Managing the Risks of Organizational Accidents¶
Reason, J. (1997). Managing the Risks of Organizational Accidents.
Cited by¶
8 citations across 8 artifacts.
Each citation links to the sentence it supports in the citing article.
Primes¶
- Counterfactual Proximity Weighting
- In the aviation case the agent is the safety organisation; the realised outcome is a non-event (no crash); the nearby counterfactual is the catastrophe just avoided (a runway incursion that came within seconds of collision); the proximity measure is causal-chain branching — how few failures separated the non-event from disaster; and the internal signal is the weight that incident enters in the risk register.
This sourceDevelops the organizational-accident and near-miss reporting framework in which non-events one step from catastrophe are entered into the safety register by causal proximity.
- In the aviation case the agent is the safety organisation; the realised outcome is a non-event (no crash); the nearby counterfactual is the catastrophe just avoided (a runway incursion that came within seconds of collision); the proximity measure is causal-chain branching — how few failures separated the non-event from disaster; and the internal signal is the weight that incident enters in the risk register.
- Escape and Leakage
- The framework compresses a large space of domain-specific containment problems (disease, pollution, data, fluid, knowledge, energy) into a unified structure: identify the desired quantity, the containment boundary, the pressure gradient driving escape, the available pathways, and the acceptable leakage rate—the same cross-domain organizational-accident framework Reason (1997) develops in Managing the Risks of Organizational Accidents.
This sourceAshgate. Cross-domain organizational-accident framework unifying safety analysis across aviation, nuclear, healthcare, and process industries into a single structure of pathways, defenses, latent conditions, and acceptable risk thresholds, enabling cross-domain transfer of leakage-management techniques.
- The framework compresses a large space of domain-specific containment problems (disease, pollution, data, fluid, knowledge, energy) into a unified structure: identify the desired quantity, the containment boundary, the pressure gradient driving escape, the available pathways, and the acceptable leakage rate—the same cross-domain organizational-accident framework Reason (1997) develops in Managing the Risks of Organizational Accidents.
- Loss And Damage
- In industrial safety, the defenses-in-depth model assumes every layer has holes, and the events that get through all of them constitute the residual budget that root-cause analysis chases.
This sourcePresents the defence-in-depth / 'Swiss cheese' model in which every layer has holes and accidents are the residual events that pass through all layers.
- In industrial safety, the defenses-in-depth model assumes every layer has holes, and the events that get through all of them constitute the residual budget that root-cause analysis chases.
- Near-Miss Normalization
- In aviation, minor altitude deviations, unstable approaches, and runway incursions accumulate without being treated as harbingers, and the next event in the same envelope is the one with a different outcome.
This sourceDevelops the latent-condition / defense-in-depth (Swiss-cheese) model and the role of near-misses as warnings of eroding margin in high-hazard operations; foundation for treating close calls as margin signals rather than reassurance.
- In aviation, minor altitude deviations, unstable approaches, and runway incursions accumulate without being treated as harbingers, and the next event in the same envelope is the one with a different outcome.
- Normalization of Deviance
- Long mean-time-between-failure plus high local autonomy plus weak external audit predicts active deviance normalization, regardless of substrate — a structural forecast from a few system parameters.
This sourceEstablishes how latent organizational conditions - long failure latencies, local autonomy, weak audit/defenses - accumulate undetected behind the "Swiss cheese" of degraded barriers, and how external audit and defense-in-depth re-anchor an organization's eroding safety standard.
- Long mean-time-between-failure plus high local autonomy plus weak external audit predicts active deviance normalization, regardless of substrate — a structural forecast from a few system parameters.
- Swiss Cheese Model (Layered Defense with Aligning Holes)
- In aviation safety, the model makes sense of crashes where each individual failure was survivable but the combination was lethal, with crew resource management, checklists, and interlocks as layers.
This sourceDevelops the Swiss cheese model of defenses-in-depth, holes (active failures and latent conditions), and accident trajectories through aligned holes.
- In aviation safety, the model makes sense of crashes where each individual failure was survivable but the combination was lethal, with crew resource management, checklists, and interlocks as layers.
Mechanisms¶
- After-Action Loss Feedback Review
- Done in a just-culture frame, where reporting is protected from punishment, it surfaces the honest causal account the fixes depend on.
This sourceFrames just culture as protecting candid reporting of honest errors so organizations can learn from causal accounts and improve safety.
- Done in a just-culture frame, where reporting is protected from punishment, it surfaces the honest causal account the fixes depend on.
- Incident and Near-Miss Review
- Its failure modes are well known — a blame culture suppresses the very reports the method feeds on
This sourceLinks a reporting culture to employees' confidence that they can report safety concerns without fear of blame.
- Its failure modes are well known — a blame culture suppresses the very reports the method feeds on
Verification¶
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Links previously used in the corpus¶
Before the registry existed this work was also linked 5 other ways.
- https://www.routledge.com/Managing-the-Risks-of-Organizational-Accidents/Reason/p/book/9781840141047 ×2
- https://www.taylorfrancis.com/books/mono/10.4324/9781315543543/managing-risks-organizational-accidents-james-reason ×2
- https://archive.org/details/managingrisksofo0000reas ×1
- https://www.routledge.com/Managing-the-Risks-of-Organizational-Accidents-1st-Edition/author/p/book/9781840141047 ×1
- https://www.routledge.com/Managing-the-Risks-of-Organizational-Accidents/Reason/p/book/9781840141054 ×1
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