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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."

The Human Factors Analysis and Classification System–HFACS

The “Swiss cheese” model
of accident causation
February 2000

Drawing upon Reason’s (1990) concept of latent and active failures, HFACS describes four levels of failure: 1) Unsafe Acts, 2) Preconditions for Unsafe Acts, 3) Unsafe Supervision, and 4) Organizational Influences. A brief description of the major components and causal categories follows, beginning with the level most closely tied to the accident, i.e. unsafe acts.

4. Organizational Influences

As noted previously, fallible decisions of upper-level management directly affect supervisory practices, as well as the conditions and actions of operators. Unfortunately, these organizational errors often go unnoticed by safety professionals, due in large part to the lack of a clear framework from which to investigate them. Generally speaking, the most elusive of latent failures revolve around issues related to resource management, organizational climate, and operational processes, as detailed below in Figure 5.

Figure 5. Organizational factors influencing accidents.

Resource Management.

This category encompasses the realm of corporate-level decision making regarding the allocation and maintenance of organizational assets such as human resources (personnel), monetary assets, and equipment/facilities (Table 4). Generally, corporate decisions about how such resources should be managed center around two distinct objectives – the goal of safety and the goal of on-time, cost-effective operations. In times of prosperity, both objectives can be easily balanced and satisfied in full. However, as we mentioned earlier, there may also be times of fiscal austerity that demand some give and take between the two. Unfortunately, history tells us that safety is often the loser in such battles and, as some can attest to very well, safety and training are often the first to be cut in organizations having financial difficulties. If cutbacks in such areas are too severe, flight proficiency may suffer, and the best pilots may leave the organization for greener pastures.

TABLE 4. Selected examples of Organizational Influences (Note: This is not a complete listing)

Resource / Aquisition Management

  • Human Resources
    • Selection
    • Staffing / manning
    • Training
  • Monetary / budget resources
    • Excessive cost cutting
    • Lack of funding
  • Equipment / facility resources
    • Poor design
    • Purchasing of unsuitable equipment

Organizational Climate

  • Structure
    • Chain-of-command
    • Delegation of authority
    • Communication
    • Formal accountability for actions
  • Policies
    • Hiring and firing
    • Promotion
    • Drugs and alcohol
  • Culture
    • Norms and rules
    • Values and beliefs
    • Organizational justice

Organizational Process

  • Operations
    • Operational tempo
    • Time pressure
    • Production quotas
    • Incentives
    • Measurement / appraisal
    • Schedules
    • Deficient planning
  • Procedures
    • Standards
    • Clearly defined objectives
    • Documentation
    • Instructions
  • Oversight
    • Risk management
    • Safety programs

Excessive cost-cutting could also result in reduced funding for new equipment or may lead to the purchase of equipment that is sub optimal and inadequately designed for the type of operations flown by the company. Other trickle-down effects include poorly maintained equipment and workspaces, and the failure to correct known design flaws in existing equipment. The result is a scenario involving unseasoned, less-skilled pilots flying old and poorly maintained aircraft under the least desirable conditions and schedules. The ramifications for aviation safety are not hard to imagine.


Organizational Climate refers to a broad class of organizational variables that influence worker performance. Formally, it was defined as the “situationally based consistencies in the organization’s treatment of individuals” (Jones, 1988). In general, however, organizational climate can be viewed as the working atmosphere within the organization. One telltale sign of an organization’s climate is its structure, as reflected in the chain-of-command, delegation of authority and responsibility, communication channels, and formal accountability for actions (Table 4). Just like in the cockpit, communication and coordination are vital within an organization. If management and staff within an organization are not communicating, or if no one knows who is in charge, organizational safety clearly suffers and accidents do happen (Muchinsky, 1997).

An organization’s policies and culture are also good indicators of its climate. Policies are official guidelines that direct management’s decisions about such things as hiring and firing, promotion, retention, raises, sick leave, drugs and alcohol, overtime, accident investigations, and the use of safety equipment. Culture, on the other hand, refers to the unofficial or unspoken rules, values, attitudes, beliefs, and customs of an organization. Culture is “the way things really get done around here.”

When policies are ill-defined, adversarial, or conflicting, or when they are supplanted by unofficial rules and values, confusion abounds within the organization. Indeed, there are some corporate managers who are quick to give “lip service” to official safety policies while in a public forum, but then overlook such policies when operating behind the scenes. However, the Third Law of Thermodynamics tells us that, “order and harmony cannot be produced by such chaos and disharmony”. Safety is bound to suffer under such conditions.

Operational Process.

This category refers to corporate decisions and rules that govern the everyday activities within an organization, including the establishment and use of standardized operating procedures and formal methods for maintaining checks and balances (oversight) between the workforce and management. For example, such factors as operational tempo, time pressures, incentive systems, and work schedules are all factors that can adversely affect safety (Table 4). As stated earlier, there may be instances when those within the upper echelon of an organization determine that it is necessary to increase the operational tempo to a point that overextends a supervisor’s staffing capabilities. Therefore, a supervisor may resort to the use of inadequate scheduling procedures that jeopardize crew rest and produce sub optimal crew pairings, putting aircrew at an increased risk of a mishap. However, organizations should have official procedures in place to address such contingencies as well as oversight programs to monitor such risks.

Regrettably, not all organizations have these procedures nor do they engage in an active process of monitoring aircrew errors and human factor problems via anonymous reporting systems and safety audits. As such, supervisors and managers are often unaware of the problems before an accident occurs. Indeed, it has been said that “an accident is one incident to many” (Reinhart, 1996). It is incumbent upon any organization to fervently seek out the “holes in the cheese” and plug them up, before they create a window of opportunity for catastrophe to strike.

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