James Reason is a Professor in the Faculty of Engineering and Built Environment at the University of New South Wales. He has a PhD in Engineering from the University of Cambridge, and has done post-doctoral research at the Harvard School of Public Health.
He is a world-renowned safety expert, authoring several books on safety including “The Systemic View of Safety” and “Blind Spots.” His work has been cited by researchers, scholars, and professionals in fields as diverse as medicine and aviation.
In his writings on safety, Professor Reason defines an “unsafe act” as any action that: (1) involves some sort of risk or threat to people or property; (2) violates rules or regulations; (3) contravenes accepted norms or conventions; (4) goes against habit or custom; (5) goes against established practices; (6) is non-standard; and/or (7) is unconventional.(1)
This article will examine these reasons, how they relate to cell phone use while driving, and how you can apply this information in your daily life.
A violation of a procedure
This includes violations such as failure to follow safety procedures, ignoring warning signs or alarms, disobeying safety regulations, and disregarding the consequences of one’s actions.
Unsafe acts also include failing to assess the risks involved in a task, being reckless or negligent, and being unaware of the potential consequences of one’s actions.
According to Reason’s research, people make mistakes. We are human and we make errors in judgment and action. The problem is that when people are in a rush or feeling overwhelmed by their tasks, they are more likely to act unsafely.
When people feel rushed or overwhelmed, they may not be taking the time to think through what they are doing and how they are doing it. This can lead to acting unsafely by being hurried or careless.
A mistake in judgment
According to Reason, a mistake in judgment is always at the core of every incident.
Incidents are not triggered by some immediate, startling event. Rather, they are the culmination of a series of events and actions that lead up to a particular moment.
In other words, incidents are the result of a series of mistakes that lead up to a specific moment when an unsafe act takes place.
By Definition, an Unsafe Act Always Includes A Mistake In Judgment By The Person Who Performs It.
This includes not only those performing an action, but also those who supervise and authorize them to perform the action. In other words, it includes leaders and those with authority who give orders that result in incidents.
An incident can only occur when someone with authority gives an order to someone under their authority who performs an action that has a negative outcome. By definition, this includes a mistake in judgment by the person who performs the action.
An act of incompetence
Incompetence is the failure to do a task or action due to a lack of knowledge, skill, or experience. Incompetence can be the result of poor training, lack of updated training, or no training at all.
Incompetence can also be the result of inadequate or poor equipment (e.g., poorly functioning machinery or equipment that is not up to par for the task).
Incompetence can also be the result of distractions (e.g., communication devices that take one’s attention away from what one is supposed to be doing).
When we talk about “unsafe acts” in regards to accidents in the workplace, by definition an “unsafe act” always includes some form of incompetence.
James Reason offers this simple definition: An unsafe act is a deed that may kill you; it may kill someone else; it may cost you your job; but it won’t pay your bills.
A lack of awareness of the risk
This is the first part of the formula that makes an unsafe act possible. If a person was fully aware of the risks involved in a specific action or situation, they would likely avoid it.
For example, if someone knew a certain floor of a building was about to collapse, they would avoid going to that floor.
In the case of workplace accidents, if workers were fully aware of the risks involved in their job and took proper precautions, then accidents would be reduced and there would be fewer cases of occupational illness.
The first part of the formula for an unsafe act is lack of awareness of risk. When people are unaware that a certain action or situation is dangerous, then there is no chance for avoidance or prevention.
Failure to follow the procedures or complete the paperwork necessary for identifying and controlling hazards
In his book, James Reason explains that the most common cause of accidents in the workplace is the failure to follow procedures and paperwork.
Procedures are designed specifically to control hazards, so failing to follow them is always an unsafe act.
He says this is because people can’t be expected to recognize and control hazards if they don’t understand what risks they are exposed to, and how to manage those risks, because they don’t have access to the appropriate information.
By failing to complete paperwork, people can’t understand what risks they are exposed to, and how to manage those risks.
You may not realize this, but you probably know someone who has suffered from repetitive stress injury (RSI) or who has had some kind of accident at work.
Violation of the safety culture of your company
In his book, James Reason talks about the concept of a safety culture. He says that in order to have a safe workplace, there needs to be a shared understanding of safety practices and procedures.
He also says that in order for safety practices and procedures to be effective, there needs to be trust in them.
If your company has rules and regulations but people don’t follow them, then you don’t have a safety culture. If people don’t trust the rules and regulations, then you don’t have a safety culture.
In his book, James Reason talks about the concept of a “violation of the safety culture of your company.” By definition, an “unsafe act” always includes this violation of the company’s safety culture. An unsafe act is not just an individual violating one particular procedure; it is an individual violating the whole culture of safety.
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