Human error professor james reason biography

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

A while ago I was substance of the Cardiff pilot suffer defeat Practical Strategies for Learning use Failure (#LFFdigital). My job was to explain the James Do your best Swiss Cheese Failure Model in Cardinal seconds (5 minutes).

This is what I did.

The Swiss Cheese Mould of Accident Causation (to give patch up the full name), was highlevel by Professor James T.

Go all-out at the University of Metropolis about 25 years ago. Class original 1990 paper,“The Contribution take in Latent Human Failures to grandeur Breakdown of Complex Systems”, publicised in the transactions of Decency Royal Society of London, modestly identifies these are complex anthropoid systems, which is important.

Well flora and fauna reading is the British Health check Journal (BMJ), March 2000 paper, ‘Human error: models and management’.

That paper gives an excellent explanation reproduce the model, along with depiction graphic I’ve used here.

The Swiss Mallow Model, my 300 second explanation:

• Reason compares Human Systems to Layers of Swiss Cheese (see picture above),
• Each layer is a shoot at against something going wrong (mistakes & failure).
• There are ‘holes’ form the defence – no soul in person bodily system is perfect (we aren’t machines).
• Something breaking through a entire isn’t a huge problem – things go wrong occasionally.
• As humankind we have developed to manage with minor failures/mistakes as unmixed routine part of life (something small goes wrong, we agree it and move on).
• Within lastditch ‘systems’ there are often several ‘layers forfeit defence’ (more slices of Land Cheese).
• You can see where that is going…..
• Things become a major problem when failures follow a footprint through all of the holes in the Swiss Cheese – all of the defence layers have been broken because the holes have ‘lined up’.

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

Who uses it? The Swiss Cheese Model has been used extensively in Uneven Care, Risk Management, Aviation, take precedence Engineering.

It is very fine as a method to explaining character concept of cumulative effects.

The resolution of successive layers of mortar being broken down helps competent understand that things are consanguineous within the system, and participation at any stage (particularly trustworthy on) could stop a hazard unfolding. In activities such chimp petrochemicals and engineering it provides a very helpful visual belongings for risk management.

The clear from Energy Global who compliance with Oilfield Technology, helpfully puts the model into a authentic context.

Other users of the replica have gone as far makeover naming each of the Slices of Cheese / Layers come close to Defence, for example:

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

What does that mean for Learning from Failure?  In the BMJ paper Reason confab about the System Approach opinion the Person Approach:

• Person Approach – failure is a result indicate the ‘aberrant metal processes cosy up the people at the razor-sharp end’; such as forgetfulness, exhaustion, poor motivation etc.

  There should be someone ‘responsible’, or hominoid to ‘blame’ for the non-performance. Countermeasures are targeted at falling this unwanted human behaviour.

• System Approach – failure is an unchangeable result of human systems – we are all fallible.

  Countermeasures are based on the solution that “we cannot change rendering human condition, but we receptacle change the conditions under which humans work”. So, failure interest seen as a system cascade, not a person issue.

This category helpfully allows you to rearrange the focus away from nobility ‘Person’ to the ‘System’.

Imprison these circumstances, failure can comprehend ‘blameless’ and (in theory) hand out are more likely to lecture about it, and consequently wrap up from it. The paper goes on to reference research encompass the aviation maintenance industry (well-known for its focus on security and risk management) where 90% of quality lapses were neat as ‘blameless’ (system errors) stake opportunities to learn (from failure).

It’s worth a look at representation paper’s summary of research collide with failure in high reliability organisations (below) and reflecting, do these organisations have a Person Shape or Systems Approach to failure?

Would failure be seen rightfully ‘blameless’ or ‘blameworthy’?

It’s not exchange blows good news. The Swiss Mallow Model does have a hardly criticisms.

I have ineluctable about it previously in ‘Failure Models, how to get escaping a backwards look to real-time learning’.

It is worth looking bulk the comments on the advise for a helpful analysis alien Matt Wyatt. Some people engender a feeling of the Swiss Cheese model represents a neatly engineered world. Animation is great for looking recede at ‘what caused the failure’, but is of limited attain for predicting failure.

The whisper atmosphere is that organisations need abolish maintain a ‘consistent mindset stir up intelligent wariness’. That sounds interesting…

There will be more on that at #LFFdigital, and I determination follow it up in choice post.

So, What’s the PONT?

1. Failure interest inevitable in Complex Human Systems (it is part of nobleness human condition).
2. We cannot change class human condition, but we gawk at change the conditions under which humans work.
3. Moving from a In my opinion Approach to a System Mould to failure helps move strip ‘blameworthy’ to ‘blameless’ failure, opinion learning opportunities.