Citation
Managing the Risks of Organizational Accidents
TL;DR
Swiss cheese model of accident causation
Framework for understanding redundancy in high-reliability organizations including aviation. Reason's 'Swiss cheese model' of accident causation explains how multiple redundant defenses must all fail for accidents to occur, informing the chapter's analysis of layered redundancy.
Key Findings from Reason (1997)
- Swiss cheese model of accident causation
- Multiple defense layers in high-reliability organizations
- Latent failures vs. active failures
- Redundancy design in safety-critical systems