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Old 29th Oct 2008, 15:44
  #2324 (permalink)  
Join Date: Mar 2003
Location: BC
Age: 72
Posts: 2,429

The Reason "Swiss Cheese Model" is well known and understood and is even being challenged these days as "limited". For it's time, it's greatest value was moving an extremely recalcitrant (hesitant, with an attitude) community off the "pilot error" excuse for an aircraft accident and into a way of considering systemic causes far removed (physically) from the actual accident. The concept was revolutionary at the time and still serves a purpose in terms of continuing to educate those who stubbornly stick to old notions about causes and how to fix them. A blame-and-punish culture and the increasing willingness to criminally prosecute rather than learn is a formula for repetition. If we examine the fatal accident rate since the late '60's, a dramatic drop is easily seen and the "curve" is almost flat at the moment, there being great difficulties in cracking the final barrier to solving the "human factors" issues. This is where Reason's model came in some twenty years ago.

Today Reason's theory has "morphed" into more sophisticated notions about causal chains. The concept and increasing reality of a "Just Culture", not limited to aviation by the way, has taken these understandings to greater and I think more helpful levels. One writer among many excellent authors is Sidney Dekker who has written, "The Field Guide to Understanding Human Factors", and "Just Culture", both well worth reading in concert with Jim Reason's work. I recommend them highly as one way into next steps after Reason. I know there are others.

As mentioned above, the accident rate has somewhat stabilized and is proving difficult to reduce. That means that any increase in traffic, (I realize present economic circumstances mitigate against such increase but we all know economics is cyclical) will bring a corresponding increase in the number of fatal accidents which causes will likely be human error.

FOQA, LOSA, AQP and a supporting cast in an enlightened management are ways forward. The trend to blame-and-punish will keep the accident rate where it is because no learning ever resulted from punishment. We could argue that lawsuits alone have forced improvements in aviation and to a certain extent that's true but the cost has been, and continues to be, extremely high in human as well as economic terms. It seems slightly more efficient and intelligent to use the best means possible to forestall and otherwise prevent accidents through knowledge rather than a rolled newspaper or worse, "jail time for the perps".
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