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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 Fatality Investigations

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

Bill Gabbert wrote this article following the release of the Yarnell Hill Fire ADOSH report

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."

A Roadmap to a Just Culture:
Enhancing the Safety Environment

Prepared by: GAIN Working Group E,
Flight Ops/ATC Ops Safety Information Sharing

First Edition • September 2004

Appendix C. Different Perspectives

C1. ICAO perspective

The ICAO position is stated very clear in Annex 13 Section Non-disclosure of records – para. 5.12: “5.12 The State conducting the investigation of an accident or incident, shall not make the following records available for purposes other than accident or incident investigation, unless the appropriate authority for the administration of justice in that State determines that their disclosure outweighs the adverse domestic and international impact such action may have on that or any future investigations:

  1. all statements taken from persons by the investigation authorities in the course of their investigation;
  2. all communications between persons having been involved in the operation of the aircraft;
  3. medical or private information regarding persons involved in the accident or incident;
  4. cockpit voice recordings and transcripts from such recordings; and
  5. opinions expressed in the analysis of information, including flight recorder information.

5.12.1. These records shall be included in the final report or its appendices only when pertinent to the analysis of the accident or incident. Parts of the records not relevant to the analysis shall not be disclosed. NOTE: Information contained in the records listed above, which includes information given voluntarily by persons interviewed during the investigation of an accident or incident, could be utilized inappropriately for subsequent disciplinary, civil, administrative and criminal proceedings. If such information is distributed, it may, in the future, no longer be openly disclosed to investigators. Lack of access to such information would impede the investigative process and seriously affect flight safety.”

Related to the subject of non-disclosure of certain accident and incident records, ICAO has issued a State Letter (dated 31st of January 2002) enclosing the Assembly Resolution A33-17 (Ref.: AN 6/1-02/14). A copy of the letter and enclosure has been circulated for information and reference at SRC13 in February 2002. The letter basically introduces the Resolution A33-17, whereas the ICAO Assembly “urges Contracting States to examine and if necessary to adjust their laws, regulations and policies to protect certain accident and incident records in compliance with paragraph 5.12. of Annex 13, in order to mitigate impediments to accident and incident investigations”.

C2. Regulatory perspective

The UK CAA (1993) requires that human error events be reported to the Authority for safety analysis: “where a reported occurrence indicated an unpremeditated or inadvertent lapse by an employee, the Authority would expect the employer to act responsibly and to share its view that free and full reporting is the primary aim, and that every effort should be made to avoid action that may inhibit reporting. The Authority will accordingly make it known to employers that, except to the extent that action is needed in order to ensure, and except in such flagrant circumstances as described, it expects them to refrain from disciplinary or punitive action which might inhibit their staff from duly reporting incidents of which they may have knowledge.”

C3. An airline perspective

ABC Airlines (Disciplinary policy used by an international air carrier). ABC Airlines understands that it needs a safe and security culture that embraces highest corporate and industry standards. To do this, ABC Airlines require a willingness to address and remedy all operational shortcomings as soon as possible. This relies on having a comprehensive reporting of all incidents that pose hazards to the customers, staff or operations. All safety issues must be reported without exception. The company is committed to the greatest possible openness in reporting.

“No blame will be apportioned to individuals following their reporting of mishaps, operational incidents or other risk exposures, including those where they themselves may have committed breaches of standard operating procedures. The only exceptions to this general policy of no blame apportionment relate to the following serious failures of staff members to act responsibly, thereby creating or worsening risk exposures.

  • Premeditated or international acts of violence against people or damage to equipment/property
  • Actions or decisions involving a reckless disregard toward the safety of our customers, our fellow employees or significant economic harm to the company or
  • Failure to report safety incidents or risk exposures as required by standard operating procedures and / or this policy

Staff who act irresponsibly in one of these ways remain exposed to disciplinary action. A staff member’s compliance with reporting requirements will be a factor to be weighed in the company’s decision-making in such circumstances. Outside these specific and rarely invoked exceptions, staff members who make honest mistakes or misjudgments will not incur blame – provided that they report such incidents in a proper fashion.”

This disciplinary policy reasonably balances the benefits of a learning culture with the need to retain personal accountability and discipline.

C4. Air Navigation Service Providers

The EUROCONTROL Performance Review Unit (on behalf of the Performance Review Commission) conducted a survey of the legal constraints, as well as the potential shortfalls in the national safety regulations that would not support “non-punitive” reporting in ATM. The report found that the main legal issues of safety reporting are about personal data protection and the use of safety data, in particular that arising from the investigation. The respondents thought that it is important that the reporting system is trusted by all interested parties and that reporters need to feel that they will not be penalized through public exposure within or outside their organization for reporting routine, unintentional (honest) mistakes (see 2.1.3). The particularly with regard to the potential use of the information in court. Some states have addressed this conflict by offering protection to parties reporting honest mistakes.

The majority of respondents considered that their States national safety regulations did not explicitly mandate the implementation of a non-punitive environment.

Two of the key messages that emerged from the survey were that in many States there are significant legal constraints to non-punitive reporting in ATM. As a result many staff feel inhibited to report. This is particularly the case where States have “Freedom of Information” legislation in place and where they have not taken steps to protect safety reports from the application of such legislation. 2) The overwhelming majority of respondents (including non-European Union States), saw EU legislative proposals as a major enabler to implement non-punitive reporting.


From the 43rd Annual IFATCA (International Federation of Air Traffic Controllers’ Association) Conference in Hong Kong in March, 2004, the following comments were discussed regarding the implementation of a Just Culture. The 2.1.1. IFATCA policy on page 4 4 2 3 paragraph 2.2 Air safety reporting systems is that:

"Whereas IFATCA thinks a Voluntary Reporting System is essential, MA's should promote the creation of Air Safety reporting systems and Confidential Reporting Systems among their members" Additionally, "IFATCA shall not encourage MA's to join Voluntary Incident Reporting System unless there is a guaranteed immunity for the controller who is reporting. Any voluntary incident reporting system shall be based on the following principles:

  1. In accordance and in co-operation with the pilots, air traffic controllers and ATC authorities;
  2. The whole procedure shall be confidential, which shall be guaranteed by law;
  3. Guaranteed immunity for those involved, executed by an independent body."

See also the section on “Collective Aviation Opinion” from the 43rd Annual IFATCA conference which briefly describes the view points of aviation organizations on prosecution of employees and the resultant effect on safety.


In a recent statement to the World's media, the IFALPA President strongly denounced the growing trend of apportioning blame following aviation accidents. This threat of civil or criminal proceedings for violations of aviation safety laws and regulations is having a profound and damaging effect on the flow of precious aviation safety information which is essential if lessons are to be learned from accident investigations. IFALPA is supported by many prominent international organizations in its concern.

<<< continue reading—A Roadmap to a Just Culture, Appendix D. Glossary >>>

Reprinted by permission from the Global Aviation Information Network.


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