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Resilience Weekly - The contribution of a latent human failures to the breakdown of complex systems - Issue #11

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Welcome back! This week we are discussing another article from the same issue of the philosophical t
 
November 26 · Issue #11 · View online
Resilience Roundup
Welcome back!
This week we are discussing another article from the same issue of the philosophical transactions of the Royal Society. This one is by Dr. Reason titled “the contribution of a latent human failures to the breakdown of complex systems” which Dr Cook points out became the book “Human Error” that Reason released the same year.
Unfortunately I wasn’t able to find a copy of this paper that wasn’t behind somewhat of a pay wall. Though I was able to locate it in JSTOR which allows a few articles a month with a free membership.  So if you click through and want to read it for yourself, you’ll need to register for a free account.
Please note that JSTOR gives articles like this out in an image format that isn’t screen reader friendly and doesn’t seem especially high-res for OCR.  Please just hit reply and let me know if it would help for me to read this article and record it.
Estimated reading time: ~12 min

The Contribution of Latent Human Failures to the Breakdown of Complex Systems
Reasons Figure 1 (a digram made of overlapping, labeled rectangles labeled "Falliable Decisions", "Line Management", "Line Management Deficiencies", "Psychological Precursors of Unsafe Acts", "Unsafe Acts, and "Inadequate Defences" with a star like symbol representing an accident behind)
Reasons Figure 1 (a digram made of overlapping, labeled rectangles labeled "Falliable Decisions", "Line Management", "Line Management Deficiencies", "Psychological Precursors of Unsafe Acts", "Unsafe Acts, and "Inadequate Defences" with a star like symbol representing an accident behind)
Reason's Figure 1 (A digram showing rectangles labeled labeled "Fallible Decisions", "Line Management", "Line Management Deficiencies", "Psychological Precursors of Unsafe Acts", "Unsafe Acts, and "Inadequate Defences" with lines labeled loop 1 connecting fallible decisions and accidents.  Line labeled loop 2 connecting fallible decisions and unsafe acts.  Line labeled loop 3 connect fallible decisions and psychological precursors of unsafe acts.  Line labeled loop 4 connecting fallible decisions and line management deficiencies.)
Reason's Figure 1 (A digram showing rectangles labeled labeled "Fallible Decisions", "Line Management", "Line Management Deficiencies", "Psychological Precursors of Unsafe Acts", "Unsafe Acts, and "Inadequate Defences" with lines labeled loop 1 connecting fallible decisions and accidents. Line labeled loop 2 connecting fallible decisions and unsafe acts. Line labeled loop 3 connect fallible decisions and psychological precursors of unsafe acts. Line labeled loop 4 connecting fallible decisions and line management deficiencies.)
That’s it for this week! How about you, what do you see as the big takeaways for your work? What about for your organization? Do you recognize your organization across these three modes? Do you see your organization failing or succeeding to fit into these modes as needed?
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