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A popular model in risk management across domains as diverse as aerospace, healthcare, mining, and manufacturing, the Swiss Cheese Mo ... Lorem ipsum dolor sit amet, consectetur adipiscing elit. Quid est enim aliud esse versutum? Duo Reges: constructio interrete. Portenta haec esse dicit, neque ea ratione ullo modo posse vivi; Quod mihi quidem visus est, cum sciret, velle tamen confitentem audire Torquatum. Nec tamen ullo modo summum pecudis bonum et hominis idem mihi videri potest. Quis enim potest ea, quae probabilia videantur ei, non probare? In qua quid est boni praeter summam voluptatem, et eam sempiternam? Quam nemo umquam voluptatem appellavit, appellat; Partim cursu et peragratione laetantur, congregatione aliae coetum quodam modo civitatis imitantur; Illa videamus, quae a te de amicitia dicta sunt. Itaque vides, quo modo loquantur, nova verba fingunt, deserunt usitata. Tollitur beneficium, tollitur gratia, quae sunt vincla concordiae. Graecum enim hunc versum nostis omnes-: Suavis laborum est praeteritorum memoria. Tuo vero id quidem, inquam, arbitratu. Sed quanta sit alias, nunc tantum possitne esse tanta. Semper enim ex eo, quod maximas partes continet latissimeque funditur, tota res appellatur. Quod cum dixissent, ille contra. Hic quoque suus est de summoque bono dissentiens dici vere Peripateticus non potest. Vos autem cum perspicuis dubia debeatis illustrare, dubiis perspicua conamini tollere. Consequentia exquirere, quoad sit id, quod volumus, effectum. Quod, inquit, quamquam voluptatibus quibusdam est saepe iucundius, tamen expetitur propter voluptatem. An eiusdem modi? Quae iam oratio non a philosopho aliquo, sed a censore opprimenda est. Causa autem fuit huc veniendi ut quosdam hinc libros promerem. Zenonis est, inquam, hoc Stoici. Cum autem in quo sapienter dicimus, id a primo rectissime dicitur.
- Assume that human error will occur.
Reason’s work was premised on the id ...
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The metaphor of Swiss Cheese has clearly resonated in safety and accident domains, though criticism has persisted. One of the prime criticisms is the simplistic nature of the metaphor that leaves it too generic and without value. Many point to the fact that Reason himself tried to expand his work with subsequent diagrams and papers which have not persisted like the Swiss Cheese Model. At worst, it's seen as a reductionist approach that was born from his period working as a consultant, at best it's seen as a tool he used to communicate important concepts, albeit relatively superficially, to management.
For example, some would argue the metaphor presents accidents as a linear occurrence, while in reality, they occur in dynamic and non-linear ways. This links to a broader criticism that it lacks a systems and dynamic view of problems, implying that each component, like a slice of cheese, can be altered and even fixed in isolation.
Another issue with the original diagram is how it continues to be interpreted so differently by practitioners. While some would argue that its broad definition allows for diverse agreement and application, others point to studies of practitioners who were revealed to have different understandings of what the model represents and what it means as a result.
Covid.
Below is Australian Virologist Ian Mackay’s repurposed version of the Swiss Cheese Model as it was applied to Covid mitigation.
Risk consultant Julian Talbot used this model to explain the devastation of the 2009 Australian bushfires in the diagram below.
Engineering.
Michigan Tech used this diagram to explore the safety elements in engineering, including a mitigation layer on the end.
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According to James Reason, his inspiration for this model came in the 1970s while he was making tea. He was distracted by his large insistent cat and absent-mindedly dolloped a large spoonful of cat food into the teapot. Reason was fascinated by the similarities of the tasks that led to his mistake and this deepened his research that culminated into his book A Life in Errors - From Little Slips to Big Disasters. He particularly was interested in the impact of mistakes with human-machine interaction, particularly in the high-stakes fields such as aerospace to nuclear power.
Others have noted that Reason had input from John Wreathall in developing what was essentially a building on traditional safety management thinking with an understanding of human error. Reason published the original work behind this model in 1990, then explored it more explicitly in the British medical journal in 2000, though it was several years before it was developed as the organisational accident model, and later known as the Swiss Cheese Model.
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