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I remember in one of the books (can't remember which one, there were so many) that I read while doing ground school. The author spoke of this "Swiss cheese" theory.


The basic premise is that, in the whole chain of flying (manufacture, maintenance, flight planning, weather, PDM, customer, etc.), any number of errors or problems can emerge. In this theory, each of these problems is represented by a hole in a brick of Swiss cheese. Holes can be of different sizes and shapes, according to the gravity of the problem. An accident or catastrophy will occur when enough holes line up so that a hole appears right through the brick.


I found this to be a very simple yet effective visual explanation. What it gets at is that there are many factors that go into a flight. The chain can tolerate a certain level of human error or mechanical failure without an accident actually occuring, but if the right number of these "holes" in the chain occur simultaneously, then sh*t happens...

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Skidz, the Swiss Cheese theory was written by James Reason in 1990.

It is considered to be one of the best theories on the complicated web of human factors that lead to accidents in aviation, as well as other transportation modes, and also medical fields etc. etc., i.e. anywhere humans can make an error.


There is lots of information on the web about it.

This link is to some Colorado fire-fighting group.



Here is a quick diagram....

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