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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 E. Report Feedback Form

Please submit this form to:
GAIN Working Group E
c/o RS Information Systems, Inc.
1651 Old Meadow Road
McLean, Virginia 22102 USA
Fax: +1 (202) 267-5234; Email:

Name: ________________________________________________________________

Title/Position: ___________________________________________________________


Mailing Address:_________________________________________________________

Phone:_________________Fax:____________________E-Mail:: __________________

1. How useful is this report to your organization? (Please circle one)

not useful     -    1    2    3    4    5    -    very useful

2. Do you plan to use this report to help implement a “Just Culture” in your organization? If so, what information will be most helpful to you?

3. What information would you like to see added to this report?

4. What activities should WG E undertake that would be most useful to your organization?

5. Would you or someone in your organization be interested in participating in WG E?

6. Would you like to be added to our mailing list?

7. Other Comments/Suggestions

Reprinted by permission from the Global Aviation Information Network.


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