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Posted By jom
This model is appearing everywhere.
It is a stupid model.
It must be possible to produce something better than cheese to explain accidents.
John.
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Posted By J Knight
How about you get your goose laying golden eggs (productive company), stuff it full of food (unsafe acts and conditions) and it's liver bursts (accident happens) producing pate de foi gras - which is very expensive???
No, thought not,
JOhn
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Posted By jom
J.
Yep, I'll go with that. Stuffed goose explodes. That's better than swiss cheese.
J.
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Posted By jom
Perhaps Professor Reason would join us in thie forum and discuss the value of the cheese model.
J.
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Posted By Robert K Lewis
Good question for a Friday. I think that the reason Prof Reason, excuse me but it reminds me that Detective Sergeant Constable once arrested Mick Jagger, is that he is trying to impart the idea that a random set of holes, events, might line up at any time and thus produce a line to a failure event.
Producing models such that we can visualise what is happening is often the key to the acceptance and understanding of a concept. In many ways it is not really different to a root cause analysis model which seeks to drill down through the various factors to the management system failures at the end of the tunnel.
Would you remember it if it wasn't for the cheese? Hale and Hale's model tried to descibe the same type of process many years ago now but it is hard to visualise the nuances of it without a prompt.
Bob
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Posted By Frank Hallett
Too clever by half for me! I still go with the Concept; Consequences; Cause; Effect process 'cos I'm a simple person. Mind you, I find the modern electronic programmes based upon astronomy seasrches make it incredibly easier to get a 360degree projection.
Still doesn't help with telling me who will actually do it wrong though.
Frank Hallett
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Posted By steven bentham
For those who have not read his books, they are by far the best on the block with very easy thinking for difficult concepts.
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Posted By jom
>For those who have not read his books, >they are by far the best on the block with >very easy thinking for difficult concepts.
Yeah, I agree. Professor Reason's text is a strong contributution to our understanding of industrial acidents. I think his words are great.
I think the Swiss cheese diagram is stupid.
But it's turning up everywhere as if it is the definitive explanation of accident causation.
It is a stupid diagram. Accidents are not caused by holes in layers of swiss sheese.
We have to work harder with out analysis.
J.
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Posted By Merv Newman
Jim Reason retired at least five years ago so I doubt he watches this chat show. I always thought that the swiss cheese model was a bit tenuous. You'd have to slice the cheese fairly thin (ie fewer and fewer chances of obstruction, or of prevention) to see daylight from one side to the other.
I prefer the various "domino" models where, in sequence, strategic, tactical, operational, behavioural and defensive measures all have to fail before there is an accident. (that's a bit simplistic but ok for saturday evening) The strategic level represents the board of directors, "Behavioural" is the exposed employee and "Defensive" represents safety precautions such as guarding, PPE or training.
Following from this model, behaviouralists try to implant "safe" behaviours which are intended to compensate for latent errors caused by the higher levels.
Does that smell any better ?
Merv
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Posted By jom
Merv,
Yes, that does smell better. And you put your case with words, not gimmicky diagrams. That's the way we will progress.
I'm worried that people will think the Swiss cheese diagram explains all about accident causation. It does not.
The domino model is a good one, I feel. It actually works. It demonstrates that one event causes another which causes another. But that's all. Once we see the point, we can leave the model behind.
Same with Swiss cheese. It cutely illustartes a few concepts, but they are easily described with words. Once understood, we should leave the model behind.
I think it is becoming a problem because it is appearing in so many places where accidents are discussed - engineering, rail, aviation, medicine. A UK parliamentary research paper on human error includes the diagram.
It's just a cute diagram that doesn't take us anywhere. Let's get bake to words.
J.
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Posted By Raymond Rapp
Whether Reason's Swiss Cheese model is a good analogy is a matter of conjecture. It is the concept that is important. However, it does leave a lasting impression on what is essentially a visual concatenation of events. There are of course other analogous examples such as the domino effect and Turner's 'trigger event'.
One should not get bogged down with descriptive examples. After all, there are many others that annoy me. For example, the Heinrich, Bird pyramid showing death and injury rates has been plagiarised for all and sundry.
Regards
Ray
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Posted By Alan Hoskins
Isn't the main point of this model that holes randomly appear in our risk control 'layers' and these may or may not get spotted and repaired.
As the number of failures increases so does the risk of an accident. There is no need for all the layers to fail for an accident to happen - that could result from just a single failure.
If all layers (controls) should fail at the same time then the chances of an accident are very high, but in practice that should never happen.
I like it - much better than dominos...
Alan
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Posted By Nigel Hammond
Great subject for a thread. I'm not sure I agree with you - as I think diagrams are great and words are boring. I doubt if Einstein was particularlty thinking in words when he came up with his theory of relativity.
Even if such diagrams do over-simplify they provide a good starting point to get your head round concepts and maybe come up with an even better analogy. What really bugs me is the word 'model'. It has become such a management-speak word!
Anyway, I've heard of the swiss cheese model but never seen it. Can anyone tell me where I can get a copy.
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Posted By Nigel Hammond
Thanks Phillip
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Posted By jom
Alan wrote:
>Isn't the main point of this model that holes >randomly appear in our risk control 'layers' >and these may or may not get spotted and >repaired.
Yes, I think that is the main point. And you've expressed it perfectly in words. You didn't mention cheese once. Not even a bit of Wensleydale.
J.
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Posted By jom
Nigel wrote:
>Great subject for a thread. I'm not sure I >agree with you - as I think diagrams are >great and words are boring.
I love diagrams. Words can be boring and a diagram is a great trick to keep the interest alive.
Diagrams are great for illustrating a point. But they are not the argument. That has to come through words. There's no choice about that.
>Anyway, I've heard of the swiss cheese >model but never seen it. Can anyone tell >me where I can get a copy.
No, you can't have a copy. Absolutely not.
J.
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Posted By Jonathan Breeze
Jom,
You obviously struggle with pictures, personally I find them very helpful as long as I 'get' the analogy.
How about changing the analogy to say football, with the hazard being say Rooney with the ball, and the defensive layers being defenders & the goalie. A goal (loss) only occurs once all the defenders are beaten & the ball is delivered into the net.
Or alternatively cricket, the ball is the hazard, the defensive layers are the spin imparted by the pitch & the batsman in front of the stumps, the potential loss being bowled out only two runs short.
Caution! The analogy is only as good as your ability to remember what each bit actually represents. Like you say it is only a visual aid to what is actually being described.
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Posted By Nigel Hammond
I'm getting cheesed-off with this tread
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Posted By jom
Jon,
>You obviously struggle with pictures,
Not at all - I love pictures & diagrams. A good schematic can be great for illustrating a point.
>How about changing the analogy to say >football, with the hazard being say Rooney >with the ball, and the defensive layers being >defenders & the goalie.
That's brilliant. It shows how the harmful energy source is an active player in seeking out the defense gaps and can even play a role in generating them. Hazards can be far from passive.
It's real too. Most people could easily relate to it.
What's a Rooney? Don't wish to talk about cricket.
J.
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Posted By Jonathan Breeze
Jom
Glad you liked the football analogy, I should write a paper on it and become rich, and famous, and take over the world Mwahaha!
> "What's a Rooney?"
He's a local football star famed for his looks and devastating striking ability. Not popular round our way since he left to play for the enemy (Man Utd).
Also plays for England.
I wouldn't worry too much about the cricket mate, you have history on your side on that one!
Another way to think about about accident causation if you are an engineer is as logic gates. The accident only occurs if a series of predetermined conditions are met.
I still prefer the Swiss Cheese model though where the holes represent management, process or procedural failures, although John Knights pate de foi gras model also appeals... Mmm food!
Nigel wrote:
>"I doubt if Einstein was particularlty thinking in words when he came up with his theory of relativity. "
As far as I am concerned any one with a predilection for rubber sheets needs therapy, not a Nobel prize!
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