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Write a 7 pages paper on piper alpha oil rig fire. Reason’s model suggests that human error is a natural evolution in any business environment and should be considered when creating a leadership or management model. Lack of concentration, carelessness or forgetfulness are human failings and are going to be present in the organizational design, thus leading to undesirable business outcomes. Further, Reason claims that “adverse events are the product of latent conditions (pathogens) within the organizational system” (Reason, 2008, p.7. Jeffries, 2005). By this, Reason means that even the most detailed and sophisticated management models, maintaining a strong focus on safety and adherence to policy, can still be interrupted by humans or organizational pathogens and lead to workplace hazards.&nbsp.Reason’s model suggests that human error is a natural evolution in any business environment and should be considered when creating a leadership or management model. Lack of concentration, carelessness or forgetfulness are human failings and are going to be present in the organizational design, thus leading to undesirable business outcomes. Further, Reason claims that “adverse events are the product of latent conditions (pathogens) within the organizational system” (Reason, 2008, p.7. Jeffries, 2005). By this, Reason means that even the most detailed and sophisticated management models, maintaining a strong focus on safety and adherence to policy, can still be interrupted by humans or organizational pathogens and lead to workplace hazards.&nbsp. At Piper Alpha, the disaster cost the company $1.4 billion in USD (Peterson, 1991). The pathogen which existed during this time period was a failure for safety workers and managers to perform follow-up with on-duty managers after changing shifts overnight. Even though the permit system had been established to ensure that machinery experiencing maintenance was isolated and closed off, shift leaders did not record the event in any appropriate log nor were the maintenance of Pump A discussed during a shift changeover. From a process perspective, the contractor working on Pump A had signed off on the work and indicated with an appropriate safety tag that the Pump should be isolated. However, managerial intervention eventually made this tag disappear from the organizational environment, thus the proverbial hole in the cheese.&nbsp. From Reason’s perspective, as a means of filling these gaps in process, there should be a stricter focus on training and ensuring that managers understand the tremendous risks involved with an oil rig safety process. What Piper Alpha had been utilizing was a permit-to-work system which experienced a managerial breakdown, thus the next shift was completely unaware that turning on Pump A could cause a devastating explosion.