James Reason - Managing the Risks of Organizational Accidents

This book is dedicated to two pilots and two surgeons who have greatly enhanced the safety of their respective domains:

Captain Gordon Vette

Captain Daniel Maurino

Dr Lucian Leape

Mr Marc de Leval

MANAGING THE RISKS OF
ORGANIZATIONAL
ACCIDENTS

JAMES REASON

First published 1997 by Ashgate Publishing

Published 2016 by Taylor & Francis
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
711 Third Avenue, New York, NY 10017, USA

Routledge is an imprint of the Taylor & Francis Group, an informa business

Copyright 1997 James Reason

James Reason has asserted hir right under the Copyright, Designs and Patents Act, 1988, to be identified as the author of this work.

All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers.

Notice:
Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe.

British Library Cataloguing in Publication Data
Reason, James
Managing the risks of organizational accidents
1.Industrial accidents 2. Hazardous substances Safety
measures 3. Industrial safety Management
I. Title
363.1106

Library of Congress Cataloging-in-Publication Data
Reason, J. T.
Managing the risks of organizational accidents / James Reason.
p. cm.
ISBN 13: 978 1 84014 105 4 (Pbk) ISBN 13: 978 1 84014 104 7 (Hbk)
1. Industrial accidents. 2. Risk assessment. I. Title.
T54.R4 1997
658.382dc21 97-24648
CIP

ISBN: 978 1 84014 104 7 (Hbk)

ISBN: 978 1 84014 105 4 (Pbk)

James Reason 1997

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without the prior permission of the publisher.

Published by
Ashgate Publishing Limited
Gower House
Croft Road
Aldershot
Hants GU11 3HR
England

Ashgate Publishing Company
131 Main Street
Burlington, VT 05401-5600 USA

Ashgate website:http://www.ashgate.com

Reprinted 1998, 1999, 2000 (twice), 2001, 2002, 2003, 2004, 2005, 2006, 2008

British Library Cataloguing in Publication Data
Reason, James
Managing the risks of organizational accidents
1.Industrial accidents 2. Hazardous substances Safety
measures 3. Industrial safety Management
I. Title
363.1106

Library of Congress Cataloging-in-Publication Data
Reason, J. T.
Managing the risks of organizational accidents / James Reason.
p. cm.
ISBN 1 84014 105 0 (pbk) 1 84014 104 2 (hbk)
1. Industrial accidents. 2. Risk assessment. I. Title.
T54.R4 1997
658.382dc21 9724648
CIP

ISBN 13: 978 1 84014 104 7 (Hbk)
ISBN 13: 978 1 84014 105 4 (Pbk)

Typeset by Manton Typesetters, 57 Eastfield Road, Louth, Lincolnshire, UK.
Printed in Great Britain by MPG Books Ltd, Bodmin, Cornwall

ACAA Australian Civil Aviation Authority

ALARP as low as reasonably practicable

AMMS Aurora Mishap Management System

AOC Air Operators Certificate

ASRS Aviation Safety Report System (NASA)

BASI Bureau of Air Safety Investigation (Australia)

BASIS British Airways Safety Information System

BB & Co. Barings Brothers & Co.

BFS Barings Futures (Singapore) Pte Limited

BSL Barings Securities Limited

CEO chief executive officer

CIMAH Control of Industrial Major Hazards

COSHH Control of Substances Hazardous to Health

CRIEPI Central Research Institute for the Electrical Power Industry

CRM crew (cockpit) resource management

EC European Commission

EM error management

EPC error-producing condition

FAA Federal Aviation Administration (US)

FDR flight data recorder

FEA failure mode and effects analysis

FMS flight management system

FSA formal safety assessment

GFT general failure type

HAZAN hazards operability study

HAZOP hazard and operability study

HEA human error analysis

HEART Human Error Assessment and Reduction Technique

HEMP Hazardous Effects Management Process

HRA human reliability analysis

HRO high-reliability organization

HSC Health and Safety Commission

HSE Health and Safety Executive

IAEA International Safety Advisory Group

IDA Influence Diagram Approach

IFSD inflight engine shutdown

INPO Institute of Nuclear Power Operations (US)

JAL Japan Airlines

KB knowledge-based

LII lost-time injury

MEDA Maintenance Error Decision Aid

MESH Managing Engineering Safety Health

MSA Marine Safety Agency

NASA National Aeronautics and Space Administration

NCO non-commissioned officer

NRC Nuclear Regulatory Commission

NTSB National Transport Safety Board

NUREG Report series issued by Nuclear Regulatory Commission

NWA Northwest Airlines

O & M organizational and managerial

PIF performance-influencing factor

PRA probabilistic risk assessment

PSA probabilistic safety assessment

PWR pressurised water reactor

RAMS reliability and maintainability study

RB rule-based

RPF railway problem factor

RBMK A Soviet-built nuclear power plant

SB skill-based

SESMA Special Event Search and Master Analysis

SIMEX Singapore Monetary Exchange

SOP standard operating procedure

SPC Statistical Process Control

SR & QA Safety Reliability and Quality Assurance Program

TBR to-be-remembered

TMI Three Mile Island

TQM Total Quality Management

VPC violation-producing factor

This book is not meant for an academic readership, although I hope that academics and students might read it. It is aimed at real people and especially those whose daily business is to think about, and manage or regulate, the risks of hazardous technologies. My imagined reader is someone with a technical background rather than one in human factors. To this end, I have triednot always successfullyto keep the writing as jargon-free as possible.

The book is not targeted at any one domain. Rather, it tries to identify general principles and tools that are applicable to all organizations facing dangers of one sort or another. This includes banks and insurance companies just as much as nuclear power plants, oil exploration and production, chemical process plants and air, sea and rail transport. The more one moves towards the upper reaches of such systems, the more similar their organizational processesand weaknessesbecome.

In a book of this type the big bang examples inevitably tend to predominate, but, although I have used case study examples to illustrate points, this is not intended to be yet another catalogue of accident case studies. My emphasis is upon principles and practicalitiesthe two must work hand-in-hand. But the real test is whether or not these ideas can eventually be translated into some improvement in the resistance of complex, well defended systems to rare, but usually catastrophic, organizational accidents.

James Reason

There are two kinds of accidents: those that happen to individuals and those that happen to organizations. Individual accidents are by far the larger in number, but they are not the main concern of this book. Our focus will be upon