Looking back - Chapter 14

Recap

Looking back on everything we learned from this book, starting in James Reason’ kitchen when he was making tea and it ended with health care and the court of law. Together with many institutions that passed by, there was also paid attention to different continents. Two things were discovered while doing research on this topic: learn as much as possible about the details of how people in these various domains work and never be judgemental.

James Reason has been employed full-time by two universities: the University of Leicester and the University of Manchester. He also mentions his mentors: Jens Rasmussen, Donald Broadbent, Don Norman and Berndt Brehmer. During the period between 1970s and 1980s he was busy with creating classifications between the varieties of unsafe acts. One of the earliest classifications is the one mentioned below:

• Slips and Lapses vs. Mistakes
• Rule-Based and Knowledge-Based Mistakes
• Errors and Violations
• Active vs. Latent Human Failures

Some distinctions

At lot of the last distinction was inspired by the observations of Mr. Justice Sheen, regarding the capsize of the Herald of Free Enterprise (a ship). Some of the latent failures regarding the capsize were: insufficient ballast pumps, no remote bridge indicators and inadequacy of the scuppers and inadequate checking of the passengers aboard.

The distinction between active and latent failures is based upon the length of time before the failures have a bad outcome, and where in the organization the failures occur. Those in direct contact with “the system” commit active failures, these failures have an immediate short-lived impact. Latent failures have a delayed effect that can be going on for years and are committed by those who are less close to the system (higher-up).