Abstract
This paper argue that serious failures of a complex, centralized system arise from the interaction between two factors:
-
• The properties of the system as a whole (the systems domain).
-
• The information-handling characteristics of the human element (the human domain).
This is a preview of subscription content, log in via an institution to check access.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
Preview
Unable to display preview. Download preview PDF.
References
Barüett, F. E. (1932). Remembering. Cambridge: Cambridge University Press.
Bignall, V., Petrers, G. and Pym, C. (1977). Catastrophic Failures. Milton Keynes: Open University Press.
Greenwald, A. G., Leippe, M. R., Pratkanis, A. R. and Baumgardner, M. H. (1986). Under what conditions does theory obstruct research progress? Psychological Review, 93: 216–229.
Hasher, L. and Zacks, R. T. (1984). Automatic processing of fundamental information: The case of frequency of occurrence. American Psychologist, 39: 1138–1372.
Hintzman, D. C. (1976). Repetition and memory. In G. H. Bower (ed), The Psychology of Learning and Motivation, (Vol 10). New York: Academic Press.
INPO (1984). An Analysis of Root Causes in 1983 Significant Event Reports. INPO 84-027, Atlanta, Georgia: Institute of Nuclear Power Operations.
INPO (1985). A Maintenance Analysis of Safety Significance Events. Nuclear Utility Management and Human Resources Committee, Maintenance Working Group, Atlanta, GA: Institute of Nuclear Power Operations.
Kasputin, R. (1986). Application of team concept/system approach to investigation of major mishaps. This volume.
Kelly, A. (1984). Maintenance Planning and Control. London: Butterworths.
Lewis, C. and Norman, D. E. (1986). Designing for error. In D.A. Norman and S.W. Draper (eds) User Centered System Design. Hillsdale, NJ: Erlbaum.
Nisbett, R. and Ross, L. (1980). Human Inference: Strategies and Shortcomings of Social Judgement. Englewood Cliffs, NJ: Prentice-Hall.
Norman, D. A. (1981). Categorization of action slips. Psychological Review, 88: 1–15.
Norman, D. E. and Bobrow, D. G. (1979). Descriptions: An intermediate stage in memory retrieval. Cognitive Psychology, 11: 107–123.
Pew, R. W., Miller, D. C. and Feeher, C. E. (1981). Evaluation of Proposed Control Room Improvements through Analysis of Critical Operators Decisions. NP-1982, Research Project 891, Cambridge, Mass.: Bolt, Baranek and Newman, Inc.
Perrow, C. (1984). Normal Accidents: Living with High-Risk Technologies. New York: Basic Books.
Rasmussen, J. (1980). What can be learned from human error reports? In K. Duncan, M. Gruneberg, and D. Walli (eds), Changes in Working Life. London: Wiley.
Rasmussen, J. and Pedrsen, O. M. (1982). Formalized Search Strategies for Human Risk Contributions: A Framework for Further Development. Riso-M-2351, Roskilde, Denmark: Riso National Laboratory.
Reason, J. T. (1986a). Catastrophic combinations of trivial errors. In T.Cox (ed.), The Psychology of Occupational Safety and Accidents. To be published by Taylor and Francis (London).
Reason, J. T. (1986b). Cognitive under-specification: Its varieties and consequences. In B. Baars (ed.), The Psychology of Error: A Window on the Mind. To be published by Plenum (New York).
Reason, J. T. and Embrey, D. E. (1985). Human Factors Principles Relevant to the Modelling of Human Errors in Abnormal Conditions of Nuclear and Major Hazardous Installations. Prepared for the European Atomic Energy Community under contract EC1 1164-B7221-84-UK, Parbold, UK: Human Reliability Associates.
Rolt, L. T. C. (1978). Red for Danger. London: Pan Books.
Sheridan, T.B. and Hennessy, R.T. (1984). Research and Modeling of Supervisory Control Behavior. Washington, DC: National Academy Press.
Turner, B. A. (1978). Man-Made Disaster. London: Wykeham Publications.
Wagenaar, W. (1986). The Cause of Impossible Accidents. The Sixth Duijker Lecture, Amsterdam, 18 March.
Woods, D. D. (1982). Operator Decision Behavior during the Steam Generator Tube Rupture at the Ginna Nuclear Power Station. Research Report 82-1C57-CONRM-R2, Pittsburgh, PA: Westinghouse R&D Center.
Woods, D. D. (1984). Some Results on Operator Performance in Emergency Events. Institute of Chemical Engineers Symposium Series No. 0: 21-13.
Author information
Authors and Affiliations
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 1987 Springer-Verlag Berlin Heidelberg
About this paper
Cite this paper
Reason, J. (1987). An Interactionist’s View of System Pathology. In: Wise, J.A., Debons, A. (eds) Information Systems: Failure Analysis. NATO ASI Series, vol 32. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-83091-4_22
Download citation
DOI: https://doi.org/10.1007/978-3-642-83091-4_22
Publisher Name: Springer, Berlin, Heidelberg
Print ISBN: 978-3-642-83093-8
Online ISBN: 978-3-642-83091-4
eBook Packages: Springer Book Archive