Quality Quote: “We can change the conditions under which humans work” (James Reason)
Psychologist James Reason, writing in the BMJ in 2000: “We cannot change the human condition, but we can change the conditions under which humans work.”
“We cannot change the human condition, but we can change the conditions under which humans work.”
James Reason, psychologist, “Human error: models and management”, BMJ (2000)
Reason, best known for the “Swiss cheese” model of accidents, drew a line between two ways of looking at error. The person approach blames the individual who slipped: retrain them, warn them, write them up. The system approach asks why the work was set up so that a normal human slip could cause harm, and what defences failed.
Most incident reports still read like the person approach. “Operator failed to follow procedure” is a description, not a cause. The useful questions come next. Was the procedure workable? Was the person rushed, tired or interrupted? Did the equipment make the wrong action easy? Were the other defences already worn thin?
ISO 45001 and ISO 9001 both push toward the system view. Corrective action has to deal with the cause, and the hierarchy of controls puts design and engineering ahead of rules and training. If your corrective actions keep ending in “retrained the worker”, that is worth a second look.
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General guidance only. This article is general information, not legal, financial, safety or compliance advice, and it does not take account of your specific circumstances. Streamline ISO Consultants are ISO management-system consultants, not lawyers or licensed advisers. Standards, laws and regulator guidance change, and details were correct only at the time of writing. Always seek professional advice before acting. See our full Disclaimer.
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