The Reason model was desgned for errors in patient care.
It has become a badly understood and widely utilised panacea for all safety issues. An unsafe act is at the pinacle of the pyramid, and, as in this case, can happen without a causal chain
Oh dear. I see that the Reason Model is understood differently in PNG?
Blackie, you better tell Mr Reason that his cheese is being abused by the airline industry. You should also advise the ATSB, NTSB and most Western regulatory bodies that Reason's cheese is really not applicable in aviation and they have all got it wrong.