At 11:50 AM 1/27/98 +0900, you wrote:
>
>Dear Barry :
>I am Hidetake Sakuma, working in Corporate Safety Dept., Japan Airlines
>mainly for implementing human factors and CRM concepts into all areas
>of airline safety business.
>I have a slightly different idea from conventional notion of "Error
>Chain" or "Chain of Events" and even from latest "James Reasons
>Model( so-called Swiss Cheese Model). I hope this could be of any help
>to your project.
>The process in which any human error leads to catastrophic results like
>accidents is very similar to water drops running down on the windows
>glass. Once a water drop is produced( human error occured) then it
>would never fail to find any other way to go in spite of any single and
>naturally existing hindrance. This is because water drop itself has a
>tendency to go downwards by gravity and significant human error has a
>tendency to lead to unwanted events since it is a part of humans
>intention. Only way to prevent both things from further proceeding may
>be positive, powerful and intentional defences which are intellectually
>constructed by other personnel like human factors specialists. This is
>why vigorous human factors knowledge and skills are being disired in
>this very area.
>
>
Surendra Ratwatte
Captain B-777
Emirates Airlines
PO Box 92
Dubai
U.A.E.