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the outer layer. The inner layer investigates the innermost cognitive reasons causing the error.
This is performed by teasing apart the processes and operations that contribute to that cause. The
diagnostic graph of cognitive operations leading to human error include four categories that all
fall under the heading of cue usage error. Cognitive biases is the first category. Examples of
these are input filter biases, info acquisition biases, info processing biases, intended output
biases, and feedback biases. Accidental slips and lapses is a second category. Examples of these
include environment/feedback errors, info acquisition errors, info processing errors, and intended
output errors. A third category is cultural motivations. Errors that occur in this category are
rational actor errors, incrementalism errors, recognition primed errors, and process control errors.
The final category is the missing knowledge category. Examples of these errors are initial
training errors, knowledge decay errors, and multidisciplinary errors. This model focuses on
errors that occur prior to time pressures and stress that occur during crisis or panic times. A
framework in which errors arise is presented and described. It is a system with four entities.
(1) The person or expert making the judgments.
(2) The task-environment within which the person makes the judgments.
(3) The feedback loop consisting of actions and reactions of people.
(4) The automated critics that try to influence a person’s judgment and decision.
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Singleton, W. T. (1973). Theoretical approaches to human error. Ergonomics, 16(6), 727-
737.
Two types of approaches to human error are discussed. The technological approach involves
coping with many problems with or without laboratory support and then attempting to generalize
the rules of the game in terms of classifications of kinds of problems with associated remedies.
The scientific approach is based on the principle that theory is the bridge between experiment
and practice. The author discusses different theoretical approaches and extracts useful elements
relevant to human error. The approaches looked at include the psychoanalytic approach, the
stimulus response approach, field theories, cybernetics, human performance and skill, Decision
Theory, the arousal/stress theories, and the social theories. The author concludes that errors and
accidents are not homogeneous, therefore it is necessary for a practitioner to match the most
relevant taxonomy and theory to the particular practical problem. It is suggested that no single
method will provide a complete answer but rather that this is where the greatest dividend is likely
to be found. From here, a comprehensive unweighted approach to problems is presented.
Stoklosa, J. H. (1983). Accident investigation of human performance factors. Proceedings
of the 2nd International Symposium on Aviation Psychology (pp. 429-436). Columbus, OH:
The Ohio State University, The Aviation Psychology Laboratory.
The paper discusses the necessary factual information for a detailed and systematic investigation
of the human performance aspects of an accident. Six profile categories are established which
include behavioral, medical, operational, task, equipment design, and environmental factors. This
concept has been successfully implemented in actual multi-modal accident investigations.
Sträter, O. (1996). A method for human reliability data collection and assessment.
Probabilistic Safety Assessment and Management ‘96 (pp. 1179-1184). New York:
Springer.
A method for evaluation of plant experience for probabilistic assessment of human actions is
described. The method is able to support root cause analysis in the evaluation of events and to
describe human failures with respect to HRA purposes. The method is applied to boiling water
reactor events and the results are compared with the data tables of the THERP handbook. The
evaluation framework was subdivided into two steps, the decomposition of an event into units
called MMS (man-machine systems), and then detailed analysis of the MMS-units. It was
concluded that it is possible to validate most of the items of the THERP handbook using the new
method. The new method is a reasonable procedure to analyze simulator data as well as to
improve Human Reliability systematically in a wide range of industries (i.e. aviation and power
plants).
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Swain, D., & Guttmann, H. E. (1980). Handbook of human reliability analysis with
emphasis on nuclear power plant applications (NUREG/CR-1278). Albuquerque, NM:
India Laboratories.
The Technique for Human Error Rate Prediction (THERP) model is presented in this handbook.
The steps in THERP define the system failures of interest, list and analyze the related human
　
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