Reading 1.3
Jackall, R. (1988)
Chapter 4, ‘Looking Up and Looking Around’, in Moral Mazes, Oxford University Press, NY.
Abstract
In the early sections of “Looking Up and Looking Around” Jackall seeks to explain the reasons behind inadequate decision making processes and ability. The circumstances and environments that cultivate ‘decision-making paralysis’ and a lack of individual decision making ability are explained. Numerous examples and reasons are outlined to communicate a manager’s fear of failure, reluctance to make decisions and inability to make effective decisions when required at all hierarchical levels. If a decision must be made, particularly for an unexpected situation or problem, there is a tendency to look up, at …show more content…

Reason identifies elements constituting a productive system and identifies the human contributions acting within those productive elements. In doing this, Reason makes it clear how accidents or incidents are an unfortunate coincidence allowed to occur through the combination of each ‘window of weakness’ of human factors acting together, failing to prevent the accident or incident occurrence.
A key lesson to draw from Reason is that the ‘root causes of serious accidents in complex technologies are present within the system long before an obvious accident sequence can be identified’. In Reason’s words, ‘there is nothing inherently unsafe about not wearing a safety helmet’, it is the combination of elements of human contributions that allow a hazard to be present that puts the individual not wearing a safety helmet in danger. Managers at all levels should put effort into the identification of those ‘failure types’, being the elements that allow accidents and incidents to occur, rather than the ‘failure tokens’, being the events or conditions that actually lead to an accident or incident occurring.
Establishment of those ‘feedback and response loops’ to identify and treat the systematic weaknesses that contribute to accident occurrence creates an overall safer organisation. In particular, recording and auditing accidents, incidents and unsafe acts alone is not sufficient. Due diligence and effort must be placed into establishing a system of