And a great summary about systems approach to failure.
James Reason Swiss Cheese Model. Source: BMJ, 2000 Mar 18:320(7237): 768-770
This week I’m at the Cardiff pilot of Practical Strategies for Learning from Failure (#LFFdigital), explaining the Swiss Cheese Failure Model in 300 seconds (5 minutes).
In the event of failure (ha ha ha, I couldn’t resist that), this is what I’m aiming to cover….
The Swiss Cheese Model of Accident Causation (to give it the full name), was developed by Professor James T. Reason at the University of Manchester about 25 years ago. The original 1990 paper,“The Contribution of Latent Human Failures to the Breakdown of Complex Systems”, published in the transactions of The Royal Society of London, clearly identifies these are complex human systems, which is important.
Well worth reading is the British Medical Journal (BMJ), March 2000 paper, ‘Human error: models and management’. This paper gives an excellent explanation of the model, along with…
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