Human error and the problem of causality in analysis of accidents.

By Jens Rasmussen. 1990

How researchers see this paper

The researchers whose trusted networks rank it highest, strongest advocate first. Every researcher gets a different order.

The 1996 Mount Everest climbing disaster: The breakdown of learning in teams (2004, background): “First, these events fit Perrow’s (1984) definition of a disaster ‘incident’, because the events led to the breakdown of specific units of an organization.”
A Review of Literature: Individual Blame vs. Organizational Function Logics in Accident Analysis (2008, background): “Many authors (Sagan, 1993; Rasmussen, 1990; Vaughan, 1996; Turner & Pidgeon, 1997; Perrow, 1999; Choularton, 2001; Busby, 2006; Elliot & Smith, 2006) underline the difficulty of learning from accidents and errors and how to act in order to prevent the risk that the same errors can occur again.”
Why Did the Pilots Shut Down the Wrong Engine? Explaining Errors in Context Using Schema Theory and the Perceptual Cycle Model (2012, background): “Human error is consistently implicated as a major contributor to accidents in safety critical systems, such as aviation (Amalberti, 2001; Rasmussen, 1990; Stanton and Salmon, 2009).”
Applying systems thinking to analyze and learn from events (2010, background): “…are separate decisions difﬁcult to identify in this model of human control, but the study of decision-making then cannot be separated from a simultaneous study of the social context, the value system in which it takes place, and the dynamic work process it is intended to control (Rasmussen, 1990).”