The Swiss Cheese and James Reason are once again quoted. A fine expample and one which is discussed at every CRM course I've been on. Pilots are often the last slice in the cheese. A fundamental charateristic of a good airman is to anticipate the traps and avoid them. Remember the old adage that 'a skillful pilot is one who avoids the scenarios where they need their skills to cope with it.'
We attend these CRM courses because it is legal we do so. IMHO they would not be run if not legally required; non revenue generating cost. Management speak with great pride about the safety culture of their airline. "We ain't had a crash so we are 100% safe." Why, oh Why do they then operate with the complete opposite philosophy to our CRM teachings. They do not want to anticipate problems and be procative. That will cost money and they may never happen; so it would have been a waste of money. They let the holes line up and hope the crews will act as the final safety net they are; and boy, do they make even that difficult at times.
CRM = Company Resource Management = All the links in the Chain.
There are too many weak links at the top end and it is the stong links at the tail end; ops, engineering, distaptch, flight crew and others, who sort out the dros sent downstairs.
When was the last time anyone even close to management was sited as contributory to a crash/incident? Occaisionally a 'culture' is commented on, but even then it has not been nailed as the cause. It was sited as being unhelpful, but the crews and others should have been able to cope. I wonder how many near misses there were, due to the 'culutre', before the final smoking hole.