Reason's Swiss Cheese Model Applied to Pandemic Defense
Human and Organizational Performance (H&OP)
After a few refinements, Ian Mackay proposes an application of Reason's model to solve the SARS-CoV-2 Pandemic
Ref: "The Swiss Cheese Infographic That Went Viral"
by Ian M Mackay virologydownunder.com December 26, 2020
James Reason originally proposed a model of what happens when an Organization's lines of defense break down. Reason called his model: "The Swiss Cheese Model of Defences". This model helps to visualize and explain the randomness of SIFs. H&OP has advanced since 1997. For the purposes of the way H&OP is being practiced in the twenties we propose slight modifications to Reason's model when used to discuss H&OP:
- Layer 1: Organization fails to mitigate all removable hazards and fails to"wrap" inherent hazards to tolerate human error by failing to a safe state.
- Layer 2: Safety Culture and Safety Management fails. (e.g. supervision)
- Layer 3: Error Reduction and Managing Defenses fails.
- Layer 4: Human Error inevitably occurs.
When the "holes line up"...the person's only hope to escape SIF is the PPE they are wearing.
Ref: "Managing the Risks of Organizational Accidents" by James Reason, Published by Routledge, Ch-1, pg-9, December 1997
Learning Organizations know that making mistakes is the key to learning how do things more efficiently than their competition. Reason's Swiss cheese accident causation model pushes Learning Organizations to ask: How can we fail safely when we make a mistake when working near a hazard?