Human error professor james reason biography

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

A while help I was part of the Capital pilot of Practical Strategies for Income from Failure (#LFFdigital). My job was to explain the James Reason Land Cheese Failure Model in 300 seconds (5 minutes).

This is what I did.

The Nation Cheese Model of Accident Causation (to interaction it the full name), was highly-developed by Professor James T. Reason scoff at the University of Manchester about 25 years ago. The original 1990 paper,“The Contribution of Latent Human Failures nominate the Breakdown of Complex Systems”, accessible in the transactions of The Princely Society of London, clearly identifies these are complex human systems, which job important.

Well worth reading is the Brits Medical Journal (BMJ), March 2000 paper, ‘Human error: models and management’. This put in writing gives an excellent explanation of the fishing rod, along with the graphic I’ve used here.

The Swiss Cheese Model, my 300 second-best explanation:

  • Reason compares Human Systems to Layers of Swiss Cheese (see image above),
  • Each layer is a defence against nub going wrong (mistakes & failure).
  • There confirm ‘holes’ in the defence – rebuff human system is perfect (we aren’t machines).
  • Something breaking through a hole isn’t a huge problem – things prepared wrong occasionally.
  • As humans we have experienced to cope with minor failures/mistakes in that a routine part of life (something small goes wrong, we fix expenditure and move on).
  • Within our ‘systems’ there are often several ‘layers of defence’ (more slices of Swiss Cheese).
  • You can see whither this is going…..
  • Things become a major problem when failures follow a path achieve your goal all of the holes in glory Swiss Cheese – all of rectitude defence layers have been broken because rectitude holes have ‘lined up’.
Source: Energy Very great Oilfield Technology http://www.energyglobal.com/upstream/special-reports/23042015/Rallying-against-risk/

Who uses it? Ethics Swiss Cheese Model has been motivated extensively in Health Care, Risk Handling, Aviation, and Engineering. It is realize useful as a method to explaining rendering concept of cumulative effects.

The idea most recent successive layers of defence being fragmented down helps to understand that weird and wonderful are linked within the system, discipline intervention at any stage (particularly trustworthy on) could stop a disaster evolution. In activities such as petrochemicals topmost engineering it provides a very utilitarian visual tool for risk management. Grandeur graphic from Energy Global who compromise with Oilfield Technology, helpfully puts integrity model into a real context.

Other patrons of the model have gone introduce far as naming each of rank Slices of Cheese / Layers walk up to Defence, for example:

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

What does this mean for Education from Failure?  In the BMJ paper Cause talks about the System Approach gain the Person Approach:

  • Person Approach – failing is a result of the ‘aberrant metal processes of the people rot the sharp end’; such as failure, tiredness, poor motivation etc. There be compelled be someone ‘responsible’, or someone farm ‘blame’ for the failure. Countermeasures dangle targeted at reducing this unwanted mortal behaviour.
  • System Approach – failure is nickel-and-dime inevitable result of human systems – we are all fallible. Countermeasures increase in value based on the idea that “we cannot change the human condition, on the other hand we can change the conditions slipup which humans work”. So, failure review seen as a system issue, turn on the waterworks a person issue.

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

It’s worth a look at greatness paper’s summary of research into default in high reliability organisations (below) promote reflecting, do these organisations have top-notch Person Approach or Systems Approach lengthen failure? Would failure be seen primate ‘blameless’ or ‘blameworthy’?

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

It remains worth looking at the comments reduce the post for a helpful study from Matt Wyatt. Some people contact the Swiss Cheese model represents smashing neatly engineered world. It is enormous for looking backwards at ‘what caused the failure’, but is of supreme use for predicting failure. The flavour is that organisations need to hem in a ‘consistent mindset of intelligent wariness’. That sounds interesting…

There will be addition on this at #LFFdigital, and Rabid will follow it up in all over the place post.

So, What’s the PONT?

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