詹姆斯·理斯 是曼彻斯特大学杰出的心理学家和教授，于 2025 年 2 月 5 日去世，享年 86 岁。
Reason 以其在人为错误和组织安全方面的开创性工作而闻名，深刻地塑造了现代对事故因果关系和风险管理的理解。
他最有影响力的贡献是瑞士奶酪模型，它说明了当多层防御（每层都有其固有的弱点）失效时，事故是如何发生的，从而为错误升级为灾难性后果创造了途径。该模型已成为从航空到医疗保健等各行各业安全分析的基石。除此之外，理性在发展公正文化理论方面发挥了重要作用，倡导一种平衡的问责方法，以区分系统性失败和个人疏忽。他 1997 年出版的《管理组织事故的风险》一书仍然是该领域的基础文本。回顾他的影响，公正文化的领导者 Sidney Dekker 博士在反思他的影响时指出：“Jim 的影响力将持续存在—不仅体现在他塑造的理念上，还体现在他教会我们注意组织直率的一端，生动地说话和写作，并以信念和幽默来挑战领导者。他的机智使他成为我们领域中令人敬畏的存在，也是一位珍贵的同事和朋友。
Reason 的学术贡献延伸到各个领域，包括人因失误犯错、航空人为因素、维护错误和医疗保健安全。他的卓越表现获得了无数荣誉，包括 2003 年因对降低医疗健康风险的贡献而获得 CBE（大英帝国司令勋章）。他还是英国科学院、英国心理学会、皇家航空学会和皇家将军学院的会员。
当我们缅怀他的名言时，他最深刻的陈述之一引起了共鸣：“工人在事故中的作用是，为致命的菜肴添加最后的装饰，其实，这食材已经烹饪了很长时间。”
解读他的名言，就是，事故的发生，是管理责任，并不是员工责任。
他的见解和学术研究将继续塑造安全科学、风险管理和人为因素领域，造福子孙后代。
James T. Reason CBE, a distinguished psychologist and professor at the University of Manchester, passed away on February 5, 2025, at the age of 86. Renowned for his pioneering work in human error and organizational safety, Reason profoundly shaped modern understandings of accident causation and risk management.
His most influential contribution, the Swiss Cheese Model, illustrates how accidents occur when multiple layers of defense—each with inherent weaknesses—fail, creating a pathway for errors to escalate into catastrophic outcomes. This model has become a cornerstone of safety analysis across industries, from aviation to healthcare.
Beyond this, Reason was instrumental in developing the theory of a just culture, advocating for a balanced approach to accountability that distinguishes between systemic failures and individual negligence. His 1997 book, Managing the Risks of Organizational Accidents, remains a foundational text in the field.
Reflecting on his impact, Dr. Sidney Dekker, a leader in just culture, noted:
"Jim’s influence will endure—not just in the ideas he shaped, but in the way he taught us to pay attention to the organizational blunt end, to speak and write vividly, and to challenge leaders with both conviction and humor. His wit made him a formidable presence in our field, and also a treasured colleague and friend."
Reason’s academic contributions extended across various domains, including absent-mindedness, aviation human factors, maintenance errors, and healthcare safety. His excellence was recognized with numerous honors, including a CBE (Commander of the Order of the British Empire) in 2003 for his contributions to risk reduction in healthcare. He was also a Fellow of the British Academy, the British Psychological Society, the Royal Aeronautical Society, and the Royal College of General Practitioners.
In remembering Reason’s legacy, one of his most profound statements resonates:
"The role of the operator in an accident is to add the final garnish to a lethal stew whose ingredients have been long in the cooking."
His insights and scholarship will continue to shape the fields of safety science, risk management, and human factors for generations to come.
