis-of-FC-Twente-Stadium-Roof-Collapse-Using-the-Swiss-Cheese-Accident-Model.pdf

https://doi.org/10.1016/S0022-5223(00)70006-7

https://doi.org/10.1016/S0020-7373(87)80010-X

https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=fdb6951c36574023c59171cc79ce1963e52181ec

https://www.amjmed.com/article/S0002-9343(20)30531-3/pdf

Click to access Hot-cheese-A-processed-Swiss-cheese-model.pdf

https://journals.sagepub.com/doi/pdf/10.3233/WOR-230186

https://doi.org/10.1136/bmj.320.7237.768

https://www.researchgate.net/publication/261592120_Driving_Errors_Driving_Violations_and_Accident_Involvement

https://www.researchgate.net/publication/12093159_Institutional_resilience_in_healthcare_systems

https://www.researchgate.net/publication/243786904_Tripod_Delta_Proactive_Approach_to_Enhanced_Safety

BOOKS (no full access … sorry)

LinkedIn post: https://www.linkedin.com/pulse/life-reason-mini-compendium-james-reasons-ben-hutchinson-sbcic