FAA Airline Transport Pilot (ATM)Human Factors and CRMHard
An accident investigation into a controlled flight into terrain (CFIT) event reveals several independent latent failures that aligned: inadequate CRM training, a fatigued crew, an outdated approach chart, and a distracting cockpit environment. No single factor alone would have caused the accident, but together they created a pathway for the error to occur. This conceptual model of accident causation, in which multiple layers of defense each have gaps that occasionally align, is known as the:
- AThreat and error management model
- BJust culture model
- CSwiss cheese model
- DDECIDE model
Show answer & explanationAnswer & explanation
Correct answer: C. Swiss cheese model
The Swiss cheese model, developed by James Reason, depicts organizational defenses as layers of cheese with holes (weaknesses); an accident occurs only when the holes in multiple layers align, allowing a hazard to pass through all defenses. It explains how multiple latent and active failures combine to cause an accident, unlike decision-making models like DECIDE.
Why the other options are wrong
- A. Threat and error management identifies and mitigates threats and errors proactively but is not the layered-defense causation model.
- B. Just culture describes how an organization responds to errors, not how accidents result from aligned failures.
- D. The DECIDE model is a sequential decision-making tool for in-flight problems, not an accident causation model.
Swiss Cheese Model
James Reason's model of accident causation depicting organizational defenses as layers with holes (weaknesses); an accident occurs when holes across multiple layers align.
- Layers include organizational influences, supervision, preconditions, and unsafe acts
- Holes represent latent and active failures
- Emphasizes that accidents rarely have a single cause
Memory trick: Holes in the cheese must line up perfectly for disaster to slip through.