Abstract
This case is described in terms of James Reason’s organizational accident framework. An organizational accident is a confluence of human, situational and other contextual circumstances that combine and breach established organizational defenses that have been erected to guard against certain hazards, when breached.
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Notes
- 1.
- 2.
Ref. [3]
- 3.
Reason 1997 [1], at 6, The Dangers of the “Unrocked Boat,” (describing the gradual erosion of safety and the slide into complacency); Ref. [4] (assumption-based planning is intended to counter this complacency); see also Reason 1998 [3] (moving toward the ideal informed safety culture includes “not forgetting to be afraid” simply because an accident is a rare event, or has not occurred); Ref. [4, 5]; THE 9/11 COMMISSION REPORT, at 339, 344–348 (citing the “failure of imagination” as a contributing factor of the U.S. Government’s failure to act).
- 4.
Reason 1997 [1] at 8 (contrast with “hard” defenses, which are defined as physical devices such as locks, alarms and warning lights).
- 5.
LUTHER GULICK, NOTES ON THE THEORY OF ORGANIZATION (L. Gulick and L. Urwick Eds., Papers on the Science of Administration 1936 at 3–35, Institute of Public Administration) (POSDCORB: planning, organizing, staffing, directing, coordinating, reporting and budgeting).
- 6.
Production hazards in policing are engaging in arrests, traffic stops, field interviews, custodial interrogations, identification procedures, search and seizure activities particularly search warrant service, vehicular pursuits, using force, employing confidential informants and other similar enforcement actions; see also Ref. [4–6] (describing the competing interests of production and safety).
- 7.
- 8.
Reason, 1997 [1] at 12.
- 9.
Accountability means to subordinate to a process, where the subject bears an obligation or willingness to accept responsibility and to proffer a statement or explanation of the reasons, causes or motives for their actions; See Iannone [7, 8] at 25–28 and Schroeder, Lombardo & Strollo [7, 8] at 26–29, [7, 8].
- 10.
See 42 USC §1983––Action for Deprivation of Rights; see also Monroe v. Pape, 365 U.S. 167, 81 S. Ct. 473 (1961) and Monell v. Department of Social Services. 436 U.S. 658 (1978) (establishing that local governing bodies and local officials can be sued directly under §1983 for damages, where their edicts or acts may fairly be said to represent de facto policy. Monell cases are informally referred to as “pattern or practice” suits even though the custom or pattern at issue has not received formal approval through the government’s official decision-making channels); see also Williams v. Anderson 599 F. 2d 923 (1979), Ford v. Byrd 544 F.2d 194 (1976) (holding management, the police agency and the jurisdiction responsible for acts committed by subordinate personnel); Ref. [9].
- 11.
- 12.
Wilson [10].
- 13.
Ref. [11]
- 14.
- 15.
- 16.
Ref. [17]
- 17.
Reason 1997 [3].
- 18.
Reason 1997 [3].
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Shane, J. (2013). Theoretical Framework. In: Learning from Error in Policing. SpringerBriefs in Criminology(). Springer, Heidelberg. https://doi.org/10.1007/978-3-319-00041-1_2
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