{"id":4042,"date":"2024-07-11T21:22:06","date_gmt":"2024-07-11T21:22:06","guid":{"rendered":"https:\/\/crmknowledgehub.com\/?p=4042"},"modified":"2024-07-11T21:22:07","modified_gmt":"2024-07-11T21:22:07","slug":"james-reasons-12-principles-of-error-management","status":"publish","type":"post","link":"https:\/\/crmknowledgehub.com\/index.php\/2024\/07\/11\/james-reasons-12-principles-of-error-management\/","title":{"rendered":"James Reason’s 12 Principles of Error Management."},"content":{"rendered":"\n

James Reason<\/a>, Professor Emeritus,\u00a0University of Manchester<\/a>,\u00a0set out 12 systemic\u00a0human factors centric principles of error management in his book\u00a0Managing Maintenance Error: A Practical Guide<\/a>\u00a0(co-written with Alan Hobbs and published in 2003). These remain guiding principles in aviation.<\/strong><\/p>\n\n\n\n

Source: Aeroassurance<\/a><\/p>\n\n\n\n

James Reason\u2019s 12 Principles <\/strong><\/h4>\n\n\n\n

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  1. Human error is both universal & inevitable:<\/strong>\u00a0<\/em>Human error is not a moral issue.\u00a0\u00a0Human fallibility can be moderated but it can never be eliminated.<\/li>\n\n\n\n
  2. Errors are not intrinsically bad:<\/strong>\u00a0<\/em>Success and failure spring from the same psychological roots.\u00a0 Without them we could neither learn nor acquire the skills that are essential to safe and efficient work.<\/li>\n\n\n\n
  3. You cannot change the human condition, but you can change the conditions in which humans work:<\/strong>\u00a0\u00a0<\/em>Situations vary enormously in their capacity\u00a0for provoking unwanted actions.\u00a0 Identifying these error traps and recognising their characteristics are essential preliminaries to effective error management.<\/li>\n\n\n\n
  4. The best people can make the worst mistakes:<\/strong>\u00a0No one is immune! The best people often occupy the most responsible positions so that their errors can have the greatest impact\u2026<\/li>\n\n\n\n
  5. People cannot easily avoid those actions they did not intend to commit:<\/strong>\u00a0<\/em>Blaming people for their errors is emotionally satisfying but remedially useless.\u00a0 We should not, however, confuse blame with accountability.\u00a0 Everyone ought to be accountable for his or her errors [and] acknowledge the errors and strive to be mindful to avoid recurrence.<\/li>\n\n\n\n
  6. Errors are consequences not causes<\/strong>:\u00a0<\/em>\u2026errors have a history.\u00a0 Discovering an error is the beginning of a search for causes, not the end.\u00a0 Only be understanding the circumstances\u2026can we hope to limit the chances of their recurrence.<\/li>\n\n\n\n
  7. Many errors fall into recurrent patterns:<\/strong>\u00a0<\/em>Targeting those recurrent error types is the most effective way of deploying limited Error Management resources.<\/li>\n\n\n\n
  8. Safety significant errors can occur at all levels of the system:<\/strong>\u00a0<\/em>Making errors is not the monopoly of those who get their hands dirty.\u00a0 \u2026the higher up an organisation an individual is, the more dangerous are his or her errors.\u00a0 Error management techniques need to be applied across the whole system.<\/li>\n\n\n\n
  9. Error management is about managing the manageable:<\/strong>\u00a0<\/em>Situations and even systems are manageable if we are mindful.\u00a0 Human nature \u2013 in the broadest sense \u2013 is not.\u00a0 Most of the enduring solutions\u2026involve technical, procedural and organisational measures rather than purely psychological ones.<\/li>\n\n\n\n
  10. Error management is about making good people excellent:<\/strong>\u00a0<\/em>Excellent performers routinely prepare themselves for potentially challenging activities by mentally rehearsing their responses to a variety of imagined situations.\u00a0 Improving the skills of error detection is at least as important as making people aware of how errors arise in the first place.<\/li>\n\n\n\n
  11. There is no one best way:<\/strong>\u00a0<\/em>Different types of human factors problem occur at different levels of the organisation and require different management techniques.\u00a0 Different organisational cultures require different \u2018mixing and matching\u2019\u2026.of techniques.\u00a0 People are more likely to buy-in to home grown measures\u2026<\/li>\n\n\n\n
  12. Effective error management aims as continuous reform not local fixes:\u00a0\u00a0<\/strong><\/em>There is always a strong temptation to focus upon the last few errors \u2026but trying to prevent individual errors is like swatting mosquitoes\u2026the only way to solve the mosquito problem is drain the swamps in which they breed.\u00a0 Reform of the system as a whole must be a continuous process whose aim is to contain whole groups of errors rather than single blunders.<\/li>\n<\/ol>\n\n\n\n

    Error management has three components, says Reason:<\/p>\n\n\n\n

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    1. Reduction<\/li>\n\n\n\n
    2. Containment<\/li>\n\n\n\n
    3. Managing these so they remain effective<\/li>\n<\/ol>\n\n\n\n

      Its the third aspect that is most challenging according to Reason:<\/p>\n\n\n\n

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      It is simply not possible to order in a package of Error Management measures, implement them and then expect them to work without further attention\u00a0 You cannot put them in place and then tick them off as another job completed.\u00a0 In an important sense, the process \u2013 the continuous striving toward system reform \u2013\u00a0<\/em>is\u00a0the product.<\/em><\/a><\/p>\n<\/blockquote>\n\n\n\n

      Further Reading on Safety (UPDATED)<\/strong><\/h4>\n\n\n\n

      The UK Civil Aviation Authority (CAA<\/a>) has commented<\/a> that:<\/p>\n\n\n\n

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      Human Factors training alone is not considered sufficient to minimise maintenance error. Most of the [contributing factors] can be attributed to the safety culture and associated behaviours of the organisation.<\/p>\n<\/blockquote>\n\n\n\n

      Two other books by James Reason are also worth attention:<\/p>\n\n\n\n