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NEMSPA


BY WILLIAM T. WINN LIFE AT THE SHARP END Anyone who has read Professor James Reason’s writings on


human factors in accident causation is familiar with his well-known model of how causative factors can line up like the seemingly ran- dom holes in slices of Swiss cheese to result in a mishap or in a serious accident. Dr. Reason is professor of psychology at


the


University of Manchester, United Kingdom. He has published books on motion sickness, human factors in transportation accidents, absent-mindedness, human error and on identifying and managing organizational risk factors.


PHOTOS: MD HELICOPTERS ROTORCRAFTPROFESSIONAL 16 In an analysis of the chain of events leading to any accident,


the sequence inevitably leads to the individual whose action or inaction most directly results in the occurrence of the event. Professor Reason refers to this unfortunate individual as the “sharp- ender,” since he or she stands at the tip of an expanding sequence of actions and circumstances which lead to the final mishap. Traditionally, the sharp-enders receive credit for causing the acci- dent. In the history of aviation accidents they have typically been pilots, aircraft mechanics, or air traffic controllers. In air medical


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