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Pedrali, M. (1997). Root causes and cognitive processed: Can they be combined in accident
investigation? Ninth International Symposium of Aviation Psychology.
A methodological approach is proposed that relies on a model of cognition and a classification of
human errors. The intent of the approach is to reconstruct the process of cognition through which
latent failures give rise to active failures. A major concern with modern methodological
approaches is that they may stray too far from the context of the accident. A classification
scheme is devised that distinguishes three categories. The first category is person-related causes.
This deals with specific cognitive functions of people and general person-related functions. The
second category, system-related causes, focuses on training, equipment, procedure, and interface
issues. The third category is environment-related causes. These include ambient conditions,
communication, organization, and working conditions. The main principles of the HERMES
model were used to create a prototype software tool called DAVID (Dynamic Analysis of Video
in Incident studies).
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Petersen, D., & Goodale, J. (1980). Readings in industrial accident prevention. New York:
McGraw-Hill.
This book is a forum for debate and information sharing of key issues in accident causation and
prevention. The first part of the book deals with the basis of philosophy of accident prevention.
Some issues examined are the differences between unsafe acts and unsafe conditions. Models of
accident phenomenon are discussed. The pros and cons of cost-benefit analyses are argued. The
idea of an “injury tax” to help offset some problems of a company’s unwillingness to increase
safety is presented. Important principles and factors when attempting to control accidents are
also explained. The second part of the book examines accident prevention methods in stages.
Data collection and analysis is an important stage. Issues examined are mathematical evaluations
and creating a safety program priority system. Systems approach issues are examined into
separate papers. Monitoring, motivating, and training are discussed due to their relevance in
preventing accidents. The third section of the book covers miscellaneous subjects such as the
professionalism of investigators and management, insurance issues, risk management and
looking at the effectiveness of OSHA.
Ramsey, J. D. (1985). Ergonomic factors in task analysis for consumer product safety.
Journal of Occupational Accidents, 7, 113-123.
The author proposes a model that identifies contributing factors to accidents. This is done by
following the information processing steps of an accident sequence and listing factors that affect
each stage of the process. The accident sequence model has four levels to it. If any level’s
criteria are not met, it leads to an increased chance of an accident occurring. If a level’s criteria
are met, the sequence progresses to the next level until a state of increased chance for no accident
occurs. When exposure to a hazardous product occurs, a person goes through four levels in order,
assuming the criteria for each level is met. Level one is the perception of the hazard. This
involves sensory skills, perceptual skills, and the state of alertness. Level two is cognition of the
hazard. Factors affecting this are experience and training, mental abilities, and memory abilities.
Level three is the decision to avoid the hazard. Factors affecting this are experience and training
again, attitude and motivation, risk-taking tendencies, and personality. The fourth and final level
is the ability to avoid the hazard. Relevant factors here are anthropometrical, biomechanical, and
motor capabilities.
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Rasmussen, J. (1981). Models of mental strategies in process plant diagnosis. In J.
Rasmussen and W.B. Rouse (Eds.), Human Detection and Diagnosis of System Failures
(pp.241-258). Plenum Press, New York.
The author states that the ultimate purpose of diagnosis in process plant control is to link the
observed symptoms to the actions which will serve the current goal properly. The paper contrasts
a topographic search versus a symptomatic search to locate problems. The author refutes the
trend to design man-machine interfaces towards a presentation of measured variables on visual
display units as bar graphs and/or mimic displays while also attempting to unload the operator by
alarm analysis and reduction. An optimal computer-based design is proposed as having sharp
distinctions disappear between the functions of alarm and safety systems, of control systems, and
of operators. A key role of the computer will be as a partner of the operator in higher level
supervisory control.
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