Cognitive failures and accidents

• Published in: Applied cognitive psychology 1990-07, Vol.4 (4), p.273-294
• Main Authors: Wagenaar, Willem A., Hudson, Patrick T. W., Reason, James T.
• Format: Article
• Language: English
• ISSN: 0888-4080; 1099-0720
• DOI: 10.1002/acp.2350040405

In this paper we argue that industrial accidents are the end‐results of long chains of events that start with decisions at management level. Often these decisions create latent failures, which may remain hidden for a long time. Latent failures can be grouped into a limited number of classes, which are called general failure types. Examples are: wrongly designed machines, unsuitable work procedures, and incompatible goals. Latent failures will affect the psychological processes determining the actual behaviour of workers on the shop floor. Consequently, these workers will commit unsafe acts that, provided the system lacks appropriate defences, will cause accidents. Our discussion of accidents and their cognitive causes follows this logic, and stresses the point that, in modern industries, preventive action will be more effective when aimed at changes based on management decisions. The reason for this is that many unsafe acts are not simple slips, but intentional and reasoned actions that end in unforeseen results. Erroneous plans are not easily avoided on the shop floor, once they are invited by operational conditions replete with latent failures. However, the removal of latent failures requires a more thorough understanding of how they shape behaviour, than is provided by our current insights in cognition.