In 1997, James Reason published 'Managing Organizational Accidents'. It was influential in popularizing his concepts around the Swiss Cheese model, his specific brand/recipe of safety (and just) culture, etc. and discussed ever since.
But it also has this line in it just throwing incredible shade:
![Text from a book:
For example, some individuals are considerably more absentminded than others. If the person in question has a previous history of unsafe acts, it does not necessarily bear upon the culpability of the error committed on this particular occasion, but it does indicate the necessity for corrective training or even career counselling along the lines of 'Don't you think you would be doing everyone a favour if you considered taking on some other job within the company?'. This is the way that management acquires some of its most distinguished members. Absentmindedness has nothing whatsoever to do with ability or intelligence, but it is not a particularly helpful trait in a pilot or control room operator.
[...]
"This is the way management acquires some of its most distinguished members" is manually highlighted and a '!!' is in the margin.](https://cdn.bsky.app/img/feed_thumbnail/plain/did:plc:uvdyep6dqes5eqb3ge5caa4n/bafkreiav6alzq2q3ziqatak2ufewr4qmw6kmhodxlqm66ngpgzj2af5hvq)
![What is striking about many accidents in complex systems is that people were doing exactly the sorts of things they would usually be doing the things that usually lead to success and safety. Mishaps are more typically the result of everyday influences on everyday decision making than they are isolated cases of erratic individuals behaving unrepresentatively.
People are doing what makes sense given the situational indications, operational pressures, and organizational norms existing at the time. Accidents are seldom preceded by bizarre behavior. People's errors and mistakes (such as there are in any objective sense) are systematically coupled to their circumstances and tools and tasks. [...] What people do makes sense to them at the time—it has to, otherwise they would not do it. People do not come to work to do a bad job; they are not out to crash cars or airplanes or ground ships. The local rationality principle says that people do things that are reasonable, or rational, based on their limited knowledge, goals, and understanding of the situation and their limited resources at the time. […] failures are baked into the nature of people's work and organization; that they are symptoms of deeper trouble or by-products of systemic brittleness in the way business is done. It means having to find out what people did back there and then actually make sense of it given the organization and operation that surrounded them.
To explain outcome failure, it is necessary to convert the search for human failures into a search for human sensemaking. The question is not "where did people go wrong?" but "why did this assessment or action make sense to them at the time?" Such real insight is derived not from judging people from the position of retrospective outsider, but from seeing the world through the eyes of the protagonists at the time. When looking at the sequence of events from this perspective, a very different story often struggles into view.](https://cdn.bsky.app/img/feed_thumbnail/plain/did:plc:uvdyep6dqes5eqb3ge5caa4n/bafkreifuhqje4o33lps7fvkgpqpa2is47szke3nmu54vqqff7aa324inia)
![Our western morality here emanates from an essential schizophrenia that derived from the concept of a munificent but omnipotent deity. [...] [Law as Western moralisty] has a vested interest in the status quo and so no great concern for changing it. Thus, CSE may be embraced by science and some limited segments of the business community but has yet to exert any proportionate social and moral impact because of the intransigence of the identified inertial institutions. [...]
5.9 CONCLUSIONS
As a result of the historical antecedents, which in the western world have divided process from purpose, our present circumstances generate complex work systems of great technological sophistication but erected upon ethical bases that are implicit, inconsistent, incomplete, and ultimately inoperable. Utilitarian, patchwork moral principles, derived from a dissolving base of religious dogma, are now morphing into ad hoc, secular legal arcana whose appeal to various poorly defined and developed human delusions, such as the notion of error, free will, and the omnivorous drive for greater efficiency, continues to subserve the dominant segment of profit-based capitalism (and polemically, see Dawkins 2009). [...]
Moral relatively has to be recognized, yet contemporary pragmatism employs and emphasizes an "as if" policy such that the search for moral certitude continues. Like error itself, morality is a convenient illusion that helps sustain societies in their necessary collective delusion. Morality is an intimate part of the narrative that we have always told ourselves (Homer 735 BC). [...]. Morality expresses social approbation and disapprobation and CSE subserves these moral goals (as well as other forms of purpose). What is good or bad, correct or incorrect are collective interpretations (most often after the fact) that support the individual and collective narrative that we have chosen as our conduit to collective reality (and, of course, see Nietzsche 1886).](https://cdn.bsky.app/img/feed_thumbnail/plain/did:plc:uvdyep6dqes5eqb3ge5caa4n/bafkreihnt3udlpqfp7szx7j5w2fai5xyubsgce3khgsqvypkss5bh5wq3i)
![Table 2: Criteria for good decision support, based on the 10 'cardinal decision issues' [Yates and Potworowski, 2012]
Options: Help to identify options, as well as help to narrow down the list of feasible or realistic options
Possibilities: Help to to identify possible outcomes for each of the identified options
Judgement: Help to judge which outcomes are most likely
Value: Help to identify the positive and negative impacts on stakeholders for each of the identified options
Trade-offs: Help to make trade-offs on the above criteria for each options
Understandable: Help to understand how and why the tools works as it does, and when it fails](https://cdn.bsky.app/img/feed_thumbnail/plain/did:plc:uvdyep6dqes5eqb3ge5caa4n/bafkreiazm75pzau4b7crjsdywvgbnoqf4kot7g5hacrset4irzzxw2j75y)
![I was once asked by a mining company CEO to take safety culture soundings [...]. I was told I could stop mining in order to talk to workers if I wanted to. So, at one mine, I asked that the whole operation be stopped in order to talk to miners at the face. [...] On arrival back at the surface, I was greeted by the mine manager who [...] went on to tell me quite aggressively that the stoppage I had requested had cost $20,000 worth of production. I was shocked. If he was willing to speak in this way to me, a representative of the CEO, it would be a very brave miner who tried to stop production for safety reasons. I am reminded of the work of the sociologist, Harold Garfinkle (1967). He suggested that the be He suggested that the best way to understand the rules that are implicitly operating in a social order is experimentally to disrupt them. The manager's reaction to my disruption of his social order demonstrated the power of the production imperative operating at his mine.](https://cdn.bsky.app/img/feed_thumbnail/plain/did:plc:uvdyep6dqes5eqb3ge5caa4n/bafkreiejrqsqdo3e7iizkt3566gg6fu7p2mzcizj3b3pnxl54xbjpbppem)
