Making Sense of Reason: A review of the message James Reason put forward for a re-think of Safety Management Principles

摘要

Mention the author James Reason and most industrial safety professions could draw and describe the "Swiss Cheese Model" and its barriers of protection; they can also quote examples of its use and perhaps have a view of the model's effectiveness and drawbacks. What most audiences concentrate on is that the model which is discussed in Chapter 1 of Reason's, Managing the Risk of Organizational Incidents [1] and not the remaining chapters. Subsequently, "Reason draws on the work of other authors, and how awareness of the operating consequences of action is more important that causes of error. It is the intention of this paper to review these later chapters, in particular in the light of current trends that promote Risk Management, Incident Recording and Lead/Lagging Indicators as the "new direction in safety management". Instead, Reason suggests to us that we need to encompass more of general management principles in the way that we think about safety in the work place and it is suggested here that perhaps we should be using the analogy of moving from Quality Control to Quality Assurance. This is a move away from the Engineering model and its linear solutions, to an Organizational Model where responsibility lies with the Individual rather than the System which is still the current trend. It will draw on case studies to demonstrate that this alternative approach may have validity.