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Swiss Cheese Model
Swiss Cheese Model
Swiss Cheese Model
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Overview

A popular model in risk management across domains as diverse as aerospace, healthcare, mining, and manufacturing, the Swiss Cheese Mo ...

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Actionable Takeaways
  • Assume that human error will occur. 

Reason’s work was premised on the id ...

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Limitations

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. 

In Practice

Covid.

Below is Australian Virologist Ian Mackay’s repurposed version of the Swiss Cheese Model as it was applied to Covid mitigation. 

Bushfires. 

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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Origins & Resources

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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