The James Reason Swiss Cheese

Failure Model in 300 Seconds

May 30, 2018 By Whatsthepont Https://Whatsthepont.Blog/2018/05/30/The-James-
Reason-Swiss-Cheese-Failure-Model-In-300-Seconds/

James Reason Swiss Cheese Model. Source: By Chris Bolton, WhatsThePont

A while ago 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 (5 minutes).
This is what I did.

The Swiss Cheese Model of Accident Causation (to give it the full name), was
developed by Professor James T. Reason at the University of Manchester about 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 Society
of London, clearly identifies these are complex human systems, which is important.
Well worth reading is the British Medical Journal (BMJ), March 2000 paper, ‘Human
error: models and management’. This paper gives an excellent explanation of the model,
along with the graphic I’ve used here.

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The Swiss Cheese Model, my 300 second explanation:

 Reason compares Human Systems to Layers of Swiss Cheese (see image above),
 Each layer is a defence against something going wrong (mistakes & failure).
 There are ‘holes’ in the defence – no human system is perfect (we aren’t machines).
 Something breaking through a hole isn’t a huge problem – things go wrong
occasionally.
 As humans we have developed to cope with minor failures/mistakes as a routine part
of life (something small goes wrong, we fix it and move on).
 Within our ‘systems’ there are often several ‘layers of defence’ (more slices of
Swiss Cheese).
 You can see where this is going…..
 Things become a major problem when failures follow a path through all of the holes
in the Swiss Cheese – all of the defence layers have been broken because the holes
have ‘lined up’.

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

The idea of successive layers of defence being broken down helps to understand that
things are linked within the system, and intervention at any stage (particularly early on)
could stop a disaster unfolding. In activities such as petrochemicals and engineering it
provides a very helpful visual tool for risk management. The graphic from Energy
Global who deal with Oilfield Technology, 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 example:

 Organisational Policies & Procedures

 Senior Management Roles/Behaviours
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 Professional Standards
 Team Roles/Behaviours
 Individual Skills/Behaviours
 Technical & Equipment

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

 Person Approach – failure is a result of the ‘aberrant metal processes of the people
at the sharp end’; such as forgetfulness, tiredness, poor motivation etc. There must
be someone ‘responsible’, or someone to ‘blame’ for the failure. Countermeasures
are targeted at reducing this unwanted human behaviour.
 System Approach – failure is an inevitable result of human systems – we are all
fallible. Countermeasures are based on the idea that “we cannot change the human
condition, but we can change the conditions under which humans work”. So,
failure is seen as a system issue, not a person issue.

This thinking helpfully allows you to shift the focus away from the ‘Person’ to the
‘System’. In these circumstances, failure can become ‘blameless’ and (in theory) people
are more likely to talk about it, and consequently learn from it. The paper goes on to
reference research in the aviation maintenance industry (well-known for its focus on
safety and risk management) where 90% of quality lapses were judged as ‘blameless’
(system errors) and opportunities to learn (from failure).

It’s worth a look at the paper’s summary of research into failure in high reliability
organisations (below) and reflecting, do these organisations have a Person Approach or
Systems Approach to failure? Would failure be seen as ‘blameless’ or ‘blameworthy’?

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

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

It is worth looking at the comments on the post for a helpful analysis 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 limited use for
predicting failure. The suggestion is that organisations need to maintain a ‘consistent
mindset of intelligent wariness’. That sounds interesting…

There will be more on this at #LFFdigital, and I will follow it up in another post.
So, What’s the PONT?

1. Failure is inevitable in Complex Human Systems (it is part of the human condition).
2. We cannot change the human condition, but we can change the conditions under
which humans work.
3. Moving from a Person Approach to a System Approach to failure helps move from
‘blameworthy’ to ‘blameless’ failure, and learning opportunities.

By Chris Bolton

About WhatsthePONT
I'm from Old South Wales and I'm interested almost everything. Narrowing it down a
bit: cooperatives, social enterprises, decent public services, complexity science, The
Cynefin Framework, behavioural science and a sustainable future. In 2018/19 I
completed a Winston Churchill Travelling Fellowship, looking at big cooperative
enterprises and social businesses in NE Spain and the USA. You can find out more here:
https://whatsthepont.com/churchill-fellowship/

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About the Author

This is an image of the Old Bridge Pontypridd , built at the fourth attempt in 1756, by William
Edwards over the River Taff, South Wales. Still standing, it was a miracle of engineering and
innovation, the worlds longest single span stone bridge for 40 years.
I’ve been using it as the background image for What’s the PONT since I started blogging in
2011.
What’s the PONT is about learning. The things I’ve learnt or find interesting and want to
share. Pont is the Welsh for bridge, and ‘What’s the PONT’ is also just that, a bridge. I’m
interested in learning and sharing knowledge for the greater good and because I think it is an
important and hopefully useful thing to do.
Disclaimer. I need to say that these are my own personal views and opinions and have nothing
to do with the views of the organisation I work for, or any of the other organisations I might
have any connection with.

The things I’m currently interested in are:

1. How people learn and share knowledge;

2. Employee engagement, continuous improvement, innovation; and
3. A better society and public services.

I’m native of the South Wales Valleys, spending much of my life within about 10 miles of
Pontypridd, which is why the William Edwards bridge is important to me. I’m a scientist by
background. I’ve worked in a number of different roles from being a marine biologist, working
with fisheries and waste water treatment. Other things I’ve done include being a corporate
planner, supporting democracy and public service improvement.
I currently work for the Wales Audit Office as part of the Good Practice Exchange Team. If
you want to look at what we do, you can find it here:

The website pages: http://www.wao.gov.uk/goodpractice/goodpracticeexchange.asp

The blog: http://goodpracticeexchange.wordpress.com/

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