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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."


Given February 1997 for use in the Fatality Fire Case Study Training Course


It has been 12 years since the Rainbow Springs Fire but thoughts of that day are still very painful. Although few names are mentioned, it is likely some former employees of the Mena District would be offended by my references to certain actions that, at best, would indicate negligence in some of our very important duties. Some will undoubtedly feel this is an attempt to rid myself of blame for many of the mistakes or misjudgement that occurred on the Rainbow Springs Incident. If that is my purpose, why would I have waited almost 13 years to give this statement? The fact is, I had no thought of giving my account of the Rainbow Springs Incident until receiving word of the training exercise that would include this fire. I was also influenced by an article written about the same time by an FMO in Region 5 who recommended greater accountability for overhead people when there is a fatality or serious injury to a firefighter.

I would do anything possible to prevent another tragedy such as Rainbow Springs. Therefore, it does not bother me at all to see a training exercise developed that allows students to review our actions at Rainbow Springs and devise hypothetical solutions that would have produced a much more favorable outcome. However, I feel much would be lost if the focus is on what happen at Rainbow Springs without any regard for why it happened. In these days of heavy workloads and fewer people, I believe it would be possible for most any district with a light fireload to let a situation develop similar to what we had on the Mena District prior the Rainbow Springs Incident.

As for greater emphasis on accountability, I have very mixed feelings as to how effective that would be. I accepted the role of IC on the Rainbow Springs Incident without a strong feeling of confidence that I was qualified for such task. Afterall, I had not been involved in fire suppression in almost 4 years and did not have a particularly strong resume for the position of IC. I did feel that I was the most qualified person that happened to be available at the time. Perhaps it is ironic that I accepted that position out of concern for the safety of our employees.

Before I say anything about pain and sacrifice, let me make it clear that the real pain and sacrifices were made by the victims and members of their immediate families. As for myself, I feel very fortunate that the group of competent and highly professional people who conducted the investigation did not recommend I go stand in the long line at the local employment office. But in all honesty, that was the least of my worry. If we have people in fire overhead positions that are more concerned about that trip to the employment office than the lives of their fellow employees, I believe we have some serious problems.


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