Thread: How many mistakes made for this to happen?

@Tommy

This video clearly demonstrates the possible result should successive layers of defences/safeguards put in place to reduce or prevent the occurance of adverse effects are affected by active and or latent conditions or failures that when lined up result in said adverse event actually occurring.

Professor James Reason explained this very well with his Swiss Cheese Model of Incident/Accident Causation.



In this case several layers of defence/safeguards were breached , the holes in the Swiss cheese slices lined up, with a final layer of defence/safeguard, I.e. the shooters awareness training and self control to cease fire at the last minute, ultimately preventing the adverse event occurring.

This could be considered a Serious Near Hit incident, someone nearly died.

It appears from the video that Range protocol and process, layers of defence designed to prevent an adverse event occurring, was not followed.

The R/O has to shoulder responsibility for this as he is responsible to ensure that the protocols and processes, layers of defence/safeguards, are followed, it appears from the video that the range was "Not Cleared" before he called "Range in Use, Shooter to the Line".

There may be many other factors that we are unaware from the video that also contributed to this incident.

At the he end of the day "Luck" played big part in preventing a more serious incident occurring due to the failures of the layers of defence/safeguards.

Hmmmmm, I can see the eyes glazing over as we speak

Guess incident causation theory isn't as sexy as I think.

Cheers
Pete