>>>As I remember his presentation, he addresses
errors as variables being present or not present, kind of like holes in
swiss
cheese, the pieces of cheese being each individual's performance. <<<
I seem to remember this presentation as profiting from Dr. Jim Reason's
organisational error analysis model, in which failures or deficiencies in
Organisational Process, Local Working Conditions, Latent defects and
Defences had to coincide before an Active Failure could become an accident
or incident. The classic diagram showed several slices of "Swiss cheese"
with the holes lined up.
The point about Reason's model is that it clearly showed error chain as
something that had actors throughout the company, not just on the deck.
This analysis is particularly interesting in conjunction with the Air
Ontario Dryden Commission report and the Erebus crash analysis: both were
at first labelled pilot error but responsibility was finally lodged with
management. ICAO's Dan Maurino in a recent study fóund that over a sample
of 24 reports, Loss of S.A. was involved in 20 (Local Working Conditions);
Training Failures in 17 (Latent Failure Dimension); Crew Coordination in 18
(Defences) and a staggering 22 reports involved policy-making failures
(Organisational Process dimension).
The point about crew awareness of the error chain is true and interesting -
personally, I think error chain should always include a brief discussion of
disaster incubation theory.
Regards,
Rick