This "Swiss Cheese Model" tries to find out the multi-causes of aviation accidents with this framework.
For example, this 2018 airplane accident happened because of a number of small mistakes and issues, each one not big enough to cause the accident, but collectively did:
Image Description
The image illustrates the Swiss Cheese Model, which demonstrates how multiple layers of defense (represented by slices of Swiss cheese) contain holes that align, allowing an accident trajectory to pass through and result in consequences. It highlights latent conditions like poor design and procedures.
Positive Aspects
The image effectively visualizes the Swiss Cheese Model, making it easy to understand how small, seemingly insignificant errors can align to cause a major accident. It succinctly labels elements like "Accident Trajectory" and "Consequences," which clarifies the process for readers.
Key Takeaways
- The Swiss Cheese Model analyzes multiple causes of aviation accidents, emphasizing that small errors collectively lead to major incidents.
- Each layer of defense in an organization can have weaknesses, and when these align, they result in accidents.
- The model identifies latent conditions such as poor design and procedures, which are critical to address to prevent accidents.
Additional Insights
Think of the Swiss Cheese Model as life’s way of saying, “Even little holes matter!” Just like in aviation, many industries can use this model to improve safety and efficiency. It's a great reminder that addressing minor issues is crucial before they align into a major problem.
