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Rasmussen, J. (1982). Human errors. A taxonomy for describing human malfunction in
industrial installations. Journal of Occupational Accidents, 4, 311-333.
A taxonomy for event analysis is presented. The taxonomy recognizes that error mechanisms and
failure modes depend on mental functions and knowledge which are activated by subjective
factors. They are not directly observed but are inferred. A model of human information
processing is needed to relate elements of human decision making and action to internal
information processes for which generic psychological mechanisms and limitations can be
identified. Such a model was developed that draws on a distinction between three levels of
behavior. Skill-based domain of behavior includes subconscious routines and performance that is
controlled by stored patterns of behavior in a time-space domain. Rule-based domain of behavior
includes performance in familiar situations and is controlled by stored rules for coordination of
subroutines. Knowledge-based domain of behavior occurs in unfamiliar situations where actions
must be planned from an analysis. In this domain decisions need to be based on knowledge of the
functional and physical properties of the system while also giving importance to the priority of
the various goals. It is possible for the same required mental function to be served by different
information processes, and each with their own error mechanism. A five dimension multi-facet
classification system is described for an accidental chain of events. The dimensions include
external causes, internal failure mechanisms, internal mental functions failed, external mode of
action failures, and external tasks. Categories of the taxonomy directly related to the
inappropriate human performance are listed. These are:
(1) Personnel task—identification of the task performed
(2) External mode of malfunction—immediate observable effect of human malfunction
(3) Internal human malfunction—internal mental function of a persons decision making which
was not performed as required by the task
(4) Mechanisms of human malfunction
(5) Causes of human malfunction—identifies possible external causes of inappropriate human
action
(6) Performance shaping and situational factors—general conditions that can influence error
probability but not cause errors in and of themselves
39
Reason, J. (1979). Actions not as planned: The price of automatization. In G. Underwood
(Ed.), Aspects of consciousness (pp. 67-89). London: Academic Press.
The author takes a detailed look at minor slips and lapses that humans make in everyday life, and
tries to sort out some of the conceptual confusion that exists between an act and its
consequences. A brief experiment of natural history observations was performed that asked
subjects to record unintended or absent-minded actions. Two predictions are made. First, test
failures will occur when the open-loop mode of control coincides with a critical decision point
where the strengths of the motor programs beyond that point are markedly different. The second
prediction is that when errors occur, it will involve the unintended activation of the strongest
motor program beyond the node. The discussion then switches to ‘Slips of action’. It is argued
that ‘slips of action’ have certain consistencies. They occur almost exclusively during the
automatic execution of highly practiced and ‘routinized’ activities. They often result from the
misdirection of focal attention. Finally, they usually take the form of some frequently and
recently performed behavioral sequence.
Reason, J. (1990). Human error. Cambridge, MA: Cambridge University Press.
The author presents a framework of accident causation. The framework is an expansion of a
“resident pathogen” metaphor, meaning that causal factors are present in a system before an
accident sequence actually occurs. This leads to a differentiation of active failures and latent
failures. An important premise of the framework is that accidents come from fallible decisions
that are made by designers and decision makers. Five basic elements of a system are first
identified and then related to breakdowns in a system. One element is that decision makers are
those who set goals for the system and can make fallible decisions (latent failures). Another
element is that line management implements the strategies of the decision makers and are subject
to deficiencies themselves (latent failures). A third element is that preconditions are conditions
that permit efficient and safe operations and can be precursors for unsafe acts (latent failures). A
fourth element is that productive activities are the actions performed by man and machine and
　
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