Wednesday, March 17, 2010

Dr. James Reason on Error Management

This podcast is excerpted from an interview of Dr. James Reason in association with VoiceMap (, a provider of live guidance applications to improve human performance.  In this first segment, Dr. Reason discusses his theory of how errors occur (person based and system based) including the existence of "error traps" within an organizational system.  Error traps are evident when different people make the same error, indicating some defect in the management system, such as something as simple as bad or ambiguous procedures.  

I believe error traps may also exist due to a more intangible conditions such as conflicting priorities or requirements on staff that may create a bias toward compromise of safety priorities.  The conditions act as a trap or decision "box" where safety compromise is either viewed as "okay" or the only viable response and even well intentioned people can be subverted.  In contrast, the competing priorities may just appear to be boxes and allow a lax person to compromise safety.  The bias toward compromising safety may actually originate in people who are predisposed to making the error, making it not a system-based error trap but a personal performance error.  How should the errors in reporting at Vermont Yankee be characterized?

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