Effectiveness of accident models: system theoretic model vs. the Swiss Cheese model: a case study of a US Coast Guard aviation mishap

Over the last several years, the US Coast Guard (CG) experienced an unusually high number of major aviation accidents. Following each major accident, the CG conducted mishap analysis board (MAB) ‐ investigations based on the Swiss Cheese accident causality model. However, these investigations were not able to identify common contributing factors that may be causing systemic failures within the CG aviation system. This paper applies the Systems Theoretic Accident Model and Processes (STAMP) model to one of the CGs major aviation mishaps in order to more fully examine the CGs aviation system for potential systemic sources of safety hazards. This analysis identified enhancements to CG aviation system controls that were not expressly identified by MABs. It demonstrates that STAMP is a more effective model than the Swiss Cheese model in determining accident causality.