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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


The term ‘no-blame culture’ flourished in the 1990s and still endures today. Compared to the largely punitive cultures that it sought to replace, it was clearly a step in the right direction. It acknowledged that a large proportion of unsafe acts were ‘honest errors’(the kinds of slips, lapses and mistakes that even the best people can make) and were not truly blameworthy, nor was there much in the way of remedial or preventative benefit to be had by punishing their perpetrators. But the ‘no-blame’ concept had two serious weaknesses. First, it ignored—or, at least, failed to confront—those individuals who willfully (and often repeatedly) engaged in dangerous behaviors that most observers would recognize as being likely to increase the risk of a bad outcome. Second, it did not properly address the crucial business of distinguishing between culpable and non-culpable unsafe acts.

In my view, a safety culture depends critically upon first negotiating where the line should be drawn between unacceptable behavior and blameless unsafe acts. There will always be a grey area between these two extremes where the issue has to be decided on a case by case basis. This is where the guide-lines provided by A Roadmap to a Just Culture will be of great value. A number of aviation organizations have embarked upon this process, and the general indications are that only around 10 per cent of actions contributing to bad events are judged as culpable. In principle, at least, this means that the large majority of unsafe acts can be reported without fear of sanction. Once this crucial trust has been established, the organization begins to have a reporting culture, something that provides the system with an accessible memory, which, in turn, is the essential underpinning to a learning culture. There will, of course, be setbacks along the way. But engineering a just culture is the all-important early step; so much else depends upon it.

James Reason

<<< continue reading—A Roadmap to a Just Culture, Executive Summary >>>

Reprinted by permission from the Global Aviation Information Network.


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