James (Jim) Reason Has Passed Away

Jim Reason was not a consultant; he was a researcher and professor, a scientist recognized by his peers. His citation index is worthy of a Nobel Prize. However, he did not revolutionize scientific knowledge or establish an entirely new theory.
In the first, lesser-known part of his academic career, he focused on motion sickness, publishing at the highest level, but soon found the potential applications disappointing. He then shifted his focus to explaining and categorizing “domestic” human error.
In the later phase of his career—the one that made him famous—he again completely redirected his academic work, aligning it with the growing focus on industrial safety. The two decades of the 1970s and 1980s were marked by disasters such as Tenerife, Three Mile Island, Bhopal, Chernobyl, Piper Alpha, and Challenger. The issue of managing the threat posed by “human error” to the safety of high-risk productive organizations had become urgent.

Jim Reason had an extraordinary sense for the pressing issues of his time. He became an expert in “human error” and could have simply capitalized on that. However, after his decisive encounter with Jens Rasmussen, he had the insight to move beyond an accident causality split between technical failure and human failure. He skillfully developed and illustrated an integrated framework, repositioning human reliability within a more systemic vision of safety. To achieve this, he synthesized the creative contributions of scholars such as Norman, Kahneman & Tversky, Leplat, Westrum, Perrow, Weick, Rochlin & La Porte & Roberts, and especially Jens Rasmussen. He was also an active member of the historic and prestigious NeTWork think tank, which is now supported by Foncsi.

Moreover, he had an exceptional talent for popularization. A vigorous yet nuanced writer, sharp yet subtle, literary yet accessible to all, he was a master of brilliant metaphors and an equally clear orator.

So how does Jim Reason’s legacy fit into “modern” industrial safety management? His impact is immense. The distinction between errors and violations, as well as between errors, violations, and faults; the differentiation between slips, lapses, and mistakes; the distinction between latent and active errors; the concept of organizational accidents and their metaphorical representation as slices of “Swiss cheese”; his contribution to the spread of the concept of safety culture—one that he advocated as fair, learning-oriented, and flexible; the numerous event analysis methods inspired by the “Swiss cheese” model (HFACS, ALARM, etc.); and the proactive safety culture diagnostic tools (Tripod Delta, MESH, etc.) based on generic failure type indicators—all of these remain fundamental elements of safety management across various industries worldwide.

From the 2000s onward, industrial safety management shifted toward an increasingly managerial perspective, emphasizing formal management systems (SMS) and leadership (safety leadership) rather than focusing on organizational design, high-level strategies, structures, and resources. The behavior of frontline operators was an object of renewed attention. Jim Reason himself had identified some risks of a shift minimizing operator responsibility, writing in 1997:
“The pendulum may have swung too far in our present attempts to track down possible errors and accident contributions that are widely separated in both time and place from the events themselves.”
He was well aware of the limitations of practitioners’ use of simplified models. He was not dogmatic, always ready to question and refine his ideas, and conscious of the complexity of the relationship between safety performance and management practices.

Meanwhile, in the field of “safety sciences” research, the main development involved expanding the concept of organization (and organizational accidents) into that of complex adaptive sociotechnical systems. In this new paradigm, safety became a matter of adaptation—at different time horizons—to external or internal variations and disturbances affecting the entities in question. Safety became a dynamic and nonlinear concept due to feedback loops and various “butterfly effects” involved. It became difficult to represent it as a succession of static barriers, even if the holes representing failures were to be imagined as moving. Jim Reason himself had invoked the metaphor of immunity to describe safety and often spoke of “pathogens”. However, he did not fully integrate this metaphor, particularly its recursive nature—the idea that defenses themselves are generated by attacks, forming a memory, both innate and acquired, generic and specific, of past threats.

Still, he was well aware of the limitations of his “Swiss Cheese Model”. In 2004, invited by the Eurocontrol Experimental Centre in Brétigny to present a reanalysis of the 2002 Überlingen mid-air collision using his own model, he arrived at the meeting with his characteristic sharp humor and a presentation titled: “Überlingen: Is Swiss cheese past its sell-by date?” He had neither the desire to reanalyze Überlingen nor to discard his modell.

René Amalberti, Director of Foncsi
Jean Pariès, Former Scientific Director of Icsi and Foncsi