Human Error¶
Reason, J. (1990). Human Error. Cambridge University Press.
Cited by¶
19 citations across 19 artifacts.
Each citation links to the sentence it supports in the citing article.
Primes¶
- Anna Karenina Principle
- In engineering reliability an airliner functions only if every redundant system, interlock, check, and procedure is in order, while a crash typically follows from one binding failure — the discipline of failure-modes analysis and the Swiss-cheese accident model are built on this asymmetry.
This sourceIntroduces the Swiss-cheese model of accident causation, in which an accident requires the simultaneous alignment of holes across multiple defensive layers — the conjunctive-necessity / disjunctive-failure asymmetry made operational for safety engineering.
Supported in partVerified against the publisher's abstract
Reason's Human Error is a book on human-error mechanisms and the reliability of hazardous technologies; the abstract held here does not itself state the Swiss-cheese model or the conjunctive-necessity asymmetry the claim rests on.
“In its treatment of major accidents, the book spans the disciplinary gulf between psychological theory and those concerned with maintaining the reliability of hazardous technologies.”
- In engineering reliability an airliner functions only if every redundant system, interlock, check, and procedure is in order, while a crash typically follows from one binding failure — the discipline of failure-modes analysis and the Swiss-cheese accident model are built on this asymmetry.
- Boundedness
- Boundedness is not the same as termination of a process, a separation Reason (1990) underscores in his analysis of safety-engineering failure modes where bounded resources and continued operation are tracked separately.
This sourcePARTIAL SUPPORT D39-082: a canonical safety/failure-mode reference, but it concerns active/latent cognitive-error types, not specifically the boundedness-vs-termination distinction the sentence attributes to it; the underlying distinction (resource-boundedness is a magnitude property, termination is temporal) is a logical point illustrated, not a Reason thesis.
- Boundedness is not the same as termination of a process, a separation Reason (1990) underscores in his analysis of safety-engineering failure modes where bounded resources and continued operation are tracked separately.
- Conjunctive Path Activation
- In aviation and process safety, the Swiss-cheese model is the alignment of holes that realizes an end-to-end path only when each layer's failure aligns simultaneously, with no single layer the cause.
This sourceIntroduces the "Swiss cheese" model of accident causation: an end-to-end failure path opens only when the holes in successive defensive layers align simultaneously.
- In aviation and process safety, the Swiss-cheese model is the alignment of holes that realizes an end-to-end path only when each layer's failure aligns simultaneously, with no single layer the cause.
- Containment
- Rather than asking "How do we eliminate this?" (often impossible), it asks "How do we define and sustain a boundary?" and "What monitoring and enforcement ensure that boundary holds?" — a reframing Reason (1990) develops in his analysis of barrier-and-defense models of risk management.
This sourceFoundational treatment of the barrier-and-defense ('Swiss cheese') model of risk management: layered defensive barriers, each imperfect, are aligned so that an escape requires holes through every layer — the reframing of an uncontrolled-propagation problem as one of defending and monitoring a finite set of barriers.
- Rather than asking "How do we eliminate this?" (often impossible), it asks "How do we define and sustain a boundary?" and "What monitoring and enforcement ensure that boundary holds?" — a reframing Reason (1990) develops in his analysis of barrier-and-defense models of risk management.
- Defense In Depth
- In safety engineering and nuclear power, it stacks fuel cladding, primary cooling, containment vessel, reactor building, and emergency siting — the "Swiss-cheese model" of accident causation.
This sourceOriginates the Swiss-cheese model of accident causation — accidents result from a trajectory through aligned holes in multiple defensive layers, with latent correlated weaknesses collapsing independence.
- In safety engineering and nuclear power, it stacks fuel cladding, primary cooling, containment vessel, reactor building, and emergency siting — the "Swiss-cheese model" of accident causation.
- Error Proofing (Poka-Yoke)
- The analysis of root causes: why do humans commit this error, and under what conditions?
This sourceCanonical cognitive account of error mechanisms; slips/lapses/mistakes taxonomy and the GEMS framework; identifies cognitive processes common across error types.
Supported in partVerified against the publisher's abstract
The abstract supports analyzing why errors occur (cognitive processes common to many error types) but says nothing about the conditions under which they occur.
“Particularly important is the identification of cognitive processes common to a wide variety of error types.”
- The analysis of root causes: why do humans commit this error, and under what conditions?
- Escape and Leakage
- Escape and leakage is the structural pattern whereby quantities or entities constrained to remain within a system boundary exit through unintended or underspecified pathways, a pattern Reason (1990) formalizes in his "Swiss-cheese" model of latent failure paths penetrating layered defenses.
This sourceDevelops the active-failure / latent-condition account of accident causation and the layered-defenses ("Swiss-cheese") framing in which aligned holes in successive barriers let hazards penetrate; the structural source for treating leakage as latent failure paths through layered defenses.
Supported in partVerified against the publisher's abstract
The abstract confirms only that Reason's Human Error is a work on error mechanisms and the reliability of hazardous technologies; it never mentions 'Swiss-cheese' layered defenses or latent failure paths.
“In its treatment of major accidents, the book spans the disciplinary gulf between psychological theory and those concerned with maintaining the reliability of hazardous technologies.”
- Escape and leakage is the structural pattern whereby quantities or entities constrained to remain within a system boundary exit through unintended or underspecified pathways, a pattern Reason (1990) formalizes in his "Swiss-cheese" model of latent failure paths penetrating layered defenses.
- Eventual Realisation of Possibility
- Epidemiology and aviation safety: any pathway with non-zero transmission will eventually produce a chain when conditions favour it; the culture of "if it can happen, it will, given enough flight hours" is this prime made institutional.
This sourceDevelops the latent-failure / Swiss-cheese model and the safety-culture premise that any pathway with non-zero probability will eventually align given enough operating exposure.
- Epidemiology and aviation safety: any pathway with non-zero transmission will eventually produce a chain when conditions favour it; the culture of "if it can happen, it will, given enough flight hours" is this prime made institutional.
- Fail-Safe
- The tension is between fail-safe-on-obvious-failure (fast, reliable) and fail-safe-on-subtle-failure (requires active monitoring and detection)
This sourceDistinguishes active failures (immediate unsafe acts) from latent conditions that lie dormant in a system until they combine with triggers — the slow/subtle failure mode.
- The tension is between fail-safe-on-obvious-failure (fast, reliable) and fail-safe-on-subtle-failure (requires active monitoring and detection)
- Responsibility Diffusion
- Swiss Cheese Model (Layered Defense with Aligning Holes)
- And in biological immune defense and criminal-justice procedure, stacked layers fail when an adversary's evasion or a shared bias opens holes in several at once.
This sourceIntroduces the latent-versus-active failure distinction and the layered-defenses model of organizational accidents, the conceptual basis of the Swiss cheese model.
Supported in partVerified against the publisher's abstract
Reason's Human Error is the origin of the layered-defences/latent-failure framing for organizational accidents, but the abstract we hold says nothing about correlated holes, fraud cases, immune defence, or criminal-justice procedure.
“In its treatment of major accidents, the book spans the disciplinary gulf between psychological theory and those concerned with maintaining the reliability of hazardous technologies.”
- And in biological immune defense and criminal-justice procedure, stacked layers fail when an adversary's evasion or a shared bias opens holes in several at once.
Domain-specific¶
- Active Failure
- An active failure, in James Reason's Swiss cheese model of accident causation (Human Error, 1990; Managing the Risks of Organizational Accidents, 1997)
Supported in partVerified against a saved copy of the source
“202 {{{Latent}}} errors and systems disasters INADEQUATE DEFENCES Active {{{failures}}} &”
- An active failure, in James Reason's Swiss cheese model of accident causation (Human Error, 1990; Managing the Risks of Organizational Accidents, 1997)
- Burkean Pentad
- Modern accident investigation enacts the pentad's substitution test as safety doctrine, largely following James Reason's "human error" work and the shift it drove in aviation and medicine
This sourceReason's Human Error, "a major theoretical integration" of human-error research that grounds improved safety in "a better understanding of human error mechanisms" and treats major accidents in hazardous technologies.
Supported in partVerified against the work's full text
“the study of {{{human error}}} and industrial accidents. I began to realize that {{{human error}}} resulted from”
- Modern accident investigation enacts the pentad's substitution test as safety doctrine, largely following James Reason's "human error" work and the shift it drove in aviation and medicine
- Latent Condition
- This is the direct structural complement to the active failure — the operator action that aligns with and closes the pre-positioned path — and it is Reason's core explanatory move against the tendency to stop accident investigation at the proximate human act: latent conditions are the "resident pathogens of the system," identifiable in principle by proactive audit before any incident activates them, which is what makes safety conceived as pathogen-removal a coherent engineering programme rather than merely a response to past events
This sourceThe 'resident pathogen' metaphor Reason applies to latent conditions, which combine with local triggering events to breach a system's defences.
Supported in partVerified against a saved copy of the source
“technological systems and {{{resident}}} {{{pathogens}}} in the human body.”
- This is the direct structural complement to the active failure — the operator action that aligns with and closes the pre-positioned path — and it is Reason's core explanatory move against the tendency to stop accident investigation at the proximate human act: latent conditions are the "resident pathogens of the system," identifiable in principle by proactive audit before any incident activates them, which is what makes safety conceived as pathogen-removal a coherent engineering programme rather than merely a response to past events
Mechanisms¶
- Causal Responsibility Mapping Workshop
- It is a direct application of the Swiss cheese model,
This sourceModels organizational accidents as the alignment of latent weaknesses across multiple defensive layers rather than as the product of a single front-line error.
- It is a direct application of the Swiss cheese model,
- Close-Call Review Protocol
- It pairs naturally with a layered-defenses view of accidents, where a close call reveals that most barriers were already breached and only the last one held.
This sourceFrames accidents through layered defenses whose weaknesses can align and permit a hazard to pass through successive barriers.
- It pairs naturally with a layered-defenses view of accidents, where a close call reveals that most barriers were already breached and only the last one held.
- Exception Handling Playbook
- Its failure mode is that a playbook is only variety for the exceptions it lists: a genuinely novel case gets forced into the nearest entry — applying an ordinarily-sound rule to a situation where its conditions don't hold
This sourceDefines rule-based mistakes to include applying a sound rule to a novel exception whose conditions require a different response.
- Its failure mode is that a playbook is only variety for the exceptions it lists: a genuinely novel case gets forced into the nearest entry — applying an ordinarily-sound rule to a situation where its conditions don't hold
- Latent Condition Rounds
- Watching for the accumulating latent conditions that lie dormant in a system until they combine is exactly the resident-pathogen view of organizational accidents.
This sourceDescribes latent conditions as dormant organizational weaknesses that combine with local triggers like resident pathogens to breach defenses.
- Watching for the accumulating latent conditions that lie dormant in a system until they combine is exactly the resident-pathogen view of organizational accidents.
- Missed Trigger Review
- Its orientation — most misses are design failures in cue, binding, or routing, not personal lapses — is the practical form of the Swiss cheese model, where failures slip through because aligned holes in successive defenses let them, so you fix the layers rather than blame the last person.
This sourceModels organizational accidents as hazards passing through aligned weaknesses in successive defenses, directing prevention toward system layers rather than only the last operator.
- Its orientation — most misses are design failures in cue, binding, or routing, not personal lapses — is the practical form of the Swiss cheese model, where failures slip through because aligned holes in successive defenses let them, so you fix the layers rather than blame the last person.
Verification¶
Does it exist? Confirmed. This work's DOI resolves to a registered record, which fixes its identity. That is all it fixes.
Does it back the claim? Read against the text for 7 of 19 citations: 7 supported in part. Each verdict is shown under its citation below, with what in the work backs the sentence.
Support is checked per citation rather than per work — the same source can be cited soundly in one article and wrongly in another. Per-citation recording began recently, so a citation with no recorded check is a gap in the record rather than evidence it went unchecked.
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Links previously used in the corpus¶
Before the registry existed this work was also linked 7 other ways.
- https://doi.org/10.1017/CBO9781139062367 ×9
- https://doi.org/10.1017/cbo9781139062367 ×3
- https://assets.cambridge.org/97805213/14190/frontmatter/9780521314190_frontmatter.pdf ×1
- https://www.cambridge.org/core/books/human-error/B0D44C2C9D9C2A2C2C ×1
- https://www.cambridge.org/core/books/human-error/B71D9DE49A2C66832F3C9B8FE8B7DD9A ×1
- https://www.cambridge.org/core/books/human-error/B71DF35CF03F4F71D8AB8E9D80C7A4DC ×1
- https://www.cambridge.org/us/universitypress/subjects/psychology/cognition/human-error?format=PB&isbn=9780521314190 ×1
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