Originally Posted by
NumptyAussie
May I please ask why you think this can be explained by the Swiss Cheese Model? (a serious question regarding the effectiveness of different types/styles/methods of incident investigation)
I would have thought that most incidences would be better explained by conducting a root cause analysis rather than a investigation into what barriers failed?
I don't think this is a case for the Swiss Cheese Model, there's not too many holes in the cheese that have lined up here.
The root cause analysis works better in this case and looking at the recommendations from the Bulgarian AAIB that appears to be what the investigators have done.