REDRESSING THE BALANCE:
A Commonsense Approach to Causation

 

Chapter Six: Reason’s (1997) Swiss Cheese Model

The essential premise of the model   130-131
Reason’s initial and on-going uncertainty in his premise 131-133
Perpetuating the management failure myth 133-136
Swiss cheese holes – latent conditions or root causes? 136-140
Swiss cheese holes – latent conditions or mere conditions?  140-144
Accident causation model or workplace inspection checklist? 144-149
‘Blame the system – save the day’ 149-154
Failed barriers and the organisational accident – fact or fiction? 154-158
Organisational accidents – products of an ill-founded ‘stop-rule’  158-161
Organisational accident or individual accident?  161-163
Latent conditions: legally absurd – philosophically ridiculous  163-170
Aggregation – another flaw in the concept of the organisational accident  170-171
Knee-jerk organisational error attributions    171-173
A fatally confused school  173-174
Organisational accidents and barriers – myths born of misrepresentation   175-179
Interim Summary  180-188

 

 

 

© Paul Difford 2011
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