Swiss cheese model
Encyclopedia
The Swiss cheese model is a organizational model, proposed by James Reason of the University of Manchester and Dante Orlandella, used to analyze the causes of systematic failures or accidents, commonly used in the fields of aviation
, engineering
and healthcare. It describes accident causation as a series of events which must occur in a specific order and manner for an accident to occur, which it compares to the holes of several unique pieces of Swiss cheese
lining up. A system is analogous to a stack of slices of Swiss cheese. The holes are opportunities for a failure or accident to occur, and each of the slices are layers of the system. A 'hole' may allow a problem to pass through a hole in one layer, but in the next layer the holes are in different places, and the problem may be stopped. Each layer is a defense against potential problems.
For a catastrophic failure or accident to occur, the holes need to align for each step in the process allowing all defenses to be defeated and resulting in an error. The model differentiates between two types of 'holes', latent failures and active ones. Latent ones are existing problems, and active ones are the acute failures that lead to an accident If the layers are set up with all the holes lined up, this is an inherently flawed system that will allow a problem at the beginning to progress all the way through to adversely affect the outcome. Each slice of cheese is an opportunity to stop an error. The more layers, the less likely an accident is to occur.
Although the Swiss cheese model is respected and considered to be a useful method of relating concepts, it has been subject to some criticism, including that it is used over broadly, and without enough other models or support. However, it is viewed as a decent model when supported.
Aviation
Aviation is the design, development, production, operation, and use of aircraft, especially heavier-than-air aircraft. Aviation is derived from avis, the Latin word for bird.-History:...
, engineering
Engineering
Engineering is the discipline, art, skill and profession of acquiring and applying scientific, mathematical, economic, social, and practical knowledge, in order to design and build structures, machines, devices, systems, materials and processes that safely realize improvements to the lives of...
and healthcare. It describes accident causation as a series of events which must occur in a specific order and manner for an accident to occur, which it compares to the holes of several unique pieces of Swiss cheese
Swiss cheese
Swiss cheese is a generic name in North America for several related varieties of cheese which resemble the Swiss Emmental. Some types of Swiss cheese have a distinctive appearance, as the blocks of the cheese are riddled with holes known as "eyes". Swiss cheese has a piquant, but not very sharp,...
lining up. A system is analogous to a stack of slices of Swiss cheese. The holes are opportunities for a failure or accident to occur, and each of the slices are layers of the system. A 'hole' may allow a problem to pass through a hole in one layer, but in the next layer the holes are in different places, and the problem may be stopped. Each layer is a defense against potential problems.
For a catastrophic failure or accident to occur, the holes need to align for each step in the process allowing all defenses to be defeated and resulting in an error. The model differentiates between two types of 'holes', latent failures and active ones. Latent ones are existing problems, and active ones are the acute failures that lead to an accident If the layers are set up with all the holes lined up, this is an inherently flawed system that will allow a problem at the beginning to progress all the way through to adversely affect the outcome. Each slice of cheese is an opportunity to stop an error. The more layers, the less likely an accident is to occur.
Although the Swiss cheese model is respected and considered to be a useful method of relating concepts, it has been subject to some criticism, including that it is used over broadly, and without enough other models or support. However, it is viewed as a decent model when supported.
See also
- AccidentAccidentAn accident or mishap is an unforeseen and unplanned event or circumstance, often with lack of intention or necessity. It implies a generally negative outcome which may have been avoided or prevented had circumstances leading up to the accident been recognized, and acted upon, prior to its...
- Aviation safety
- EngineeringEngineeringEngineering is the discipline, art, skill and profession of acquiring and applying scientific, mathematical, economic, social, and practical knowledge, in order to design and build structures, machines, devices, systems, materials and processes that safely realize improvements to the lives of...
- Organizational models of accidents
- SafetySafetySafety is the state of being "safe" , the condition of being protected against physical, social, spiritual, financial, political, emotional, occupational, psychological, educational or other types or consequences of failure, damage, error, accidents, harm or any other event which could be...
- Systems modelling