Swiss Cheese Model
I thank Jessica for pointing out this podcast and inviting a discussion of Reason's model.
I agree with Pete and Ralph that the model is simplistic and not useful for determining causation. There are a variety of more robust protocols for examining an incident and determining the direct, contributing, and root causes. There are even better graphical methods of presenting causation analysis, such as a fishbone diagram.
The value of the Swiss Cheese graphic is its ability to clearly present layer of protection. Ralph does this with respect to Covid. I have done this in discussing risks associated with working on high-pressure systems and on systems using toxic gases. I have found it very useful when I am asking senior management to fund engineering parameters for system design or upgrade.
All models are reliant on the assumptions used to build the model. If a presentation uses the Swiss Cheese model, it is reasonable to dissect the assumptions underlying each layer, to understand the strengths and weaknesses of the layer and the model. The same should be said for any model.
Just like our current safety paradigm "RAMP", this model must be used with recognition of its virtues and its limitations.
Neal
From: ACS Division of Chemical Health and Safety <DCHAS-L**At_Symbol_Here**Princeton.EDU> On Behalf Of Reinhardt, Peter
Sent: Saturday, May 1, 2021 1:36 PM
To: DCHAS-L**At_Symbol_Here**Princeton.EDU
Subject: Re: [DCHAS-L] Is Swiss cheese helpful for understanding accident causation?
I do agree that, in my opinion, the Swiss cheese metaphor is unhelpful for understanding accident causation.
On the flip side, the Swiss cheese metaphor is very helpful for understanding risk management. Each element of risk management is imperfect (has holes), so it is best to layer them. Driver's education + minimum driver's age + minimum standards for breaks + speed limits = good risk management.
When an accident happens, there are various reasons that may or may not correspond to a failure of a risk management element (cheese layer). Perhaps a ball bearing failed.
Pete Reinhardt, Yale EHS
Hello all,
I just listened to a very interesting episode of "The Safety of Work" podcast. The two researchers/practitioners (Rae and Proven) discussed the Swiss cheese model and asked whether it was a helpful metaphor for understanding accident causation - and the two people discussing it DISAGREED on the answer :).
I invite everyone to have a listen to the podcast if you are interested, and then reply on this thread with what you think about it. Have you used the Swiss cheese model in any of your work? Did you find it helpful? Did you find it simplistic and meaningless? Have you actually read any of Reason's work behind the model? What do you think of what Rae and Provan had to say about it? And who is right? I'd love to hear your thoughts!
Best,
NSF Graduate Research Fellow
Pinkhassik Group, Department of Chemistry
University of Connecticut
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