This succinct but absorbing book covers the main way stations on James Reason's 40-year journey in pursuit of the nature and varieties of human error. In it he presents an engrossing and very personal perspective, offering the reader exceptional insights, wisdom and wit as only James Reason can. The journey begins with a bizarre absent-minded action slip committed by Professor Reason in the early 1970s - putting cat food into the teapot - and continues up to the present day, conveying his unique perceptions into a variety of major accidents that have shaped his thinking about unsafe acts and latent conditions. A Life in Error charts the development of his seminal and hugely influential work from its original focus into individual cognitive psychology through the broadening of scope to embrace social, organizational and systemic issues. The voyage recounted is both hugely entertaining and educational, imparting a real sense of how James Reason's ground-breaking theories changed the way we think about human error, and why he is held in such esteem around the world wherever humans interact with technological systems. This book is essential reading for students, academics and safety professionals of all kinds who are interested in avoiding breakdowns that can cause serious damage to people, assets and the environment.

Managing the Risks of Organizational Accidents introduced the notion of an 'organizational accident'. These are rare but often calamitous events that occur in complex technological systems operating in hazardous circumstances. They stand in sharp contrast to 'individual accidents' whose damaging consequences are limited to relatively few people or assets. Although they share some common causal factors, they mostly have quite different causal pathways. The frequency of individual accidents - usually lost-time injuries - does not predict the likelihood of an organizational accident. The book also elaborated upon the widely-cited Swiss Cheese Model. Organizational Accidents Revisited extends and develops these ideas using a standardized causal analysis of some 10 organizational accidents that have occurred in a variety of domains in the nearly 20 years that have passed since the original was published. These analyses provide the 'raw data' for the process of drilling down into the underlying causal pathways. Many contributing latent conditions recur in a variety of domains. A number of these - organizational issues, design, procedures and so on - are examined in close detail in order to identify likely problems before they combine to penetrate the defences-in-depth. Where the 1997 book focused largely upon the systemic factors underlying organizational accidents, this complementary follow-up goes beyond this to examine what can be done to improve the 'error wisdom' and risk awareness of those on the spot; they are often the last line of defence and so have the power to halt the accident trajectory before it can cause damage. The book concludes by advocating that system safety should require the integration of systemic factors (collective mindfulness) with individual mental skills (personal mindfulness).

Situations and systems are easier to change than the human condition - particularly when people are well-trained and well-motivated, as they usually are in maintenance organisations. This is a down-to-earth practitioner's guide to managing maintenance error, written in Dr. Reason's highly readable style. It deals with human risks generally and the special human performance problems arising in maintenance, as well as providing an engineer's guide for their understanding and the solution. After reviewing the types of error and violation and the conditions that provoke them, the author sets out the broader picture, illustrated by examples of three system failures. Central to the book is a comprehensive review of error management, followed by chapters on:- managing person, the task and the team; - the workplace and the organization; - creating a safe culture; It is then rounded off and brought together, in such a way as to be readily applicable for those who can make it work, to achieve a greater and more consistent level of safety in maintenance activities. The readership will include maintenance engineering staff and safety officers and all those in responsible roles in critical and systems-reliant environments, including transportation, nuclear and conventional power, extractive and other chemical processing and manufacturing industries and medicine.

Managing the Risks of Organizational Accidents introduced the notion of an 'organizational accident'. These are rare but often calamitous events that occur in complex technological systems operating in hazardous circumstances. They stand in sharp contrast to 'individual accidents' whose damaging consequences are limited to relatively few people or assets. Although they share some common causal factors, they mostly have quite different causal pathways. The frequency of individual accidents - usually lost-time injuries - does not predict the likelihood of an organizational accident. The book also elaborated upon the widely-cited Swiss Cheese Model. Organizational Accidents Revisited extends and develops these ideas using a standardized causal analysis of some 10 organizational accidents that have occurred in a variety of domains in the nearly 20 years that have passed since the original was published. These analyses provide the 'raw data' for the process of drilling down into the underlying causal pathways. Many contributing latent conditions recur in a variety of domains. A number of these - organizational issues, design, procedures and so on - are examined in close detail in order to identify likely problems before they combine to penetrate the defences-in-depth. Where the 1997 book focused largely upon the systemic factors underlying organizational accidents, this complementary follow-up goes beyond this to examine what can be done to improve the 'error wisdom' and risk awareness of those on the spot; they are often the last line of defence and so have the power to halt the accident trajectory before it can cause damage. The book concludes by advocating that system safety should require the integration of systemic factors (collective mindfulness) with individual mental skills (personal mindfulness).

This book explores the human contribution to the reliability and resilience of complex, well-defended systems. Usually the human is considered a hazard - a system component whose unsafe acts are implicated in the majority of catastrophic breakdowns. However there is another perspective that has been relatively little studied in its own right - the human as hero, whose adaptations and compensations bring troubled systems back from the brink of disaster time and again. What, if anything, did these situations have in common? Can these human abilities be 'bottled' and passed on to others? The Human Contribution is vital reading for all professionals in high-consequence environments and for managers of any complex system. The book draws its illustrative material from a wide variety of hazardous domains, with the emphasis on healthcare reflecting the author's focus on patient safety over the last decade. All students of human factors - however seasoned - will also find it an invaluable and thought-provoking read.

Situations and systems are easier to change than the human condition - particularly when people are well-trained and well-motivated, as they usually are in maintenance organisations. This is a down-to-earth practitioner's guide to managing maintenance error, written in Dr. Reason's highly readable style. It deals with human risks generally and the special human performance problems arising in maintenance, as well as providing an engineer's guide for their understanding and the solution. After reviewing the types of error and violation and the conditions that provoke them, the author sets out the broader picture, illustrated by examples of three system failures. Central to the book is a comprehensive review of error management, followed by chapters on:- managing person, the task and the team; - the workplace and the organization; - creating a safe culture; It is then rounded off and brought together, in such a way as to be readily applicable for those who can make it work, to achieve a greater and more consistent level of safety in maintenance activities. The readership will include maintenance engineering staff and safety officers and all those in responsible roles in critical and systems-reliant environments, including transportation, nuclear and conventional power, extractive and other chemical processing and manufacturing industries and medicine.

The authors believe that a systematic organizational approach to aviation safety must replace the piecemeal approaches largely favoured in the past, but this change needs to be preceded by information to explain why a new approach is necessary. Accident records show a flattening of the safety curve since the early Seventies: instead of new kinds of accident, similar safety deficiencies have become recurrent features in accident reports. This suggests the need to review traditional accident prevention strategies, focused almost exclusively on the action or inaction's of front-line operational personnel. The organizational model proposed by the authors is one alternative means to pursue safety and prevention strategies in contemporary aviation; it is also applicable to other production systems. The model argues for a broadened approach, which considers the influence of all organizations (the blunt end ) involved in aviation operations, in addition to individual human performance (the sharp end ). If the concepts of systems safety and organizational accidents are to be advanced, aviation management at all levels must be aware of them. This book is intended to provide a bridge from the academic knowledge gained from research, to the needs of practitioners in aviation. It comprises six chapters: the fundamentals, background and justification for an organizational accident causation model to the flight deck, maintenance and air traffic control environments. The last chapter suggest different ways to apply the model as a prevention tool which furthermore enhances organizational effectiveness. The value of the organizational framework pioneered by Professor Reason in analyzing safety in high-technology production systems is felt by his co-authors to have an enduring role to play, both now and in coming decades. Applied now in this book, it has been adopted by ICAO, IFATCA, IMO, the US National Transportation Safety Board, the Transportation Safety B

This succinct but absorbing book covers the main way stations on James Reason's 40-year journey in pursuit of the nature and varieties of human error. In it he presents an engrossing and very personal perspective, offering the reader exceptional insights, wisdom and wit as only James Reason can. The journey begins with a bizarre absent-minded action slip committed by Professor Reason in the early 1970s - putting cat food into the teapot - and continues up to the present day, conveying his unique perceptions into a variety of major accidents that have shaped his thinking about unsafe acts and latent conditions. A Life in Error charts the development of his seminal and hugely influential work from its original focus into individual cognitive psychology through the broadening of scope to embrace social, organizational and systemic issues. The voyage recounted is both hugely entertaining and educational, imparting a real sense of how James Reason's ground-breaking theories changed the way we think about human error, and why he is held in such esteem around the world wherever humans interact with technological systems. This book is essential reading for students, academics and safety professionals of all kinds who are interested in avoiding breakdowns that can cause serious damage to people, assets and the environment.

Major accidents are rare events due to the many barriers, safeguards and defences developed by modern technologies. But they continue to happen with saddening regularity and their human and financial consequences are all too often unacceptably catastrophic. One of the greatest challenges we face is to develop more effective ways of both understanding and limiting their occurrence. This lucid book presents a set of common principles to further our knowledge of the causes of major accidents in a wide variety of high-technology systems. It also describes tools and techniques for managing the risks of such organizational accidents that go beyond those currently available to system managers and safety professionals. James Reason deals comprehensively with the prevention of major accidents arising from human and organizational causes. He argues that the same general principles and management techniques are appropriate for many different domains. These include banks and insurance companies just as much as nuclear power plants, oil exploration and production companies, chemical process installations and air, sea and rail transport. Its unique combination of principles and practicalities make this seminal book essential reading for all whose daily business is to manage, audit and regulate hazardous technologies of all kinds. It is relevant to those concerned with understanding and controlling human and organizational factors and will also interest academic readers and those working in industrial and government agencies.

Major accidents are rare events due to the many barriers, safeguards and defences developed by modern technologies. But they continue to happen with saddening regularity and their human and financial consequences are all too often unacceptably catastrophic. One of the greatest challenges we face is to develop more effective ways of both understanding and limiting their occurrence. This lucid book presents a set of common principles to further our knowledge of the causes of major accidents in a wide variety of high-technology systems. It also describes tools and techniques for managing the risks of such organizational accidents that go beyond those currently available to system managers and safety professionals. James Reason deals comprehensively with the prevention of major accidents arising from human and organizational causes. He argues that the same general principles and management techniques are appropriate for many different domains. These include banks and insurance companies just as much as nuclear power plants, oil exploration and production companies, chemical process installations and air, sea and rail transport. Its unique combination of principles and practicalities make this seminal book essential reading for all whose daily business is to manage, audit and regulate hazardous technologies of all kinds. It is relevant to those concerned with understanding and controlling human and organizational factors and will also interest academic readers and those working in industrial and government agencies.

This book explores the human contribution to the reliability and resilience of complex, well-defended systems. Usually the human is considered a hazard - a system component whose unsafe acts are implicated in the majority of catastrophic breakdowns. However there is another perspective that has been relatively little studied in its own right - the human as hero, whose adaptations and compensations bring troubled systems back from the brink of disaster time and again. What, if anything, did these situations have in common? Can these human abilities be 'bottled' and passed on to others? The Human Contribution is vital reading for all professionals in high-consequence environments and for managers of any complex system. The book draws its illustrative material from a wide variety of hazardous domains, with the emphasis on healthcare reflecting the author's focus on patient safety over the last decade. All students of human factors - however seasoned - will also find it an invaluable and thought-provoking read.

The authors believe that a systematic organizational approach to aviation safety must replace the piecemeal approaches largely favoured in the past, but this change needs to be preceded by information to explain why a new approach is necessary. Accident records show a flattening of the safety curve since the early Seventies: instead of new kinds of accident, similar safety deficiencies have become recurrent features in accident reports. This suggests the need to review traditional accident prevention strategies, focused almost exclusively on the action or inaction's of front-line operational personnel. The organizational model proposed by the authors is one alternative means to pursue safety and prevention strategies in contemporary aviation; it is also applicable to other production systems. The model argues for a broadened approach, which considers the influence of all organizations (the blunt end ) involved in aviation operations, in addition to individual human performance (the sharp end ). If the concepts of systems safety and organizational accidents are to be advanced, aviation management at all levels must be aware of them. This book is intended to provide a bridge from the academic knowledge gained from research, to the needs of practitioners in aviation. It comprises six chapters: the fundamentals, background and justification for an organizational accident causation model to the flight deck, maintenance and air traffic control environments. The last chapter suggest different ways to apply the model as a prevention tool which furthermore enhances organizational effectiveness. The value of the organizational framework pioneered by Professor Reason in analyzing safety in high-technology production systems is felt by his co-authors to have an enduring role to play, both now and in coming decades. Applied now in this book, it has been adopted by ICAO, IFATCA, IMO, the US National Transportation Safety Board, the Transportation Safety B

The narrative of Chancellorsville begins in Mississippi and the situation on the western front. Before reaching Vicksburg, Cory Brannon stumbles into a campsite where all is not well and briefly encounters a cautious Confederate patrol. A veteran of the battles of Forts Henry and Donelson and Shiloh, but not a soldier in the Confederate army, h continues to search for Lucille Farrell, the daughter of his late employer. When he finds her, he also discovers that he may have a role to play in supplying the South with the food, weapons, and ammunition being brought in through Texas by blockade-runners. The path, however, is strewn with renegades and outlaws, and on the horizon there may be a rival for Lucille’s affections. Meanwhile, Cory’s brothers, Will and Mac, enjoy a brief visit with the family members still in Culpeper. Will is greatly relieved that his mother, Abigail, who had banished him from the farm in the weeks before the war, now welcomes him with open arms. Brother Titus’s marriage to Polly Ebersole comes as a surprise to the two brothers in gray, but their presence stirs a sense of obligation and duty in the hotheaded Titus. Shortly after the two return to their units—Will to the Shenandoah with Jackson and Mac with Stuart near Richmond—the Confederate cause claims another Brannon, this one a gifted rifleman. In December 1862 a new Union commander launches another campaign to claim the Southern capital, and Ambrose Burnside brings the Federal army to Fredericksburg. With him marches the conscience-driven Nathan Hatcher. When the battle breaks loose, Will and Mac are on the right side of the Confederate line, and Titus is on the left. After the terrible bloodletting of the Federal defeat, news comes that Titus has been lost. The brothers carry the information back to Culpeper, where the aloof Polly surprisingly grieves over the loss of Titus, her husband. She reaches out to the Brannon family and finds a comforting response from the people she has tried to keep at arm’s length. In early 1863 a fitful calm pervades the Virginia front until yet another Union commander is named. Joe Hooker leads his army into the wooded wilderness of the Rappahannock again and confidently stakes his fortunes to an encounter with Robert E. Lee near the roadside inn at Chancellorsville. As the battle rushes toward them, Will and Mac witness the boldest move a field commander can make and the greatest loss the Confederacy can struggle to bear. Chancellorsville is the fourth book in a series of historical novels spanning the Civil War.

In this eighth volume of the ten-volume Civil War Battle Series, the action returns to northern Virginia and Culpeper County. The long absent Titus Brannon returns home on Christmas Day, 1863, just over a year since his disappearance during the battle of Fredericksburg. As much as his family is startled to learn that he is alive, he is surprised to find that his wife, Polly, is now married to his brother Henry. And she is pregnant. As spring approaches, Will Brannon recuperates from his Gettysburg wound and returns to his regiment. In the meantime, a new commander leads the Union army into northern Virginia - U. S. Grant. To block Grant's march on Richmond, Robert E. Lee attacks. Grant, however, does not retreat after this surprise engagement but marches on. The two armies clash again and again, maneuvering ever closer to the Rebel capital.

In early 1862 the Civil War comes within view of the Brannon family farm in Culpeper County, Virginia. The din of drilling soldiers sweeps over the quiet county seat, and another Brannon son, Mac, answers the call to arms.The long-anticipated spring offensive pitches the Union and Confederate armies against each other on the Virginia Peninsula, and it appears that Richmond and the fledgling Confederacy are doomed. As the Southerners fall back before the slowly advancing Northern army, Mac is reunited with his older brother, Will, when Stonewall Jackson's triumphant troops arrive from the Shenandoah Valley to blunt the Federal onslaught. The fortunes of the Southern army change dramatically when Robert E. Lee is made commander.Lee's army strikes a stunning blow to the Northern army as his legions cross the Potomac River into Maryland. When the Federals intercept the Rebels near Antietam Creek, the two brothers are brought together in the bloodiest trial of the war thus far. The air is thick with shot and shell as wave after wave of Northern soldiers are hurled upon the Southern lines grouped near the town of Sharpsburg and a river of death.Antietam is the third book in this ten-volume series, spanning the Civil War and describing one Southern family. As the Brannon brothers answer the call to arms the family finds itself struggling with dilemmas it had never imagined.

The third volume in the Civil War Battle Series of novels spanning the war, Antietam brings the war to within view of the Brannon family farm in Culpeper County, Virginia. When the Federals intercept the Rebels near Antietam Creek, two of the Brannon brothers are brought together in the bloodiest trial of the war thus far.

As the civil war careers towards its inevitable end, members of the Brandon family are spread across the South and involved in every theatre of the war. Among the war's last victims is the Brannon farm itself. As carpetbaggers move into the South, this prime real estate is too good to leave in the hands of staunch Confederates.

On December 20, 1860, two friends take part in a momentous occasion in the graceful old city of Charleston, South Carolina. The stories of these young people and their friends & families play out against the drumbeat of impending war & many of their romantic notions about the glory of war are shattered.

Chancellorsville is the fourth book in a series of historical novels spanning the Civil War that features the Brannon family. Previous books in this series have been described as "detailed works of historical fiction written by a gifted author." Chancellorsville opens with Cory Brannon, the son who had gone west to seek his fortune. He discovers that he may be able to help provide the South with food, weapons, and ammunition brought into the country through Texas by blockade-runners but the path is strewn with unsavoury characters. Cory's brothers return to their units - Will to the Shenandoah with Stonewall Jackson and Mac with Jeb Stuart near Richmond - and shortly afterward Titus signs up as a sharpshooter. In December 1862 a new Union commander brings the Union army to the Rappahannock River and Fredricksburg. After the terrible bloodletting of the Federal defeat, Will and Mac learn that Titus has been lost, and they carry the news back to Culpeper. In early 1863 a fitful calm pervades the Virginia front until yet another Union commander is named. Joe Hooker leads his army into the wooded wilderness of the Rappahannock again and confidently stakes his fortunes to an encounter with Robert E. Lee near the roadside inn at Chancellorsville. As the battle rushes toward them, Will and Mac witness the boldest move a field commander can make and the greatest loss the Confederacy can struggle to bear.

Vicksburg is the fifth volume in a series of historical novels spanning the Civil War featuring the Brannon family of Culpeper County, Virginia. The focus turns to the west and the Southern stronghold of Vicksburg, Mississippi, where Cory Brannon is working to keep the town supplied by wagon train and railroad from Texas. Vicksburg is the key to the Mississippi River and the future of the Confederacy. For almost a year the Federal army and navy have tried to dislodge the Confederates, but they have gained nothing. Finally, Union Gen. Ulysses S. Grant, the hero of the battles at Forts Henry and Donelson and the battle of Shiloh, is dispatched to take the town. Cory and the woman he loves, Lucille Farrell, are working with her uncle, Col. Charles Thompson, and a small contingent of dedicated Southerners. In the spring of 1863, as the Union army begins to close in, Cory must abandon that venture to take on a vital mission for Confederate Gen. John Pemberton, the commander in charge of Vicksburg's defenses. At the end of Cory's journey, however, is an even more dangerous foray into Western Tennessee and over the border into Kentucky with the horse soldiers of Nathan Bedford Forrest, Cory's mentor from the battle of Shiloh. To help save Vicksburg, Cory becomes a cavalry raider and even a spy. Yet his efforts cannot prevent the inevitable as the Yankees eventually surround and lay siege to Vicksburg. with the Northern army set to seize the city, Lucille must also cope with additional challenges as she encounters a returning friend with secret plans of his own. The Federal bombardment, illness, injury, and starvation all take their toll on the defenders of Vicksburg, forcing Cory and Lucilleto face decisions that threaten not only their love but their very lives.

Vicksburg is the fifth volume in a series of historical novels spanning the Civil War featuring the Brannon family of Culpeper County, Virginia. The focus turns to the west and the Southern stronghold of Vicksburg, Mississippi, where Cory Brannon is working to keep the town supplied by wagon train and railroad from Texas. Vicksburg is the key to the Mississippi River and the future of the Confederacy, and Abraham Lincoln wants to put that key in his pocket. For almost a year the Federal army and navy have tried to dislodge the Confederates, but they have gained nothing. Finally, Union Gen. Ulysses S. Grant, the hero of the battles at Forts Henry and Donelson and the battle of Shiloh, is dispatched to take the town.

Manassas, by James Reasoner, is the first novel in The Civil War Battles series based on the Brannon family of Culpeper County, Virginia. This initial volume describes the mood in the South prior to the outbreak of hostilities and follows one of the Brannon sons into the army and onto the scene of the first major battle of the war.

As the Civil War sweeps across the country, it finds the most wayfaring member of the Brannon family of Culpeper County, Virginia, working as a wharf rat at the Mississippi River port of New Madrid, Missouri. Caught up in a bar fight he tried to avoid, Cory Brannon is rescued by Capt. Zeke Farrell of the riverboat Missouri Zephyr. Later, when a small party of men attempts to burn the boat, Cory sounds a timely warning and finds himself the newest member of the crew.

The Zephyr makes the journey from New Madrid to New Orleans in late 1861. During this time, Cory matures and finds that he has an interest in the ways of the rivermen and in the captain's daughter, Lucille. Later, in early 1862, the Zephyr reaches Cairo, Illinois, and is greeted by Union gunboats. The war is now on the water, and there is little room for river commerce.

When Farrell, his ship, and his cargo head down the Tennessee River to avoid Union harrassment, they are drawn into the battle lines around two strongpoints on the river: Confederate Forts Henry and Donelson. A Union force under Ulysses S. Grant is advancing toward the forts to claim the area for the North, and Cory and his crewmates join in the fight to see which side will control the river. Captain Farrell is killed when the Zephyr is destroyed by a Union gunboat.

Taken prisoner, Cory loses contact with Lucille. When he learns that Grant is preparing to move farther south, he tries to alert Southern leaders of the danger growing in Western Tennessee. Again he takes up arms, this time at the battle of Shiloh, where the armies in the West collide to determine the fate of the war in the western theater.

Although Stonewall Jackson was dead, Confederate morale was never higher. The victory at Chancellorsville had come against overwhelming odds, and the Southerners savored the sight of the Union army in retreat. In less than a year's time, the Federals had been pushed back from the outskirts of Richmond and now virtually out of Virginia.

Thus begins Gettysburg, the newest addition to The Civil War Battle Series, the Brannon family saga that has been praised as "robust, detail-rich and well-paced...equal parts pathos and accuracy" (Publishers Weekly) and "fraught with passion, tension, and tenderness" (Booklist).

Will and Mac, the two eldest Brannon sons, are in the ranks of the Stonewall Brigade and Jeb Stuart's cavalry. A short bivouac allows them to visit the family farm for some rest and recuperation from the fighting. Almost as soon as Will rejoins his company, Jackson's former corps marches up the Shenandoah Valley, sweeping the Union troops out of Winchester. A natural route to the North lies open, and Lee's army heads in that direction.

The eventual clash known as the battle of Gettysburg occupies the rest of the book. Will, who is involved from the first day, is kept in the thick of the combat around Culp's Hill and the right side of the Union line. Mac arrives on the evening of the second day, and he sees action with the Southern cavalry at Hanover. Both are swallowed up in the melee of the fighting, and neither emerges unscathed.

Bruised and bleeding, the Confederate army stumbles back into Virginia, leaving a fourth of their number behind on the Pennsylvania ground. News of the defeat and the huge number of casualties spreads quickly. Like thousands of families acrossthe South, the Brannon clan in Culpeper County anxiously awaits word of the fates of two sons.

When Cody, a Texas private investigator, is hired to look into what should be a straightforward missing person case, he soon realizes that he's taken on more than he bargained for. The facts surrounding the disappearance of Fort Worth businessman's daughter, twenty-year-old Mandy Traft, are far from clear. Did she run off with her boyfriend? Or has she been kidnapped? With each step Cody takes, the case becomes increasingly dangerous. Before long, he's been warned off, and bodies are starting to tumble. He knows he should get out while he still can. But he can't. Not until he finds Mandy. TEXAS WIND is James Reasoner's debut novel that has achieved a legendary status since its publication in 1980. Considered by many to be one of the best private eye novels ever written, TEXAS WIND is finally back in print. Includes a new introduction by Ed Gorman.