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Swiss Cheese Model

swiss cheese slice

The Human Factors Analysis and Classification System—HFACS

Cover and Documentation
1. Unsafe Acts
2. Preconditions for Unsafe Acts
3. Unsafe Supervision
4. Organizational Influences

HFACS and Wildland Firefighting Investigations

Hugh Carson wrote this article a few days after the Cramer Fire

A Roadmap to a Just Culture: Enhancing the Safety Environment

Cover and Contents
Forward by James Reason
Executive Summary
1. Introduction
2. Definitions and Principles of a Just Culture
3. Creating a Just Culture
4. Case Studies
5. References
Appendix A. Reporting Systems
Appendix B. Constraints to a Just Reporting Culture
Appendix C. Different Perspectives
Appendix D. Glossary of Acronyms
Appendix E. Report Feedback Form

Rainbow Springs Fire, 1984 — Incident Commander Narration

Years Prior
April 25th
Fire Narrative
Lessons Learned

U.S. Forest Service Fire Suppression: Foundational Doctrine

Tools to Identify Lessons Learned

An FAA website presents 3 tools to identify lessons learned from accidents. The site also includes an animated illustration of a slightly different 'Swiss-cheese' model called "defenses-in-depth."

Swiss Cheese Model and Firefighter Safety

Organizational History Protection vs. Production
Dr. James Reason developed this chart to describe the relationship between protection and production over the history of a hypothetical organization. Those in high-hazard ventures — such as wildland firefighting — should operate above the parity zone, that is, protection should at least “match the hazards of productive operations.”

The 10th Fire Order reflects our need to balance production and protection: “Fight fire aggressively, having provided for safety first.” Like others in high hazard ventures, firefighters have traded improvements in protection for productive advantage. The availability of fire shelters has led some to fight fire in the absence of escape routes and safety zones.

Organizations develop layers of defense between the hazards and people/assets at risk from operations. However the layers are rarely perfect, with holes like a slice of Swiss cheese.

When the “holes” of every “slice” line up, the system provides a trajectory for an accident to occur.

It doesn't really matter if this is something you were born to do.

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