A document well worth reading is
“Revisiting the Swiss Cheese Model of accidents”, which provides historical background and insight into the use of the model.
Although James Reason is credited with the ‘Swiss Cheese’ title, IIRC he acknowledges that it originated from Dr Rob Lee. However, the concept of error and systematic failure, and the graphic model are from Reason’s work.
The short paper
“Human Error” compares the ‘person view’ with the ‘system view’ of safety and thereafter the origins of the Swiss Cheese Model.
I was particularly impressed by the paragraphs on high reliability organizations (Page 4), which could be taken as the basis of SMS or a personalized CRM/TEM.
Also of note is the comment on military organizations – clarity of goals.
For those who wish to reconsider the concept of blame and punishment see
Safety and the 'Just Culture'.
From this, individuals would do well to remember that “
we must all be held accountable for our efforts to make the system safer”, but also when judging others that “
the important question is whether human factors learning from events outweigh the deterrent effect of punishment against negligent employees. If the threat of discipline increases one’s awareness of risk or at least increases one’s interest in assessing the risks, does this heightened awareness outweigh the learning from thorough error investigations”.
The paper does not provide a clear cut answer – there isn’t one; even Dekker notes that whilst having a just culture is important, the real key to this is in who draws the line.
After reading the above, I agree that a just culture is essential, but in those few marginal cases, perhaps a tribunal consisting of Operations (safety/training), Human Factors, and Legal (company/personnel interests) might provide an optimum solution opposed to a view of just one individual.
However, there could be some wide ranging differences amongst cultures, e.g. the extreme legalistic approach in the USA vs a more tolerant approach (trusting/ learning) in other parts of the world.
Tee Emm “…ATC who asked him to keep up speed on final approach…” is just one example of a latent factor, a systematic weakness, which both individuals and operators can challenge. See the theme in
‘Just Say No – its OK to Go Around’.