mostly conducted under the ‘human error’ paradigm. The 1980s were marked by a
series of industrial accidents (Three Mile Island, 1979; Bhopal, 1984, Chernobyl
and Challenger, 1986; Herald of Free Enterprise and King’s Cross Station 1987;
Piper Alpha, 1988). Investigations following these accidents brought the Safety
community to question the understanding of accidents solely based on operator’s
error. In this scientific, industrial and social context, NATO and the World Bank
funded many multidisciplinary workshops on accidents. The first one was held in
Bellagio, Italy, 1981. It received the name of “first human error clambake”.
At Bellagio’s Clambake, Reason and Wreathall met. This fortuitous meeting led
them to become (in Wreathall words) “social friends”. Indeed, according Wreathall,
“intellectual communion was quick with Reason but also with other researchers in
vogue on the issues of human error at the time. Swain, Moray, Norman”. Reason
and Wreathall started corresponding and met at different conferences during the
1980s. Both took commercial projects for industrial groups such as British Airways
and US NRC in which they employed each other as professional colleagues. At that
time Reason was ending his taxonomy of unsafe acts. He started writing a book on
human error aimed to his cognitive psychologist peers. The Safety Culture Decade
context and choice of reducing first chapter’s size brought him into writing a
chapter on industrial accidents. Therefore, he intended his book to both the research
and the industrial world (he progressively became familiar with thanks to his
Wreathall & Co’s joint missions as well as others). To communicate his new vision
of organizational accidents, Reason called on his friend Wreathall to help to design
a simple but effective model that would be included in the 7th chapter of Human
Error. This model was to become, ten years later, the famous SCM.
3 Birth and Growth of the SCM
Section 2 has presented the two SCM’s fathers, their backgrounds and the context
in which they were brought to meet. This section focuses on their collaboration
from 1987 (when the writing of Human Error begun) to 2000 (publication of the
latest SCM version). We first look back at the discovery and exploitation by Reason
of the nuclear field (Sect. 3.1). We then explicit the shift that the psychologist made
from fundamental to applied research (Sect. 3.2). Section 3.3 is devoted to the
percolation of defense in depth into the SCM. Finally, we look at the developments
which led the Wreathall and Reason’s early accident model, to become, in 2000 the
famous and widely used SCM (Sect. 3.4).
3.1 Reason, Human Error and NPPs
In the late 1970s Reason is still far from the nuclear power plant (NPP) control
rooms. Yet this industrial field will be one of the most influential for its work. In
260
J. Larouzée
series of industrial accidents (Three Mile Island, 1979; Bhopal, 1984, Chernobyl
and Challenger, 1986; Herald of Free Enterprise and King’s Cross Station 1987;
Piper Alpha, 1988). Investigations following these accidents brought the Safety
community to question the understanding of accidents solely based on operator’s
error. In this scientific, industrial and social context, NATO and the World Bank
funded many multidisciplinary workshops on accidents. The first one was held in
Bellagio, Italy, 1981. It received the name of “first human error clambake”.
At Bellagio’s Clambake, Reason and Wreathall met. This fortuitous meeting led
them to become (in Wreathall words) “social friends”. Indeed, according Wreathall,
“intellectual communion was quick with Reason but also with other researchers in
vogue on the issues of human error at the time. Swain, Moray, Norman”. Reason
and Wreathall started corresponding and met at different conferences during the
1980s. Both took commercial projects for industrial groups such as British Airways
and US NRC in which they employed each other as professional colleagues. At that
time Reason was ending his taxonomy of unsafe acts. He started writing a book on
human error aimed to his cognitive psychologist peers. The Safety Culture Decade
context and choice of reducing first chapter’s size brought him into writing a
chapter on industrial accidents. Therefore, he intended his book to both the research
and the industrial world (he progressively became familiar with thanks to his
Wreathall & Co’s joint missions as well as others). To communicate his new vision
of organizational accidents, Reason called on his friend Wreathall to help to design
a simple but effective model that would be included in the 7th chapter of Human
Error. This model was to become, ten years later, the famous SCM.
3 Birth and Growth of the SCM
Section 2 has presented the two SCM’s fathers, their backgrounds and the context
in which they were brought to meet. This section focuses on their collaboration
from 1987 (when the writing of Human Error begun) to 2000 (publication of the
latest SCM version). We first look back at the discovery and exploitation by Reason
of the nuclear field (Sect. 3.1). We then explicit the shift that the psychologist made
from fundamental to applied research (Sect. 3.2). Section 3.3 is devoted to the
percolation of defense in depth into the SCM. Finally, we look at the developments
which led the Wreathall and Reason’s early accident model, to become, in 2000 the
famous and widely used SCM (Sect. 3.4).
3.1 Reason, Human Error and NPPs
In the late 1970s Reason is still far from the nuclear power plant (NPP) control
rooms. Yet this industrial field will be one of the most influential for its work. In
260
J. Larouzée