James Reason (1990)
Cambridge University Press.
DOI: https://doi.org/10.1017/cbo9781139062367
Abstract. The definitive treatment of human error. Develops the distinction between slips (execution failures), lapses (memory failures), and mistakes (planning failures), and introduces the Swiss cheese model of accident causation in which multiple imperfect layers of defence must fail simultaneously for a catastrophe to occur.
Tags: error safety foundational