You seem to be entralled with James Reason's model. This model is designed to take the responsibility away from the end user and put it on the corporate entity.
What a load of crap Blackhand. The Swiss Cheese model is a look at causal factors in an accident. The emphasis on 'factors', plural. No one accident has just one cause. Nowhere in the Reason model is a trigger, formula or method so as to induce blame or throw the monkey on to a corporate identity.
The Norfolk accident contains numerous factors. I agree that the PIC, in this case Dom, was the last line of defence. He stuffed up and became the last hole in this accident. But what has also come to light is some of the other factors that contributed to the accident - inadequate S.O.P's, operational pressure, lack of company support, company culture, fatigue, lame regulatory oversight and the list goes on.