Okay, we all know about James Reason's Swiss Cheese model.
However, in a moment of enthusiasm the other day, I looked him up on Amazon and discovered a fair number of books concentrating upon safety, accident causality, and so-on.
Amongst them, was a new book which came out in the last year called
The Human Contribution.
In even more enthusiasm, I spent my own money on a copy - which I'm currently about 1/3rd through at the moment.
After a rather turgid introduction, it gets into some really interesting concepts of the concepts of "violations" - failures to follow procedure, and how these should be related to good and bad procedures, and also learning opportunities. The extensive use of case studies (in particular a lot of discussion of Chernobyl, but also various aviation cases) makes it particularly readable and I find it's giving me a lot of food for thought about the way my organisation works.
Once I've finished, I'll find this thread again and post a more full review, but in the meantime I thought I'd at-least flag it up as a very interesting read, and a good sample of the latest thinking of somebody who we all regularly refer to, but probably not enough have actually read.
G