Managing the Risks of Organizational Accidents¶
Reason, J. (1997). Managing the Risks of Organizational Accidents. Ashgate.
Cited by¶
16 citations across 16 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.
Supported in partVerified against the work's full text
The publisher's description supports Reason's cross-domain accident framework but not the claim that his framework is this five-part containment structure.
“James Reason deals comprehensively with the prevention of major accidents arising from human and organizational causes. He argues that the same general principles and management techniques are appropriate for many different domains.”
- 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.
Supported in partVerified against the publisher's abstract
Publisher description supports defences-in-depth for major accidents including air transport, not the survivable-failures or CRM and checklist specifics.
“Major accidents are rare events due to the many barriers, safeguards and defences developed by modern technologies.”
- 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.
Domain-specific¶
- Active Failure
- Reason's framework was developed initially in the nuclear and aviation safety domains and subsequently became standard across healthcare quality, maritime safety, and financial operations risk
Supported in partVerified against the work's full text
“domain-related events using a common classificatory {{{framework}}}. This reveals patterns of cause and effect that”
- Reason's framework was developed initially in the nuclear and aviation safety domains and subsequently became standard across healthcare quality, maritime safety, and financial operations risk
- Latent Condition
- In James Reason's organisational-accident model the term names the upstream, blunt-end stratum of causation: the conditions are laid down by designers, managers, and policy-makers far from the sharp end in both time and organisational distance, and they sit embedded in the system's defence layers as pre-positioned holes
This sourceReason's organisational-accident model, in which latent conditions are the upstream, blunt-end stratum set against sharp-end operators. Reason's worked nuclear examples, including the removal of successive defence layers at Chernobyl, as illustrations of upstream latent conditions.
Supported in partVerified against a saved copy of the source
“the human-system interface—the front-line or ‘{{{sharp}}}-{{{end}}}’ personnel. Latent conditions, on the other hand”
- In James Reason's organisational-accident model the term names the upstream, blunt-end stratum of causation: the conditions are laid down by designers, managers, and policy-makers far from the sharp end in both time and organisational distance, and they sit embedded in the system's defence layers as pre-positioned holes
Mechanisms¶
- Accountability Chain Review
- Its natural anchor is the sharp end and blunt end,
This sourceDistinguishes sharp-end operators at the point of hazardous work from the blunt-end organizational context that shapes resources, constraints, and priorities.
- Its natural anchor is the sharp end and blunt end,
- 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.
- Catastrophic Case Protocol
- Well-built, it layers independent safeguards so no single failure is decisive — the logic of defense in depth.
This sourceDescribes organizational accidents as penetrating successive defensive layers, so multiple safeguards prevent any single failure from becoming decisive.
- Well-built, it layers independent safeguards so no single failure is decisive — the logic of defense in depth.
- 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
- Near-Miss Reporting System
- The guarding concept is a just culture — Reason's distinction between honest error, which is protected and learned from, and recklessness, which is not — because a system that punishes error kills its own signal, and one that excuses everything loses accountability.
This sourcePresents a just culture as protecting and learning from honest error while retaining accountability for culpable or reckless conduct, thereby sustaining candid reporting.
- The guarding concept is a just culture — Reason's distinction between honest error, which is protected and learned from, and recklessness, which is not — because a system that punishes error kills its own signal, and one that excuses everything loses accountability.
- No-Retaliation and Follow-Up Protocol
- Its strength is that it operationalizes just culture
This sourceTreats a just culture as part of an informed safety culture that depends on trustworthy reporting rather than indiscriminate blame.
- Its strength is that it operationalizes just culture
- Organizational Culture Shaping
- Leadership owns the shift — it dies the moment a senior captain visibly punishes a challenge — and the airline watches its safety-report volume as a signal: rising reports of near-misses mean the culture is working, because people feel safe naming them.
This sourceExplains that a reporting culture depends on people being prepared to report errors and near misses under organizational handling of blame and punishment.
- Leadership owns the shift — it dies the moment a senior captain visibly punishes a challenge — and the airline watches its safety-report volume as a signal: rising reports of near-misses mean the culture is working, because people feel safe naming them.
- Repair or Reentry Reflection
- Instead the organization runs a repair-and-reentry reflection under a just-culture frame.
This sourceIdentifies a just culture as a component of an informed organizational safety culture.
- Instead the organization runs a repair-and-reentry reflection under a just-culture frame.
Verification¶
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Links previously used in the corpus¶
Before the registry existed this work was also linked 7 other ways.
- https://www.routledge.com/Managing-the-Risks-of-Organizational-Accidents/Reason/p/book/9781840141054 ×4
- https://www.routledge.com/Managing-the-Risks-of-Organizational-Accidents/Reason/p/book/9781840141047 ×3
- https://doi.org/10.4324/9781315543543/managing-risks-organizational-accidents-james-reason ×2
- https://www.routledge.com/Managing-the-Risks-of-Organizational-Accidents-1st-Edition/author/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://search.worldcat.org/title/803620333 ×1
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