Originally Posted by
megan
A seminal accident for the James Reason Swiss Cheese model. RIP all.
Megan I know you love to quote Reason's Swiss Cheese model; but as someone like myself who is regularly involved in incident analysis can I advise you the model is mercifully no longer as trendy as it once was, and Reason himself has said the model has been way over quoted. It's failings are it doesn't identify relevance differentials between the factors (slices of cheese) and also doesn't identify what was a "factor" and what was an "error". For example the weather over Ross Island was a factor in this disaster; but only became one because of the human factors surrounding it. It's important to make the distinction, because the reasons behind the errors are where the learning points lie.
I guess Erebus isn't the worst application of Reason's model I've ever seen; but it needs to remembered this was nothing more than a 1990's cute way of saying "adverse events are multifactorial".
Sorry for digression.