whats the premise to sswiss cheese theory and how is it applied to safety?

James Reason Swiss Cheese Model. Source: BMJ, 2000 Mar 18:320(7237): 768-770

A while agone I was part of the Cardiff pilot of Practical Strategies for Learning from Failure (#LFFdigital). My job was to explain the James Reason Swiss Cheese Failure Model in 300 seconds (v minutes).

This is what I did.

The Swiss Cheese Model of Accident Causation (to requite it the full name), was developed by Professor James T. Reason at the University of Manchester nearly 25 years ago. The original 1990 paper,"The Contribution of Latent Human Failures to the Breakdown of Complex Systems", published in the transactions of The Royal Social club of London, clearly identifies these are complex human systems, which is of import.

Well worth reading is the British Medical Journal (BMJ), March 2000 paper, 'Human fault: models and management'. This paper gives an excellent explanation of the model, along with the graphic I've used hither.

The Swiss Cheese Model, my 300 second caption:

• Reason compares Human Systems to Layers of Swiss Cheese (see prototype above),
• Each layer is a defence against something going wrong (mistakes & failure).
• There are 'holes' in the defence force – no human organisation is perfect (we aren't machines).
• Something breaking through a pigsty isn't a huge problem – things become wrong occasionally.
• As humans we accept developed to cope with pocket-size failures/mistakes every bit a routine function of life (something small-scale goes wrong, we fix it and move on).
• Within our 'systems' there are often several 'layers of defence force' (more slices of Swiss Cheese).
• You can see where this is going…..
• Things go a major trouble when failures follow a path through all of the holes in the Swiss Cheese – all of the defence layers have been cleaved because the holes have 'lined upwardly'.

Source: Energy Global Oilfield Technology http://www.energyglobal.com/upstream/special-reports/23042015/Rallying-against-gamble/

Who uses information technology? The Swiss Cheese Model has been used extensively in Health Intendance, Risk Management, Aviation, and Engineering science. Information technology is very useful as a method to explaining the concept of cumulative effects.

The thought of successive layers of defence being broken downwardly helps to understand that things are linked within the system, and intervention at any stage (particularly early on) could terminate a disaster unfolding. In activities such equally petrochemicals and applied science it provides a very helpful visual tool for run a risk management. The graphic from Energy Global who deal with Oilfield Applied science, helpfully puts the model into a real context.

Other users of the model have gone as far as naming each of the Slices of Cheese / Layers of Defence, for instance:

• Organisational Policies & Procedures
• Senior Management Roles/Behaviours
• Professional Standards
• Squad Roles/Behaviours
• Individual Skills/Behaviours
• Technical & Equipment

What does this mean for Learning from Failure?  In the BMJ paper Reason talks about the Arrangement Approach and the Person Approach:

• Person Approach – failure is a result of the 'abnormal metallic processes of the people at the sharp terminate'; such as forgetfulness, tiredness, poor motivation etc. There must be someone 'responsible', or someone to 'arraign' for the failure. Countermeasures are targeted at reducing this unwanted human behaviour.
• System Arroyo – failure is an inevitable effect of human being systems – nosotros are all fallible. Countermeasures are based on the idea that "we cannot change the human status, but nosotros can change the conditions under which humans work" . So, failure is seen every bit a system issue, not a person issue.

This thinking helpfully allows y'all to shift the focus away from the 'Person' to the 'System'. In these circumstances, failure tin become 'blameless' and (in theory) people are more probable to talk about it, and consequently learn from information technology. The paper goes on to reference research in the aviation maintenance industry (well-known for its focus on safe and gamble management) where 90% of quality lapses were judged as 'blameless' (organisation errors) and opportunities to learn (from failure).

It's worth a await at the newspaper'southward summary of research into failure in loftier reliability organisations (below) and reflecting, practise these organisations have a Person Approach or Systems Approach to failure? Would failure be seen every bit 'blameless' or 'blameworthy'?

High Reliability Organisations: Source BMJ, 2000 Mar 18:320(7237): 768-770

It's not all good news. The Swiss Cheese Model does take a few criticisms. I have written about it previously in 'Failure Models, how to get from a backwards look to real-time learning'.

Information technology is worth looking at the comments on the post for a helpful assay from Matt Wyatt. Some people feel the Swiss Cheese model represents a neatly engineered world. It is great for looking backwards at 'what caused the failure', but is of express employ for predicting failure. The suggestion is that organisations demand to maintain a 'consequent mindset of intelligent wariness'. That sounds interesting…

There will be more than on this at #LFFdigital, and I will follow it upwardly in another post.

And so, What'due south the PONT?

1. Failure is inevitable in Circuitous Human Systems (it is office of the human condition).
2. We cannot change the human being condition, but we can change the conditions under which humans work.
3. Moving from a Person Approach to a System Arroyo to failure helps move from 'blameworthy' to 'clean-living' failure, and learning opportunities.

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Source: https://whatsthepont.blog/2018/05/30/the-james-reason-swiss-cheese-failure-model-in-300-seconds/