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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 D. Glossary of Acronyms

AAIB Air Accidents Investigation Branch (UK CAA)
ANSP Air Navigation Service Provider
ARS Mandatory Aviation Reporting System (British Airways)
ASAP Aviation Safety Action Program
ASRS Aviation Safety Reporting System
ATC Air Traffic Control
ATCO Air Traffic Control Operator
ATM Air Traffic Management
BASIS British Airways Safety Information System
CAA Civil Aviation Authority
CHIRP Confidential Human Factors Incident Reporting Programmed
CIRAS Confidential Incident Reporting (UK Railway Industry)
ERS Error Reporting System (UK CAA)
ESAAR EUROCONTROL Safety Regulatory Requirements
EU European Union
EUROCONTROL European Organization for the Safety of Air Navigation
FAA Federal Aviation Administration
FOQA Flight Operational Quality Assurance
GA General Aviation
GAIN Global Aviation Information Network
HFACS Human Factors and Analysis Classification System
HFRP Human Factors Reporting Programmed (British Airways)
HR Human Resources
IEP Internal Evaluation Program
IATA International Air Transport Association
IAEA International Atomic Energy Agency
ICAO International Civil Aviation Organization
IFALPA International Federation of Air Line Pilots' Associations
IFATCA International Federation of Air Traffic Controllers' Associations MAs Member Associations
MERP Maintenance Error Reduction Policy MOR Mandatory Occurrence Reporting
NASA National Aeronautics and Space Administration
NZ New Zealand
OPS Operations
SAASCo South African Confidential Reporting System
SIDD Safety Investigation and Data Department (UK CAA)
SOP Standard Operating Procedure
SPD Signal Passed at Danger (Railway Industry)
SRC EUROCONTROL Safety Regulation Commission
SRU EUROCONTROL Safety Regulation Unit
UK United Kingdom
WG Working Group

<<< continue reading—A Roadmap to a Just Culture, Appendix E. Report Feedback Form >>>

Reprinted by permission from the Global Aviation Information Network.


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