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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

5. References

American Law Institute Model Penal Code, Article 2. General Principles of Liability, Explanatory Note 2.02, 1962.

Barach, P., & Small, S. D. (2000). Reporting and preventing medical mishaps: lessons from non-medical near-miss reporting systems. British Medical Journal, 320, 759-763.

Berman, J., & Collier, D. (1996). The collection and use of near miss data - Is 'no blame' just wishful thinking? Paper presented at Managing Risk in a Changing Organisational Climate. Safety and Reliability Society, Swindon, England.

Chappell, S. L. (1994). Using voluntary incident reports for human factors evaluations. In N. McDonald & N. Johnston & R. Fuller (Eds.), Aviation Psychology in Practice (pp. 149- 172). Aldershot, UK: Ashgate.

Clarke, S. (1998). Organisational factors affecting the incident reporting of train drivers. Work and Stress, 12(1), 6-16.

Cox, S., & Cox, T. (1991). The structure of employee attitudes to safety: a European example. Work and Stress, 5, 93-106.

Fleming, M., Flin, R., Mearns, K., & Gordon, R. (1998). Risk perceptions of offshore workers on UK oil and gas platforms. Risk Analysis, 18(1), 103-110.

Flin, R., & Slaven, G. (1996). Managing the Offshore Installation Workforce. Tulsa, Oklahoma: PennWell Books.

Gordon, R. (2002) The Contribution of Human Factors to Incidents in the Offshore Oil Industry: Development of a Human Factors Investigation Tool, Unpublished PhD Thesis, University of Aberdeen, Aberdeen, Scotland.

GAIN (1999) GAIN Operator’s Flight Safety Handbook,

GAIN (2002) GAIN: Using Information Proactively to Improve Aviation Safety,

GAIN (2003) Pilot/Controller Collaboration Initiatives: Enhancing Safety and Efficiency,

GAIN Working Group E, Report available from the GAIN website:

Hudson, P. (2001) Aviation Safety Culture, Safeskies Conference, Canberra, Australia.

IAEAa, Developing Safety Culture in Nuclear Activities, Safety Report Series Nr. 11

IAEAb, Key Practical Issues in Strengthening Safety Culture, INSAG-15

IFATCA (March, 2004) A just culture in safety reporting. Paper presented at the 43rd Annual Conference, Hong Kong, China.

IFATCA (Sept 2003) The need for a just culture in aviation safety management. Paper presented at the 11th Air Navigation Conference, Montreal, Canada.

Johnson, C. (2003) Failure in Safety-Critical Systems: A Handbook of Accident and Incident Reporting, University of Glasgow Press, Glasgow, Scotland.

Lawson, J. M. (1991). Evaluation and development of an accident report form. Paper presented at the Ergonomics and Human Environments. Proceedings of the 27th Annual Conference of the Ergonomics Society of Australia, Coolum, Australia.

Lucas, D. A. (1991). Organisational aspects of near miss reporting. In T. W. van der Schaaf & D. A. Lucas & A. R. Hale (Eds.), Near Miss Reporting as a Safety Tool. Oxford: Butterworth, Heinemann.

Marx, D. (2001) Patient safety and the “Just Culture”: A Primer for health care executives, Report for Columbia University under a grant provided by the National Heart, Lung and Blood Institute.

Mearns, K., Flin, R., Fleming, M., & Gordon, R. (1997). Human and Organisational Factors in Offshore Safety (Offshore Technology Report OTH 543). London: UK Health and Safety Executive.

Mearns, K., Flin, R., Gordon, R. and Fleming, M. (1998). Measuring safety climate on offshore installations. Work and Stress, 12(3), 238-254.

Norbjerg P.M. (2004) The creation of an Aviation safety reporting culture in Danish Air Traffic Control. Paper presented at the Open Reporting and Just Culture Workshop: Legal Impediments, held at EUROCONTROL, Brussels.

NZ CAA Personal correspondence with Max Stevens (and website:

O'Leary, M. (1995). Too bad we have to have confidential reporting programmes! some observations on safety culture. In N. McDonald & N. Johnston & R. Fuller (Eds.), Applications of Psychology to the Aviation System. Aldershot, England: Avebury Aviation.

Pimble, J., & O'Toole, S. (1982). Analysis of accident reports. Ergonomics, 25(11), 967-979.

Reason, J. (1997). Managing the Risks of Organisational Accidents. Hants, England, Ashgate Publishing Ltd.

Reason, J. and Hobbs, A. (2001) Managing Maintenance Errors: A Practical Guide. Chapter 11. Safety Culture, Hants, England, Ashgate Publishing Ltd.

Robinson & Grall (1983) Element Analysis in Defining Criminal Liability: The Model Penal Code and Beyond. 35 Stan. L. Rev. 681, pp 695-96.

SRU (2000) EUROCONTROL ESARR 2 Workshops and Guidance to ATM Safety
Regulators: “AGAS and Just Culture” EAM2-GUI 6

Stanton, S. (1990). Accident reporting form substance. Accident Prevention, December, 13-16.

Tamuz, M. (1994). Developing organisational safety information systems for monitoring potential dangers. Paper presented at the Proceedings of PSAM II, International Conference Devoted to the Advancement of System-based Methods for the Design and Operation of Technological Systems and Processes, San Diego, California.

UK CAA (2003) The Mandatory Occurrence Reporting (MOR) Scheme. Information and Guidance. CAP 382, UK CAA, SIDD, Safety Regulatory Group, West Sussex (available

van der Schaaf, T. W. (1991). A framework for designing near miss management systems. In T. W. van der Schaaf, D. A. Lucas & A. R. Hale (Eds.), Near Miss Reporting as a Safety Tool. Oxford, Butterworth-Heinemann.

Vecchio-Sadus, A.M. and Griffiths, S. (2004) Marketing strategies for enhancing safety culture, Safety Science, 42, 601-619.

Wright, P. and Barnard, P. (1975). 'Just fill in this form' - A review for designers. Applied Ergonomics, 6(4), 213-220.

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Reprinted by permission from the Global Aviation Information Network.


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