'Swiss Cheese' Model

Paper Summary:

This paper uses the Reason Model of Accident Causation to analyse the events following the Qantas accident in Bangkok in 1999. The issues relating to the crew's actions in the minutes prior to the precautionary disembarkation are investigated. The paper makes specific reference to the functions of organisational defences as described by Professor James Reason and stresses the significance of his accident causation model in aviation. It continues by suggesting the use of the accident causation model is not exclusive to accident investigation, but also using the concept as an error management tool to improve organisational safety performance. Recommendations are made for managers to implement a Safety Management System considering organisational defences and providing sufficient training to minimise active failures.

Outline
Abstract
Introduction and Background
Functions of Defences and Accident Causation
Case Study: The QF1 Accident
Using the Reason Model in Practice
Conclusion and Implications

From the Paper:

"The investigation report (ATSB, 2001) into the accident thoroughly details the events of the approach, landing and disembarkation. As the Boeing 747 attempted to land in extremely heavy rain, inaccurate aircraft handling by the first officer (pilot flying) led to the aircraft floating much further along the runway than planned. As the captain of the flight realised this he instructed the pilot flying to apply full power in an attempt to go-around. Almost simultaneously the aircraft's main wheels touched down on the runway. As a consequence, the captain rejected the go-around by retarding the thrust levers, but without specifying this to the first officer. Subsequently, confusion in the cockpit between the first officer and captain resulted in reverse thrust not being applied at any stage during the landing roll."

More papers on 'Swiss Cheese' Model:

• Analytical Essay # 8279 : "Who Moved My Cheese" by Spencer Johnson"
• Term Paper # 122079 : "The Myth of Swiss Banking"
• Analytical Essay # 73429 : "The Cheese And The Worms"

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