Nice little report from James Reason on achieving a safe culture
There's actually a nice little book by Reason called "Managing the Risks of Organisational Accidents" which was printed in the 90's! If you look at the ICAO SMM manual it pretty much lifts the whole book to come up with the aviation wunderkind of SMS as a fix it solution for aviation safety. As Pel Air and CASA have demonstrated just including the words "Reason" and "swiss cheese" in your manuals does not a safety system make.