1979, the TMI incident operates an awareness of the influence of local workplace
conditions on the operator’s performance. While Charles Perrow sees in TMI the
advent of a normal accident, Reason finds the first level of his taxonomy: distinction between active and latent errors. In 1985, Reason and Embrey publishes
Principles Human factors relating to the modeling of human errors in abnormal
condition of nuclear power plants and major hazardous installations. One year
later, the Chernobyl disaster provides an unfortunate case study. Reason introduces
a new distinction between errors and violations in his taxonomy. In 1987, he
publishes an article in British Psychological Society bulletin devoted to Chernobyl
errors’ study from a theoretical perspective. In 1988, he publishes modeling the
basic tendencies of human operator error, thus introducing an error model which
allows modeling the human behaviour of problem solving (the Generic Error
Modeling System, GEMS). Reason’s cognitive models were then based on
observations in NPPs control rooms as case study of human behavior.
The development of distinction between accidents theories based on active or
latent errors and violations, is strongly linked to the development of nuclear energy
and its safety culture. From 1979 to 1988, Reason uses accident investigations and
gets used to the field and its culture. For all that, his productions remains designed
to his peers. A turning point is met when the observation process becomes a
collaborative one and that Reason’s psychologist work mingles with the engineering one of Wreathall.
3.2 From Fundamental to Applied Research
1987 represents a break in Reason’s work [2]. After studying everyday errors for
ten years, Reason holds a major contribution to his discipline with the taxonomy of
unsafe acts [3, p. 207]. He publishes the Generic Error Modelling System ([4]
Fig. 1a), a combination of his classification with the Skill Rule Knowledge model of
Danish psychologist Rasmussen [5]. It presents the types of human failures linked
with the specificities of a given activity. This theoretical cognitive model still
belongs to the field of psychological research (model quoted 192 times).
The same year, Reason works on a chapter of Human Error dedicated to
industrial accidents and designed for security practitioners. He has the backing of
his friend Wreathall. Reason says he looked for a manner of “showing people what
our work was about”. Wreathall talks in these terms of the genesis of the first model
“during an exchange in a pub (the Ram’s Head) in Reason’s home town (Disley
Cheshire, England), we have drawn the very first SCM on paper napkin. Initially,
James saw the organizational accident as a series of “sash” windows opening or
closing thus creating accident opportunity”. Wreathall allowed the psychologist to
combine his accident theory (resident pathogens metaphor; [6]) and his error taxonomy with a pragmatic model of any productive system.
The shift over, the cognitive and theoretical model changed into a descriptive
and empirical one (Fig. 1b). The book Human Error received a warm welcome by
Human Error and Defense in Depth …
261
conditions on the operator’s performance. While Charles Perrow sees in TMI the
advent of a normal accident, Reason finds the first level of his taxonomy: distinction between active and latent errors. In 1985, Reason and Embrey publishes
Principles Human factors relating to the modeling of human errors in abnormal
condition of nuclear power plants and major hazardous installations. One year
later, the Chernobyl disaster provides an unfortunate case study. Reason introduces
a new distinction between errors and violations in his taxonomy. In 1987, he
publishes an article in British Psychological Society bulletin devoted to Chernobyl
errors’ study from a theoretical perspective. In 1988, he publishes modeling the
basic tendencies of human operator error, thus introducing an error model which
allows modeling the human behaviour of problem solving (the Generic Error
Modeling System, GEMS). Reason’s cognitive models were then based on
observations in NPPs control rooms as case study of human behavior.
The development of distinction between accidents theories based on active or
latent errors and violations, is strongly linked to the development of nuclear energy
and its safety culture. From 1979 to 1988, Reason uses accident investigations and
gets used to the field and its culture. For all that, his productions remains designed
to his peers. A turning point is met when the observation process becomes a
collaborative one and that Reason’s psychologist work mingles with the engineering one of Wreathall.
3.2 From Fundamental to Applied Research
1987 represents a break in Reason’s work [2]. After studying everyday errors for
ten years, Reason holds a major contribution to his discipline with the taxonomy of
unsafe acts [3, p. 207]. He publishes the Generic Error Modelling System ([4]
Fig. 1a), a combination of his classification with the Skill Rule Knowledge model of
Danish psychologist Rasmussen [5]. It presents the types of human failures linked
with the specificities of a given activity. This theoretical cognitive model still
belongs to the field of psychological research (model quoted 192 times).
The same year, Reason works on a chapter of Human Error dedicated to
industrial accidents and designed for security practitioners. He has the backing of
his friend Wreathall. Reason says he looked for a manner of “showing people what
our work was about”. Wreathall talks in these terms of the genesis of the first model
“during an exchange in a pub (the Ram’s Head) in Reason’s home town (Disley
Cheshire, England), we have drawn the very first SCM on paper napkin. Initially,
James saw the organizational accident as a series of “sash” windows opening or
closing thus creating accident opportunity”. Wreathall allowed the psychologist to
combine his accident theory (resident pathogens metaphor; [6]) and his error taxonomy with a pragmatic model of any productive system.
The shift over, the cognitive and theoretical model changed into a descriptive
and empirical one (Fig. 1b). The book Human Error received a warm welcome by
Human Error and Defense in Depth …
261