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Daniel E. Maurino, James Reason, Neil Johnston, Rob B. Lee
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Human Dimensions of Fire Management
Organizational Learning & Innovation

NRFSN number: 15883
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Aviation human factors investigations have typically blamed individual behavior as the primary cause of serious work accidents. However, this book argues that organizations are responsible for two aspects that contribute to work related accidents: 1) the local working conditions that restrict how workers can behave and 2) the safeguards used to protect workers from potential accidents. The authors provide a theory for making sense of disasters that predicts negative consequences that may result from organizational practices and helps investigators trace the causes of an accident back to their organizational roots. Using several case studies of aviation accidents, they show how their theory could work in practice and then clarify the steps needed to carry out this kind of analysis during an actual investigation.


Maurino DE, Reason J, Johnston N, Lee RB. 1995. Beyond aviation human factors: safety in high technology systems. Brookfield, VT: Ashgate. 169 p.

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