A life of Reason: A mini-compendium of James Reason's contributions

A life of Reason: A mini-compendium of James Reason's contributions

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 and extracts not from Reason but whom have leveraged his work.

https://safety177496371.wordpress.com/2023/03/02/james-reason-and-his-bitter-refusal-around-error/


https://safety177496371.wordpress.com/2023/03/07/12-varieties-of-rule-following-behaviour/


https://safety177496371.wordpress.com/2022/09/09/diagnosing-vulnerable-system-syndrome-an-essential-prerequisite-to-effective-risk-management/


https://safety177496371.wordpress.com/2024/08/20/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/


https://safety177496371.wordpress.com/2024/08/06/coronial-inquiry-fatal-drill-rig-design-poor-machine-interface-and-numerous-error-traps/


https://safety177496371.wordpress.com/2022/11/25/has-the-pendulum-swung-too-far-in-investigations-and-safety/


https://safety177496371.wordpress.com/2022/10/25/too-little-and-too-late-a-commentary-on-accident-and-incident-reporting-systems/


https://safety177496371.wordpress.com/2022/10/07/risks-of-automation-and-removing-people/


https://safety177496371.wordpress.com/2022/09/30/the-blame-cycle/


https://safety177496371.wordpress.com/2022/09/27/beyond-the-organisational-accident-the-need-for-error-wisdom-on-the-frontline/


https://safety177496371.wordpress.com/2022/08/30/safety-paradoxes-and-safety-culture/


https://safety177496371.wordpress.com/2022/08/26/of-heroes-villains-error-traps-and-accidents/


https://safety177496371.wordpress.com/2022/08/19/safety-paradoxes/


https://safety177496371.wordpress.com/2022/08/12/safety-as-a-dynamic-non-event/


https://safety177496371.wordpress.com/2024/07/12/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


https://pmc.ncbi.nlm.nih.gov/articles/PMC1055294/pdf/qualhc00016-0008.pdf


https://pmc.ncbi.nlm.nih.gov/articles/PMC1743973/pdf/v014p00056.pdf


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


https://www.eurocontrol.int/sites/default/files/library/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


https://www.nislab.dk/Publications/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


https://www.researchgate.net/profile/Anthimos-Anastasiadis-2/publication/377781580_Failure_Analysis_of_FC_Twente_Stadium_Roof_Collapse_Using_the_Swiss_Cheese_Accident_Model/links/65b8b7431bed776ae315b211/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


https://www.researchgate.net/profile/Yunqiu-Li/publication/263743419_Hot_cheese_A_processed_Swiss_cheese_model/links/568fa5a708aead3f42f42151/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)













John Kunzler

Advising professional services clients and regulators on claim avoidance and reduction

3 天前

Amazing - resource thanks. "Org Acc Revisited" was actually on my desk and "bitter refusal" was an important page I had forgotten - thanks for the reminder and all the other stuff

Lyle Brown

CAAM, CPEng, FS Eng (TüV Rheinland), MIEAust, NER, and RPEQ

2 周

The following recognition of Reason by the ATSB may be of interest, despite that you may be aware etc: https://www.dhirubhai.net/pulse/dr-james-reason-cbe-australian-transport-safety-bureau-bp8lc/?trackingId=0D4k%2FrM3kTyezxZYknR70g%3D%3D Regards, Lyle.

Andrea Paynter, LLB(Hons), COHSProf, MAICD

Founder & Director | Safety and Compliance Expert with a Legal Edge

2 周

Thank you for sharing this, Ben. It is a fitting collection of Reason’s works, given his significant impact on the fields of quality and safety. It brings back memories of my quality assurance Uni studies in the 1990s!

James Coffey

Strategy Execution Expert - Certified Management Coach - Author - Speaker

2 周

I find 'malicious compliance" interesting; you create rules and then a culture where ignoring them is ok, until something happens. In a worse case, operators wind up deciding which rules to follow to get the job done and unsafe practices proliferate. I'm not saying all rules make sense or apply in every situation. We've all, no doubt, been in situations where the rule made no sense or could be ignored safely, but if working to the rule causes serious disruptions there are deeper issues at play as well besides labor unrest.

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