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Swiss Cheese Model

swiss cheese slice

The Human Factors Analysis and Classification System—HFACS

Cover and Documentation
Introduction
1. Unsafe Acts
2. Preconditions for Unsafe Acts
3. Unsafe Supervision
4. Organizational Influences
Conclusion
References

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

Introduction
Years Prior
April 25th
Fire Narrative
Lessons Learned
Conclusion

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

Table of Contents

Acknowledgements v
Foreword
 vi
Executive Summary viii
1. Introduction 1
     1.1 Purpose of Report 1
     1.2 GAIN Overview
 1
     1.3 Flight Ops/ATC Ops Safety Information Sharing Working Group (WG E)
 2
     1.4 Overview of the Issue 3
2. Definitions and Principles of a Just Culture
 4

2.1 Definition of Just Culture 4

2.2 Principles of a Just Culture 4
  2.3 Four types of unsafe behaviors
 6
  2.4 Defining the border of “unacceptable behavior”
 6
  2.5 Determining ‘culpability’ on an individual case basis
 7
3. Creating a Just Culture 13
  3.1 Benefits of a Just Culture
 13
  3.2 What is expected to change in an organization with a Just Culture
 14
  3.3 Creating and implementing a Just Culture
 15
4. Case Studies
 20
  4.1 Danish System
 20
  4.2 New Zealand – CAA
 22
  4.3 UK – CAA MOR (Mandatory Occurrence Reporting System)
24
  4.4 Alaska Airlines
 26
5. References
 28
Appendix A. Reporting Systems
 30
  A1. Mandatory accident and incident systems
 30
  A2. Voluntary incident systems
 30
  A3. Confidential accident and incident systems
 30
Appendix B. Constraints to a Just Reporting Culture
 34
Appendix C. Different Perspectives 41
  C1. ICAO perspective 41
  C2. Regulatory perspective 41
  C3. An airline perspective 42
  C4. Air Navigation Service Providers 42
  C5. IFATCA 43
  C6. IFALPA 43
Appendix D. Glossary of Acronyms 44
Appendix E. Report Feedback Form 46

Acknowledgements

The co-chairs and members of the Flight Ops/ATC Ops Safety Information Sharing Working Group (WG E) of Global Aviation Information Network (GAIN) would like to thank all of the individuals and organizations that made this report possible.

Developers

Peter Stastny, Safety Regulation Unit, EUROCONTROL (WG E co-chair)
Captain Al Garin, Check Airman A330, US Airways (WG E co-chair)

Rachael Gordon, Experimental Centre, EUROCONTROL
Carolyn Edwards, Office of System Safety, Federal Aviation Administration
Margaret Ann Johnson, Independent Studies, Human Factors and Ethics
Patrick Moylan, GAIN Program Office (RS Information Systems)
Joe Schanne, Air Traffic Organization, Federal Aviation Administration

Reviewers and Contributors

Jim Burin, Flight Safety Foundation
Freddie D. Cline, Duotech Services Inc.
Captain Bill Curtis, Air Canada
Captain Stu Julian, International Federation of Air Line Pilots’ Association
Tony Licu, Safety Regulation Unit, EUROCONTROL
Ian McClelland, New Zealand Transport Accident Investigation Commission
Mike Moodi, The Boeing Company
Peter Nørbjerg, Naviair
Dave Prewitt, Alaska Airlines
John Vincent, United Kingdom Civil Aviation Authority
Dale Wright, National Air Traffic Controllers’ Association

Independent Reviewers

Patrick Hudson, Professor of Psychology, University of Leiden
James Reason, Retired Professor of Psychology, University of Manchester
Bert Ruitenberg, International Federation of Air Traffic Controllers’ Associations
Max Stevens, New Zealand Civil Aviation Authority

<<< continue reading—A Roadmap to a Just Culture, Forward by James Reason >>>

Reprinted by permission from the Global Aviation Information Network.

 

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