Organizational Accidents Revisited

Well written, easy read, with lots of very good information.

This book adds some extra to the original organisational accidents but don’t sure if it was enough to warrant a new book. Surprised at the number of errors/spelling issues that made it through to publication.

I enjoy reading books were leading safety experts look back on their own approaches and compare them with upcoming ways of thinking safety.

James Reason is a pioneer and leader in understanding and prevention of "organizational accidents." That alone is sufficient reason to read this book if you're interested in this topic, which is why I read it. However, Reason doesn't really break new ground with this book, so people who are already well versed in this field may not get much out of this book.The bottom line is that there are no easy answers when it comes to safety, and no one theoretical framework can cover all needs, so a multifaceted approach tailored to each organizational situation is likely the best way to go. Reason offers one such framework, and briefly comments on other frameworks in this book. Here are some points noted in the book which I think are worth highlighting:• The contributors to incidents can involve all levels of a system, ranging from individuals working at the “sharp end,” to groups, to organizations, to broader systems which include regulators. Efforts to prevent incidents will typically be best directed at multiple levels simultaneously, with both top-down support and bottom-up feedback. Efforts targeted to only a few specific areas are prone to not being effective because we can’t anticipate the specific ways adverse factors may “line up” to produce incidents, particularly in complex systems (and complex systems are the norm, not the exception).• “Human errors” can’t be eliminated, but their incidence and consequences can be reduced. As long as they are managed properly, human errors can also be a source of helping us learn how a system works.• People are naturally more inclined toward skill-based functioning, rather than more slow and laborious knowledge-based functioning. This influences the types of human errors which occur.• There will almost always be a competing tradeoff between safety and other goals such as production, performance, profit, etc. Safety is therefore usually under continual pressure and requires continual mindful vigilance. At the same time, too much emphasis on safety can impede operation of a system to the point where the system becomes no longer viable, so proper balance is needed.• In developing safety metrics, it should be noted that rates of minor incidents are not necessarily correlated with rates of major incidents. Sometimes, there can be even be an opposite correlation between the two, such that major incidents occur after a period of declining rate of minor incidents.• Due to complexity, uncertainties, limited resources, tradeoffs, and human fallibility, it is generally not possible to reduce incident rates to zero.

Hmmm ... not what I thought. I was expecting an updated edition of the previous classic. Instead, this is a collection of case studies without much of the theory in the original book. Not helpful for teaching a class.