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Originally Posted by STEED
These things happen..................  |
Swiss cheese!!
The
Swiss Cheese model of accident causation is a model used in the
risk analysis and
risk management of human systems. It likens human systems to multiple slices of
Swiss cheese, stacked together, side by side. It was originally propounded by British psychologist James T. Reason in 1990, and has since gained widespread acceptance and use in healthcare, in the
aviation safety industry, and in emergency service organizations. It is sometimes called the
cumulative act effect.
Reason hypothesizes that most accidents can be traced to one or more of four levels of failure: Organizational influences, unsafe supervision, preconditions for unsafe acts, and the unsafe acts themselves. In the Swiss Cheese model, an organization's defences against failure are modelled as a series of barriers, represented as slices of Swiss cheese. The holes in the cheese slices represent individual weaknesses in individual parts of the system, and are continually varying in size and position in all slices. The system as a whole produces failures when all of the holes in each of the slices momentarily align, permitting (in Reason's words) "a trajectory of accident opportunity", so that a hazard passes through all of the holes in all of the defenses, leading to a failure.