TASTE PREFERENCES OF TRANSPORT SAFETY INVESTIGATORS: WHO DOESN'T LIKE SWISS CHEESE?

摘要

When it comes to incidents and accidents, the popular template adopted for human factors investigations has been James Reason's "Swiss cheese" model. One of the implications of this has been the tenacious search for latent conditions leading up to the incident. However, it is questionable whether the focus on factors such as management and regulation has gone too far, and whether we should redress some of our efforts back to the human in control and the working environment. This paper uses a recent aviation case study to illustrate the contention that human action at the sharp end can be more significant than has been traditionally assumed. A critique of the Reason model is presented, highlighting a number of key issues with its application. Whilst the organisational model has been an incontrovertible success, we believe it may be time for a rethink.