Human Error¶
Reason, J. (1990). Human Error. Cambridge University Press.
Cited by¶
12 citations across 12 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.
- 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.
- 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.
- 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.
- 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.
Mechanisms¶
- 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
Verification¶
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Links previously used in the corpus¶
Before the registry existed this work was also linked 4 other ways.
- 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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