The very nature of Humans is that we make mistakes, and most of the time, not deliberately.

During the early introduction of ejector seats, the list of instructions to the pilot was firmly glued to the canopy. When identifying why pilots were involved in too many errors when using the said emergency escape, the accident investigators pointed out that Step 1 of the instructions, “Release Canopy” was the cause, because not only did the canopy fly off, but so did the rest of the instructions as well!

One of my inspirational teachers at Leicester University was Dr James Reason, who taught the module of Psychology known as ‘Man in Motion’, and because of him I chose in due course to become a teacher too. Just because Mum and Dad were teachers causes many to imagine that I had no choice other than to choose this vocation. The reality is far from that, and it was Dr Reason’s ability to tell stories, make difficult science accessible that gave me the inspiration to do the same, and hence became a  Maths and Science teacher.

Jim moved on to Manchester for a professorship, and amongst other notable achievements, it was his Swiss Cheese Model for the description of accidents that helps explain that accidents will happen only if multiple barriers fail, thus creating a path from an initiating cause all the way to the ultimate, unwanted harms assets, the environment, property and of course human life itself. 

I met Professor Reason much more recently, when his grandchildren joined the junior school, and now the last is completing their A-level studies with us in the Sixth Form. My tribute to James Reason appears now because he passed away on 4 February, having suffered a short illness. He was 86. Such was his fame that the Times newspaper (amongst others) carried his obituary, and his daughter tells me he would have been delighted to have been alive to have read them! Perhaps the best can be found here in the New York Times, which carries a photograph of Jim as I remember him at University or on the CBS news channel live. 

Youtube carries the Professor in action, buying the Swiss cheese in his local shop:

I quote from his obituary – “In the Chernobyl nuclear accident, he identified latent conditions that had been in existence for years: a poorly designed reactor; organizational mismanagement; and inadequate training procedures and supervision for frontline operators, who triggered the catastrophic explosion by making the error of turning off several safety systems at once.” 

“By analyzing hundreds of accidents in aviation, railway travel, medicine and nuclear power, Professor Reason concluded that human errors were usually the byproduct of circumstances — in his case, the cat food was stored near the tea leaves, and the cat had walked in just as he was boiling water, and thus made a cat food cuppa — rather than being caused by careless or malicious behavior.

That was how he arrived at his Swiss cheese model of failure, a metaphor for analyzing and preventing accidents that envisions situations in which multiple vulnerabilities in safety measures — the holes in the cheese — align to create a recipe for tragedy.”

In his own field, Professor Reason was as notable as any in research, and given the inevitable reality that we humans will continue to make errors, his name is worth remembering!