Accident Causation Model
1. PROJECT. To Design an Accident Causation Model
2. SCOPE. The Accident Causation Model (or "Swiss Cheese Model") is a theoretical model that illustrates how accidents occur in organisations. The model focuses on both organisational hierarchy and human error. It postulates that the typical accident occurs because several (human) errors have occurred at all levels in the organisational hierarchy in a way that made such accident unavoidable. For example, decision makers may have made ill decisions when purchasing aircraft (fallible decisions), line management may have pushed for faster turnarounds (line management deficiencies), pilots may have felt pressurised to cope with a stressful climate, an unsafe culture and little rest (preconditions), the particular pilot who suffered the accident may have gotten distracted with other tasks three seconds prior to the accident (unsafe act), and the aircraft systems fail in providing unmistakable warnings of the danger (inadequate defences).
3. PURPOSE/UTILITY. To illustrates how accidents occur in organisations. The model focuses on both organisational hierarchy and human error
4. BRIEF DISCRIPTION The Accident Causation Model was first published by Reason in 1990. Since then, it has progressively influenced contemporary views on the management of human error in organisations. For instance, the International Civil Aviation Organisation (ICAO) has formally adopted Reason's model to facilitate a systemic understanding of human factors issues within the aviation community . Below example illustrates key concepts in the Accident Causation Model:
(a) Active errors (also called unsafe acts) are the proximal causes of the accident: the pilot got distracted. Hadn't the pilot got distracted, he would have prevented the accident.
(b) Latent errors are the remaining elements in the organisation which contributed to the accident: senior managers purchasing decisions, line management pressures, unsafe climate and culture
2. SCOPE. The Accident Causation Model (or "Swiss Cheese Model") is a theoretical model that illustrates how accidents occur in organisations. The model focuses on both organisational hierarchy and human error. It postulates that the typical accident occurs because several (human) errors have occurred at all levels in the organisational hierarchy in a way that made such accident unavoidable. For example, decision makers may have made ill decisions when purchasing aircraft (fallible decisions), line management may have pushed for faster turnarounds (line management deficiencies), pilots may have felt pressurised to cope with a stressful climate, an unsafe culture and little rest (preconditions), the particular pilot who suffered the accident may have gotten distracted with other tasks three seconds prior to the accident (unsafe act), and the aircraft systems fail in providing unmistakable warnings of the danger (inadequate defences).
3. PURPOSE/UTILITY. To illustrates how accidents occur in organisations. The model focuses on both organisational hierarchy and human error
4. BRIEF DISCRIPTION The Accident Causation Model was first published by Reason in 1990. Since then, it has progressively influenced contemporary views on the management of human error in organisations. For instance, the International Civil Aviation Organisation (ICAO) has formally adopted Reason's model to facilitate a systemic understanding of human factors issues within the aviation community . Below example illustrates key concepts in the Accident Causation Model:
(a) Active errors (also called unsafe acts) are the proximal causes of the accident: the pilot got distracted. Hadn't the pilot got distracted, he would have prevented the accident.
(b) Latent errors are the remaining elements in the organisation which contributed to the accident: senior managers purchasing decisions, line management pressures, unsafe climate and culture