Show Notes
In this special episode of the Pre-Accident Investigation Safety Podcast, hosted by Todd Conklin, we take a moment to honor the legacy of James Reason, a prominent figure in the field of safety and human error study, who passed away on February 5th, 2025. James Reason revolutionized the way we understand human errors, particularly in complex systems, with groundbreaking concepts such as the Swiss cheese model and the theory of a just culture.
Listen as we delve into the life and contributions of James Reason, from his early conversations that expanded our understanding of organizational accidents to his influence in various sectors, including healthcare and aviation. Featuring a special tribute from David Woods, this episode reflects on Reason's enduring impact and challenges us to continue advancing in the world of safety and reliability.
Join us in remembering a man whose work has profoundly shaped the foundation of modern safety practices. In a unique tribute, we invite you to enjoy a sandwich with Swiss cheese, a nod to Reason's famous model, and reflect on his contributions to the field. Thank you, James Reason, for your remarkable influence on safety and human error research.
Show Transcript
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Music.
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Hey, everybody. Todd Conklin, Pre-Accident Investigation Safety Podcast.
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And this is kind of a special podcast.
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In fact, it's even noted as a special podcast because this week was a sad week
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for a really profound reason.
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And that is on Wednesday of this week, the 5th of February, 2025,
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James Reason passed away.
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And it's hard to do the work we do at any level without thinking of the people who went before us.
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And it was so interesting because to have that thought, many names come into place.
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Richard Cook, remarkable people, Jim Howe, and of course, James Reason.
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And James Reason did things for us that we would not be having these conversations.
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We would not even be close to having these conversations without James Reason
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having some conversations early on.
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And so I think it's worthwhile for us to take a moment and sort of think about
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where we've come from in order to understand where we're going to.
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And James Reason passing is a pretty important moment in the stories that we tell.
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James T. Reason was born on the 1st of May, 1938, and he was a professor of
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psychology at the University of Manchester.
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He graduated University of Manchester in 1962, and he was a tenured professor from 77 to 2001.
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What he's probably most famous for are the works he did and specifically his books on human error,
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including such aspects as absent-mindedness or aviation human factors, maintenance error,
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risk management, to look at organizational accidents.
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And these are all terms, this is amazing to me because he coined many of these
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ideas. the idea of an organizational accident, of a systems accident, was really new.
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In 2003, he was awarded an honorary doctor of science by the University of Aberdeen.
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He was a fellow in the British Academy, the British Psychological Society,
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the Royal Aeronautical Society, and the Royal College of General Practitioners.
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He received his CBE in 2003 for his services in the reduction of the risks in health care.
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And in 2011, he was elected an honorary fellow of the Safety and Reliability Society.
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Among the multitude of contributions, one of the things James Reason introduced
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was the Swiss cheese model.
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And if you followed any recent journalism now,
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you're hearing everybody talk about the Swiss cheese model, a conceptual framework
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for the description of accidents based upon the notion that accidents will happen
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only if multiple barriers fail.
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Thus creating a path from an
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initiating cause all the way to the ultimate and unwanted consequence such as
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harm to people or assets or the environment reason also described the first
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fully developed theory of a just culture in his 97 book managing the risks of
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organizational accidents.
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We'll miss Jim a lot because Jim always started out, as David Woods told me, fighting the zombies.
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And there are more zombies now than probably ever before.
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But the path he cut, the swath that he laid, made it possible for the rest of
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us to do the work and have the ideas and think the things that we think.
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He's made the world a better place.
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And I just happened to be talking to David Woods from the Ohio State University,
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the Center for Resilience Engineering.
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And I asked David, what legacy Jim Reason will leave the world?
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And this is his response. Listen carefully, because he told us this just for us.
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So this is David Wood's tribute to Jim Reason.
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Music.
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So I think there are many, many things.
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One is that he was part of a group who created modern safety.
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Not in any specific thing they did, but in the enterprise, the line of inquiry they started.
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It started in 1980, and I got to join directly, intimately with it in 1983 at the Bellagio meeting.
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Not Las Vegas, the real Bellagio.
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And I should show you a picture of Eric and I there when we were young and handsome.
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And I could talk all day while running.
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And as what would happen in those days is we'd have this elegant,
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multi-course European dinner at the villa, and then I'd go, great,
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that was a wonderful appetizer. I need some food.
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Let's go down to the town and eat dinner now. Yeah.
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But anyway, it was an enterprise that was started. Richard Cook and I called
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it the new look behind human error.
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Later, you know, in many ways got called Safety 2 by Eric.
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Again, trying to move people forward, but also running the risk of it being
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as a compromise breaking down.
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But the momentum built and grew and more stuff happened.
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And yeah, not as concentrated and following a single path.
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But often it was multi-path discovery about the nature of surprise,
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how accidents were impossible.
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They were normal because of the
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complexities. All of them highlighting fundamental points underneath it.
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We now see the nature of their fundamentalness more clearly because of the progress that went on.
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So Jim was central in the way he worked, the way he worked with people,
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not because we were always right or he was always right, but because we produced
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the energy and persistence in the face of all the pressures to compromise,
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all the things, but it's just a human's error.
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We don't have to change the system. We don't have to do things differently.
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We can ignore the systemic factors that matter.
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And and so we've built up cases success
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stories techniques now we
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haven't organized them we've talked about a field guide because we've made so
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much progress from people like jim so that's the first point is he and others
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and i've gone back looking at the pictures from 83 looking for somewhere there's
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a picture of the 80 meeting of which was a clam bake on a beach in Maine.
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And the people who initiated this line of inquiry, you know,
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it is funny, sometimes in these things, there really is an origin point,
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despite multiple influences.
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And this was the Clambake meeting in 1980 that started things going,
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you know, just like resilience engineering started because NASA had accidents
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in 1999, and they didn't rationalize it away as human error.
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They said it was a systemic factor of pressure from the faster,
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better, cheaper pressure led, you know, successful managers to cut what didn't
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to be efficient, which turned out,
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as Eric put it later, not to be thorough.
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Right? What's not to be thorough?
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Shortcuts, right? The shortcuts look good, like, and it turned out they were
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undercutting important things that contributed, right?
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And how did they contribute? you this is the second thing this is what jim pointed
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out in the in the mid to late 80s and it first appeared in the 1990 book in
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last or second to last chapter.
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Which is easily summarized as, right, accidents happen due to multiple contributors,
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each necessary but only jointly sufficient.
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And many of those contributors were present in the system for a much longer
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period of time prior to the trigger and the immediate sequence of events that led to the accident.
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And you can see that, for example, in the BP accidents of Deepwater Horizon
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in Texas City, that you can see that.
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Jim saw it in the Herald of Free Enterprise ferry disaster in Zabrugia Harbor.
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And many people have gone on, again, as we try to use cartoons,
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Swiss cheese, simple metaphors, right?
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Multiple lines of defense still have holes in them. There are gaps to close.
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And misunderstanding the ways that gaps get closed.
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And if you don't understand how gaps are getting closed locally,
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it may turn out that closing one gap exposes you to others.
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Or closing one gap means the system doesn't fail or give the evidence of potential
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failure. So everybody thinks the system's working when it's full of holes.
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Richard and I wrote the gaps paper in 2000, And, you know, again,
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trying to highlight the key point that this, you know, that goes that that arose
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in the late 80s due to Jim and others work.
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And guess where we are now? We now have theorems about this that say the messiness
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is inherent in this universe.
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It will have gaps. No matter the successes you have, no matter the advances
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you bring to bear, new gaps will move.
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Gaps will move around. Surprises will recur.
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Snafu is a natural part of this universe.
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And snafu catching is essential. Now, that can go on in local ad hoc ways,
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or that can be synchronized, coordinated, and empowered in our systems and organizations.
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If you leave it local and ad hoc, you're going to end up with systems that are
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competent but brittle, where these hidden local sources of adaptive capacity
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keep the system working.
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And so you think the system is more effective than it really is, right?
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Or competent and extensible, which provisions the system to be responsive in
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the face of new challenges and change.
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Why does this happen? We now have the basics for why this is.
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We can prove these things in the most powerful sense of the word prove, right?
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Finite resources are always the case. Sometimes we try to hide that,
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but in the end, finite resources always constrict what we do.
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It means there's trade-offs.
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Change never stops. It may seem quiescent for a bit, but the world will start again.
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Change will come forward.
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And three, others are there, too, who are adapting. And what are they adapting to? Our successes.
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In other words, one of the drivers of change, adaptation, and the need for extensibility is success.
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As you deploy new capabilities, right, to build competence, what do you do?
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You scale up systems. They grow.
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Interdependencies grow. Others adapt. And so, you know, this is something that
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you can look at in the two videos.
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One is called Growth and Complexification. and you can look at it in the example
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of the rise of high-frequency trading.
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And then what goes with that is a new one we just put out, which uses George
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Box's old line, all models are wrong, some models are useful.
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And I run through how people compromised his insights, his challenge, right?
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And they rationalized in a bunch of ways, They say, yes, models are limited
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but valuable, but the limits don't really matter now, or the limits only matter occasionally.
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What matters is how much more valuable it is than it used to be,
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how much more powerful it is.
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And the world's basically the same. And the answer is, no, it's not.
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You produce growth, and growth produces complexification.
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And these factors kick in, producing new kinds of surprises and new demands for extensibility.
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And so I end it with the new version of Box's original line.
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And I won't give away the punchline to the video. It's only 16 minutes long.
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And it's beautifully done. It's really a great video.
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What do you think James Reason's lasting legacy will be?
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And would he be happy with that? So first,
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I feel very confident that he rested easy in his last illnesses,
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that he had made a difference,
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that he had fought the battles to grow safety, to create safety,
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and that he had an impact,
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that he had made a difference.
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And over his, the life that began,
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I mean, because it was a complete change in the direction of his research and
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activity that began in 1980 and continuing in 83 when I first met him and on,
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that that period of his life really made a positive difference in healthcare,
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oil and gas, and other places.
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On the other hand, remember, The battles don't stop. We have to refight them.
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The human tendencies to oversimplify, to linearize, to defer,
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the pressures now that are real.
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To be effective and efficient right now in order to be competitive,
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in order to meet expectations of other roles and parties who have power and authority.
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All of these tend to simplify how this world really works.
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And so I think the difference is he started a process that hopefully fought
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successfully but did not end the need to fight on.
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And that we now have reached a new phase in honor of his and others' legacy
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in that journey, which is we now have solid foundations, right?
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And we can challenge, but that requires a cadre of people who understand what's fundamental.
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And in that, they can see a range of compromise around how to use those fundamentals
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now and how to use them in different contexts, given various pressures and constraints,
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without compromising on the fundamental, right?
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You can't compromise on the fundamental. You can compromise on how you bring
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the fundamental point to bear.
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That's the difference.
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So that's the impression that david woods has
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and really since i asked him what he offered us and i can't not think that the
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most important tribute you can have from one of your peers is the realization
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that your life's work has made a difference i mean i wish that for all of us every single one of us.
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I hope we all feel that way. That's remarkable.
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Take some time, think about all the work you do, and then think about how important
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James' reason was to that work.
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And do me a favor. This is kind of a special favor, but at some point in the
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next week or two, have a sandwich that has Swiss cheese on it.
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I can think of no better tribute at all than that.
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Because James Reason introduced the idea of Swiss cheese and then throughout
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his career lived with that idea of Swiss cheese.
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And it's an important model for an introduction into the way we think to the world.
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It's a compromise for sure, as Dave Woods would say.
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But what better tribute you can have than to enjoy a sandwich with Swiss cheese.
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Thank you, James Reason. You made a huge difference, and I appreciate you greatly.
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Learn something new every single day. Have as much fun as you possibly can.
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Be good to each other. Be kind to each other. Check in on one another.
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And for goodness sakes, be safe. Thanks, Uncle Jim.
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Music.
