The
"Reason Model" has just been quoted in a Sydney Morning Herald article, regarding the "Jet into Water" incident, but deserves a better airing than being just hidden away.
The Model, otherwise known as the "Swiss Cheese" model, is about the times that when something goes wrong, usually it usually has a number of friends to help the first problem become larger.
The following puts the rationale well:
Swiss cheese model - Wikipedia, the free encyclopedia
The recent Brazillia report into the Darwin "accident" demonstrates this wel, but casa and ATSB fail to use this to demonstrate EFATO issues or the underlying problems that can quickly escalate, rather saying ".......the operator has implemented simulator training ..........".
The challenge today is:
Can you give some really good examples of the "Reason Model" occurring in an aircraft accident over the past 20 years???