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operations. The results are finer grained and support stronger conclusions than those originally
found.
Samanta, P. K., & Mitra, S. P. (1982). Modeling of multiple sequential failures during
testing, maintenance and calibration (NUREG/CR-2211). Brookhaven National Lab.
This report looks at the nature of dependence among human failures in a multiple sequential
action and how it differs from other types of multiple failures. It is necessary to consider
dependant failures in a system because otherwise there are serious doubts as to the usefulness of
a reliability calculation that considers random events only. There are two types of dependant
failures. Common cause failures are caused by an event outside the group but common to the
components. Cascade failures are caused from within the group such as a single component
failure which results in the failure of all components concerned. A multiple sequential failure
during testing and maintenance is modeled by taking into account the processes involved in such
a failure. The data suggest that the dependence among failures increases as the number of
components in the system increases. Human error causes selective failure of components
depending on when the failure started. Since previous models of dependent failures were found
to be lacking, two models were developed. The first is very general and does not require any
dependent failure data. The second model took multiple sequential failures into account.
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Sanders, M. S. & McCormick, E. J. (1993). Human error, accidents, and safety. In Human
factors in engineering and design (7th ed.) (pp. 655-695). New York: McGraw-Hill, Inc.
This chapter deals with human error, accidents and improving safety in the domain of human
factors. Human error is defined as an inappropriate or undesirable human decision or behavior
that reduces, or has the potential for reducing, effectiveness, safety, or system performance. A
review of three classification schemes is performed. Swain and Guttmann’s omissioncommission
model is the first reviewed. A model by Rouse and Rouse is the second model
reviewed. Rasmussen’s skill-rule-knowledge based model is the third reviewed. An argument for
three general types of accident causation theories is made. These three types are accidentproneness
theories, job demand versus worker capability theories, and psychosocial theories.
Three aspects of risk perception are examined. These are the availability heuristic, the “It can’t
happen to me” bias, and relative risk. It is noted that warnings and product liability have become
important legal issues in today’s society. As a result of this, human factors has a large role to
play in these issues. The remainder of the article discusses Sanders and Shaw’s contributing
factors in accident causation model (CFAC). This model has five important tiers. Tier one
concerns itself with management issues. Tier two focuses on the physical environment,
equipment design, the work itself, and the social/psychological environment. The third tier
involves the worker and coworker factors. Tier four is where all unsafe behaviors from the
previous tiers are grouped. The fifth tier is the level of chance that leads to an accident. Unique
features of CFAC include the emphasis on management and social-psychological factors, the
recognition of the human-machine-environment system and the model’s simplicity and easy
comprehension.
Shappell, S. A. & Wiegmann, D. A. (1995). Controlled flight into terrain: The utility of
models of information processing and human error in aviation safety. Proceedings of the
Eighth International Symposium on Aviation Psychology, 8, 1300-1306.
A study of controlled flight into terrain (CFIT) accidents in the U.S. military was conducted to
try and ascertain why pilots do this. The study looked at an 11 year period. The four stage
information processing model of Wickens and Flach was used to classify 206 of the 278 pilot
causal factors found. These four stages are short-term sensory store, pattern recognition, decision
and response selection, and response execution. Reason’s model of unsafe acts was applied to the
data and allowed for the classification of 223 of 278 pilot causal factors. It was concluded that
any intervention needs to focus on the decision process of the pilot, specifically with mistakes
and violations.
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Shappell, S. A. & Wiegmann, D. A. (1997). A human error approach to accident
investigation: The taxonomy of unsafe operations. International Journal of Aviation
Psychology, 7(4), 269-291.
A framework is provided and discussed called the Taxonomy of Unsafe Operations. This
framework bridges the gap between classical theories and practical application by providing field
　
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