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Swiss Cheese Model

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We always take precautions and maintain proper safety procedures during working, but accidents do inevitably happen. But many questions related to these accidents may come to our mind like why do accidents happen? From where do they originate? 

The Sweet Cheese Model is an ideal model that is implemented in risk management and analysis in the section like engineering, healthcare, a foundation for layered security, safety of the aviation, computer security and defense. 

The Swiss cheese model is a theoretical assumption that is used in risk management, risk analysis, and risk prevention before any accident. Any component of an organization is considered as a cheese slice of this model. Management, resource allocation, efficient safety program, operational support all are considered as a part of the cheese slice.

If there are any flaws or deficiencies in the cheese slices of an agency or organization, then there will be a hole in those slices. If there is a line up of the holes within each slice of an enterprise, it leads to the creation of one big hole instead of small ones, thus causing an accident. Big holes are formed due to the ignorance of one weakness into another.

Accidents happen due to confluence of one or more than one factors. The accidental factors can vary from organizational errors to unsafe acts of an individual. Most of the accidents are caused due to latent errors that are lying dormant and are waiting to be activated by several errors. To avoid accidents and to save humans from any operational errors, it is essential to install highly maintained and the latest systems to mitigate manual errors.

Active Errors or failures are the unprotected acts that are committed by mankind. An example of active failure is an employee who decides not to follow the safety measures during cleaning debris that are flammable from a working machine. But according to the theory of the Swiss Cheese Model, active errors are not the eventual source of the accidents. 

According to the Swiss cheese model, accidents occur due to windows of negative opportunities or weaknesses. These weaknesses are open in all levels of the production system, allowing a chain of events starting at the higher levels of the structure and moving down.

This template will primarily be useful to health and safety professionals. You can use the slides in this template to describe the potential risks to your company if safety rules are not followed.

Also, crisis managers can use this template when identifying weaknesses in the company and preparing measures to eliminate them.

Swiss Cheese Model is a professional and modern template that contains four stylish and fully editable slides. You can independently change the size and type of fonts, position and size of infographics according to your corporate requirements. This template will be useful for analysts, financiers, company executives and startups. Swiss Cheese Model template will be a worthy addition to your collection of professional presentations.

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Ultimate Guide to Swiss Cheese Model and Its Applications

By Sebastian Traeger

Updated: May 13, 2024

Reading Time: 7 minutes

What is the Swiss Cheese Model?

How the model works, applications of swiss cheese model across industries, benefits of the swiss cheese model, limitations of the swiss cheese model, real-world examples of the model in action, incorporating the swiss cheese model in daily operations.

With over two decades in business – spanning strategy consulting, tech startups, and executive leadership – I am committed to helping your organization thrive.

At Reliability , we’re on a mission to help enhance strategic decision-making and operational excellence through the power of Root Cause Analysis, and I hope this article will be helpful! 

Our goal is to help you better understand root cause analysis by offering insights and practical tips based on years of experience. Whether you’re new to doing RCAs or a seasoned pro, we trust this will be useful in your journey towards working hard and working smart.

——————— 

The Swiss Cheese Model is a term used to describe risk management and human error in complex systems. This metaphor is commonly applied in healthcare, aviation, engineering and other fields to demonstrate that if they have to pass through numerous defenses (each represented by a slice of cheese), errors can be prevented.

These layers contain gaps which represent points of weakness or vulnerability — so what should be done is to establish the necessary arrangement in such a way as there are no two sets of hole areas which overlap thereby creating a continuous line for failure propagation.

One of our earlier article showed a different view to Swiss Cheese Model . In this post we will discuss what the Swiss cheese model means, where it can be used and why every safety plan or risk management strategy needs it.

Developed by James Reason as a tool for preventing risks and errors in the 1990s, the Swiss Cheese Model is now one of the most basic concepts on which safety rests within various domains including healthcare aviation and engineering. As stated, many defenses ought to work together even though each might have some weaknesses because then they will prevent catastrophes from occurring.

The brilliance behind this lies with recognizing that all protective measures are fallible individually; but when combined successively with other levels they enhance system-wide safety greatly. This becomes very handy in areas where small missteps may lead to great failures hence require tight control over possibilities of making mistakes.

As an example, think about different pieces of Swiss cheese put side by side with irregular gaps. Patterns can be discerned between layers therefore some weak points are compensated for by stronger ones found within another sheet thereby reducing risks.

If you were to place several slices of Swiss cheese next to each other wherein there are random holes scattered throughout, you would get something resembling the Swiss Cheese Model visually.

These perforations represent single layer defense vulnerabilities such as human errors or security protocol breaches. But what makes these perforated sheets effective is their positioning relative to one another. Since the gaps are distributed in an unsystematic manner, it follows that typically a solid portion from one slice will cover up for the gap on another.

This arrangement therefore significantly minimizes opportunities through which threats or errors can pass undetected across multiple levels. Simply put, it is a diagrammatic representation that helps us understand how various safety nets overlap so as to catch and stop mistakes before they turn into disasters.

Redundancy within critical systems is emphasized by this model where even if one fails there should still be other backups providing necessary protection against risks.

In healthcare, nothing is more important than patient safety. The Swiss cheese model provides an excellent foundation for improving it. Every aspect of patient care, from prescribing medication to carrying out medical procedures can be thought of as a slice of cheese.

Through this model, providers can identify where they are weak at each step in the process so that they may tighten those areas up and lessen their chances of making errors which could hurt patients. For instance, multiple checks on patient identification with medication dosage calculation along surgical procedure planning ensure detection and correction of mistakes made at one point from another thus guarding against what happens to a patient.

The aviation industry relies heavily on the Swiss cheese model because failures have such severe consequences. Pilot training has to be rigorous, aircraft maintenance needs thoroughness while air traffic control operations should be careful if we want critical safety layers in aviation to exist.

According to this model, every layer is like a slice of cheese that helps cover possible holes that may lead into accidents. Therefore, these layers are probed one after another systematically – checking until balance among them is attained since any slackness on one part will always be picked at by subsequent parts thereby keeping record safe with crew’s lives being also protected.

 Engineering

The world today has safety-critical fields such as nuclear or chemical engineering which put great emphasis on safety more than anything else anywhere else in the world today. Swiss Cheese Model offers real-world rather than just theoretical fail-safe design against human and mechanical errors within these domains since it serves better here when employed meticulously compared to being only used as a conceptual framework somewhere else.

Many people do not know but there must always be several levels for prevention whenever this occurs therefore even if any single level fails then others shall come into play so as to prevent disaster stepwise carefully without leaving out anything. Even now were it not for such models we would still experience bigger frequent accidents internationally and nationally.

Enhanced Safety

One more point that has made the Swiss Cheese Model so popular is its ability to enhance safety significantly. This involves identifying weaknesses in each safety measure, which then becomes the basis for requiring several layers of defense to overlap.

In doing so, it greatly reduces the likelihood of any single failure point causing a complete system failure. What does this mean practically? It means there will be many more protections built into working systems themselves and also individuals who depend on them, hence becoming widely adopted in industries where safety cannot be taken lightly.

Improved Error Management

The Swiss Cheese Model is very good at realizing error dynamics in complex systems. It promotes safety before accidents by recommending different preventive measures that should also be duplicated.

When organizations take up such a model, they develop stronger ways of identifying errors and correcting them which leads to a significant decrease in both the probability and impact of errors. This systematic approach to mistake management prevents failures while fostering reliable structures for operational activities.

Fosters a Culture of Continuous Improvement

The Swiss cheese model’s greatest strength lies in its ability to foster a culture of continuous improvement among organizations. Teams would use this model for failure analysis as a way to keep refining their safety procedures over time.

Such an ongoing process prepares establishments for potential threats thereby making them proactive and responsive to new challenges which ensures that defenses remain strong throughout while maintaining secure operations always. 

One of the proactive approaches to continuous improvement is the PROACT® method. The PROACT® method supports operational excellence by promoting a culture of continuous improvement. By identifying and addressing root causes, organizations can prevent recurring issues, improve efficiency, and enhance performance. This proactive approach to problem-solving encourages a mindset of prevention rather than reaction, fostering a culture that values quality, safety, and efficiency.

As good as the Swiss cheese model may look, it does come with its own share of flaws. Critics say that it simplifies too much for complex systems like modern ones which are highly dynamic and interconnected. In other words, this model fails to capture these aspects adequately.

They point out that sometimes it only shows some paths through which errors can travel in an organization or industry with many parts that depend on each other, yet there could be more routes along which mistakes might move through such a system.

Despite the shortcomings, critics still know very well also that such models are able to serve as useful starting points for safety management improvement.

Aviation Incident Analysis

Every day in the aviation sector where peoples’ lives are at stake accidents become a great worry since they pose a danger to human life. The Swiss cheese model is used extensively as an accident investigation tool within this field because prevention measures must be strong due to the high risks involved.

After an unfortunate event happens, investigators trace failures across multiple layers of protection until slices line up like cheese during their analysis revealing weaknesses in airline systems through which hazards can enter if appropriate actions were not taken earlier enough thereby prompting relevant authorities’ intervention before another similar incident occurs.

 Healthcare Quality Assurance

The significance of the Swiss Cheese Model cannot be overemphasized when it comes to quality control assurance processes in hospitals and any other health care setting worldwide. Healthcare facilities need to be places where a patient’s safety is guaranteed because everyone would expect to leave there feeling better than when they came seeking medical attention.

Healthcare providers use the Swiss Cheese Model during investigations into adverse events to determine where errors occurred while delivering care to individuals with diverse needs. Staff responsible for patient welfare and managing equipment functions, among other tasks, use this model to identify weaknesses when addressing health issues.

Through doing such, areas where breakdown in communication might have occurred leading to failure to communicate among them will be identified which would enable correction of such situations earlier before−hand if necessary for effective provision of care services to patients.

Risk Assessment

The Swiss cheese model can be used in daily operations of many businesses especially during risk evaluation stages. It requires them to view their systems and processes as Swiss Cheese layers so that they can identify points of failure, institute necessary controls and make sure there is overlap among the controls.

These measures enable firms to deal with weaknesses in their activities before they are discovered through errors or failures. For instance, weak areas along production lines should be identified and strengthened against costly defects which might necessitate product recalls, thereby safeguarding both reputation and bottom line of manufacturing enterprises.

Training and Awareness

One approach for building resilience into an organization is by ensuring everyone understands the Swiss Cheese Model. In order to create a culture where risks are managed proactively through constant vigilance it would be best if establishments trained widely on principles underpinning this model as well as its various applications.

Workers who know how safety nets can be layered will not only be able to see potential failure points earlier than others, but also handle them appropriately before they escalate into serious problems. For example, staff members armed with knowledge about Swiss Cheese Model may notice abnormal behaviors indicative of hacking attacks, thus helping prevent compromise of sensitive data or computer network breaches.

This is said to be one of the simplest, yet most effective methodologies across all sectors worldwide – since no other error prevention technique has achieved such universal success like the Swiss Cheese Model. It greatly enhances safety levels in any system from the aviation industry up to healthcare, among many other sectors.

It significantly increases overall system resilience through compensatory layering. Hence, if any business wants higher standards of safety coupled with reduced hazards, then it must adopt this strategic view on weaknesses together with promoting continuous improvement through vigilance.

I hope you found this guide to Swiss Cheese model insightful and actionable! Stay tuned for more thought-provoking articles as we continue to share our knowledge. Success is rooted in a thorough understanding and consistent application, and we hope this article was a step in unlocking the full potential of Root Cause Analysis for your organization.

Reliability runs initiatives such as an online learning center focused on the proprietary PROACT® RCA methodology and EasyRCA.com software. For additional resources, visit Reliability Resources .

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Swiss Cheese Model PowerPoint Template

Swiss Cheese Model PowerPoint Template presents a risk management concept with an eye-catching PPT design. The Swiss Cheese Model is commonly used in the health sector for risk analysis. In addition, it is a part of "safety science" since wrong diagnosis results are often considered human errors. It also has importance in other fields like engineering, defense, aviation, and cyber security. In this template, a slice of Swiss Cheese represents a given measure taken to minimize risk. Each cheese slide symbolizes organization management, allocation of resources, and an effective safety program.

The risk management PowerPoint template of the Swiss Cheese model has many sliced kinds of cheese arranged sequentially to show hazardous events and how to avoid dangerous incidents. Here the wholes signify organizations' weaknesses, and non-wholes represent productive safeguards. Here, the initiation of hazardous events is shown by red PowerPoint lines, and the yellow cheese shows the fragility as well as strength of an organization.

The Swiss Cheese PowerPoint Template contains two slides of square shapes in a linear process flow; this could be used as an alternative presentation for demonstrating success and opportunities. The users can add descriptive texts or PowerPoint images according to their presentation concept. Download concept presentation templates now!

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Swiss Cheese Model: Bridging the Gap in Safety

Have you ever wondered why, despite taking all possible measures and precautions, accidents happen? Well, the reason is – we tend to focus on the bigger picture, but we forget to look at the minute aspects, which ultimately leads to mishappenings. 

Let’s understand this with an example. Suppose you are a nurse. One day, during a busy shift change, you entered a patient’s room with a fellow nurse (to whom you were giving a handoff report) and found that the patient’s IV pump attachments to chest tubes were detached. The patient’s attendant told you that he had been waiting for you, and he tried to reach you via the nurse call system. However, you didn’t get the message because whoever answered the call didn’t relay the message. 

Even after getting calls from the patient’s attendant several times, not a single time you were informed. It clearly indicates that the hospital administration focused merely on the big picture, i,e., installing a nurse call system, but failed to train the nurses on other aspects. The lack of accountability, inability to understand the urgency of the message, miscommunication on the part of nurses, and the failure of system automation to escalate the message to the next appropriate individual could be a life-threatening situation for the patient.

Safety has been a major concern in almost all sectors – be it patient care, information exchange, or industrial processes. In this context, James T. Reason, a psychologist and researcher, developed a model called the Swiss Cheese Model that emphasizes human error and safety management in complex systems. 

In this article, we have covered all the ins and outs of this model. Read on!

What is the Swiss Cheese Model?

The Swiss Cheese Model is a conceptual model that illustrates how smaller and multiple failures end up causing a big disaster or hazard. 

This model comprises multiple layers of protection. However, no layer is perfect, and each has holes of different shapes and sizes. The number of holes in each layer may also vary. These holes represent shortcomings. 

Sometimes the holes in one or more layers are covered by other layers, and each layer supports other layers, thus strengthening the overall defense system. But sometimes, one or more holes in each layer get lined up, which increases the risk of mishappenings.

In a nutshell, according to this model, there is no single reason for an accident; it occurs due to a combination of errors, which could be latent or active. The latent errors are intrinsic to a system, machine, or process. Active errors are those committed by individuals. Active errors trigger latent errors. So, while assessing risks, one must consider both types of errors.

Role of the Swiss Cheese Model in Various Sectors

1. healthcare.

The Swiss Cheese Model has become a dominant paradigm in the healthcare sector, specifically for analyzing and figuring out patient safety incidents and medical errors. This model lays a foundation for risk management.

This model was very effective in educating people about how to defeat Covid-19. It explains how several layers, i.e., masks, social distancing, cleaning and disinfectants, frequent handwashing, and vaccination, combined together and created an impenetrable barrier for the virus. Getting rid of this pandemic would have been impossible if we had missed any of these measures. 

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2. Aviation

The Swiss Cheese Model has been accepted by various aviation authorities, including the International Civil Aviation Organization. This model helps make informed decisions in a timely manner that ultimately results in accident prevention.

In aviation, there may be many factors of accident causation – loopholes in rules and regulations, incorrect decisions made by the authorities, the physical health and personal life of the pilot, air traffic controllers, insufficient training of pilots, technical issues in the plane, weather, etc. 

The major defense layers in aviation are – flight crew response, sensor reliability, flight crew training, sensor fault information, adequate repairs, correct maintenance, aircraft fault history, and crew resource management. A disaster happens when flaws in each layer align. 

For example, a plane will likely crash if a stressed and improperly trained pilot, who is working with a poorly managed aviation company, is flying the plane in seriously bad weather.

Image Credit – Stephen Dosman

3 . Manufacturing and Construction

This model is quite useful for manufacturing and construction companies to get a clue about what went wrong, despite their best prevention efforts, that caused the accident. It aims to help organizations improve their productivity while minimizing or completely avoiding risk. The model helps figure out safety gaps, enabling firms to take proactive actions. 

If we see the safety in the construction industry from the lens of the Swiss Cheese Model, we will find many holes in the defense layers. One common hole in each layer is the prioritization of productivity, ignoring workforce safety. Inefficient communication, non-availability of PPE on sites, noncompliance with PPE, lack of training, lack of safety tech, lack of encouragement from upper management, and lack of monitoring of on-site movements with drones are some other holes, which when aligns lead to catastrophe. 

This model stresses the importance of a balance between productivity, economy, and safety to make manufacturing and construction industries safer. In addition, this model holds everyone (entry-level employee, line manager,  supervisor, management, etc.) responsible for workplace accidents and injury and emphasizes the need for streamlined communication, adjustment in the planning process, and prioritizing safety in all decision-making.

To sum up, by minimizing holes and strengthening defense layers, these industries can transform slices of Swiss Cheese into American cheese.

4. Transportation

The Swiss Cheese Model can be used in the transportation sector as a framework for error management and analyzing human error-related data. It highlights various latent and active errors that can result in road accidents and helps design countermeasures to address the latent conditions and mistakes humans commit.

According to research, 75% of road accidents occur due to negligence or errors on the part of drivers. In this context, the Swiss Cheese model has been instrumental in shifting the focus from road users to system-wide neglect. It stresses the need for effective driver training, implementation of advanced driving assistance systems, strengthening management systems and safety culture, and enhancement of vehicle and road infrastructure to ensure safer transportation and reduce the number of accidents.

This model also provides useful insights into how to develop automated vehicles (AVs) so that they can be used in the safest manner, contributing to transport equity and accessibility. The most important protection layers for AVs would be seatbelts, airbags, and other occupant safety devices.

5. IT and Cybersecurity

The Swiss Cheese Model has been applied by various IT and technology-based companies to visualize different defenses and control measures that have been implemented to protect the firm from cyber attacks. These measures include both technical (like antivirus software, firewall, two-factor authentication, etc.) and non-technical activities (like stringent policies, employee training, etc.).

For any firm, the defense layers for data security can be-

• Employee Training
• Network Security
• Real-time Monitoring
• Perimeter Security
• Endpoint Security
• Disaster Recovery

All these measures and controls are like a slice of cheese that acts as protective layers. However, each slice has unique holes (vulnerabilities). In the event of a cyber attack, the attacker exploits these vulnerabilities, and if the vulnerabilities in each layer get in a sequence, the attack becomes successful.

To sum up, this model provides a holistic approach to cybersecurity. It acknowledges that no single control or defense can completely secure any organization from cyber threats; multiple layers of defense must be in place to strengthen the overall security posture and protect sensitive data, information, and assets.

6. Other Sectors

In addition to the above-mentioned sectors, the Swiss Cheese Model has a multitude of applications in military and defense, engineering domains, nuclear power plants, space exploration, etc.

For example, this model visualized the mismatch between metric and imperial units in software as the major cause of the failure of the 1999 Mars Climate Orbiter mission. The flaws in the software remain undetected during quality assurance, design reviews, and testing.

 Similarly, the major cause of the 2005 London bombings was a series of intelligence failures, due to which terrorists got an opportunity to exploit weaknesses and gaps.

Educating the Workforce About this Model

Risk managers and crisis managers must educate the workforce about this model so that each employee can understand their accountability and behave responsibly to avoid accidents at the workplace.

Business leaders, senior executives, and team leaders can deliver an informative presentation using a pre-designed Swiss Cheese Model template to encourage employees’ commitment to risk prevention. Through presentation, you can visualize past accidents that happened in your organization and give a visual representation of this model to make employees understand the causal factors of hazards and how they can be prevented in the future by working together.

The Swiss Cheese Model is an explanatory and descriptive framework for understanding the causes of accidents. This model has its own set of limitations – the major one is that it is reactive and retrospective and can’t predict or prevent potential incidents. 

However, this model draws our attention to latent errors along with active errors. It is of immense help in learning lessons from past mistakes and strategizing accordingly to prevent similar errors in the future. Despite limitations, the system foundations of this model make it relevant in most sectors.

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Download our MS PowerPoint and Google Slides compatible Swiss Cheese Model presentation template to describe the risk management concept that emphasizes the importance of having diverse safeguards to compensate for individual weaknesses or vulnerabilities.

Risk experts can use this set to explain how the barrier thinking approach, under the context of the Swiss Cheese Model, focuses on proactively identifying and strengthening barriers within a system to prevent errors or failures. You can further describe how this model enables organizations to recognize the interconnectedness of defenses and enhance their overall resilience. Using this deck, you can present the Swiss Cheese Model of accident causation and adverse events. Moreover, you can depict the key learnings, advantages, and disadvantages of this model.

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The Swiss cheese model: Designing to reduce catastrophic losses

Failures and errors happen frequently. A part breaks, an instruction is misunderstood, a rodent chews through a power cord. The issue gets noticed, we respond to correct it, we clean up any impacts, and we’re back in business.

Occasionally, a catastrophic loss occurs. A plane crashes , a patient dies during an operation, an attacker installs ransomware on the network. We often look for a single cause or freak occurrence to explain the incident. Rarely, if ever, are these accurate.

The vast majority of catastrophes are created by a series of factors that line up in just the wrong way, allowing seemingly-small details to add up to a major incident.

The Swiss cheese model is a great way to visualize this and is fully compatible with systems thinking. Understanding it will help you design systems which are more resilient to failures, errors, and even security threats.

Holy cheese

The Swiss Cheese Model was created by Dr. James Reason , a highly regarded expert in the field of aviation safety and human error. In this model, hazards are on one side, losses are on another, and in between are slices of Swiss cheese.

Each slice is a line of defense, something that can catch or prevent a hazard from becoming a catastrophic loss. This could be anything: backup components, monitoring devices, damage control systems, personnel training, organizational policies, etc.

Of course, Swiss cheese is famous for its holes. In the model, each hole is a gap in that layer that allows the hazard condition to progress. A hole could be anything: a broken monitoring device or backup system, an outdated regulation or policy, a misunderstanding between a pilot and air traffic control, a receptionist vulnerable to social engineering, a culture of ‘not my job’.

If you stack a bunch of random slices of Swiss, the holes don’t usually line up all the way through. A failure in one aspect of the system isn’t catastrophic because other aspects of the system will catch it. This is a “defense in depth” strategy; many layers means many opportunities to prevent a small issue from becoming a major issue.

As shown in the diagram, sometimes the holes do line up. This is the trajectory of an accident, allowing an issue to propagate all the way through each layer until the catastrophic loss.

A great example is UPS Flight 6 , which crashed in Dubai in 2010. A fire broke out on board, started by lithium ion batteries which were being improperly shipped. Other planes, including UPS planes, have experienced similar fires but were able to land safely. This fire had to proceed through many layers before the crash happened:

• hazardous cargo policy — failed to properly identify the batteries and control where they were loaded in the plane
• smoke detection system — inhibited because rain covers on the shipping pallets contained the smoke until the fire was very large
• fire suppression system — not intended for the type of fire caused by batteries, thus less effective
• flight control systems — unable to withstand the heat and made controlling the plane increasingly difficult
• air conditioner unit failed — apparently unrelated to the fire, allowed the cockpit to fill with smoke
• cockpit checklists and crew training — didn’t have sufficient guidance for this type of situation, leading the crew to make several mistakes which exacerbated the situation
• pilot’s oxygen mask was damaged by the heat — he became incapacitated and likely died while still in the air
• copilot oxygen mask — he had on a mixed-atmosphere setting instead of 100% oxygen, allowing some smoke into his mask and reducing his effectiveness
• air traffic control wasn’t monitoring the emergency radio frequency — copilot tried to use this (international-standard) frequency, but air traffic controllers were not; he couldn’t find the airport without directions from the controllers

Ultimately, the flight control systems failed completely and the copilot could no longer control the aircraft. As you can see, this incident could have ended very differently if any single one of those nine layers did not allow the accident to progress 1 .

Applying the model in design

This model is most often used to describe accidents after-the-fact. But it’s just as applicable for describing the resiliency of the system during the design phase, where applying it can have the greatest impact on the safety and security of the system.

Add layers deliberately and with care

The layers of cheese in the model suggest that the easy solution to many holes is to add more layers of cheese. Another inspection step, component redundancy, a review gate, etc.

This is a defense-in-depth strategy and it’s essential for the first few layers. However, it quickly becomes onerous and costly. It can also backfire by providing a false sense of security (‘I don’t have to catch 100% of problems because the next step will’).

Before adding a slice, carefully analyze the system to determine if there may be a better way to address the concern.

Fill the holes

Most often, the best solution is to minimize the holes in each layer by making them more robust or to replace a layer with one that better addresses all of the risks.

An easy example might be the copilot’s oxygen mask setting from the UPS example above. The copilot had chosen a setting which varied the amount of oxygen based on altitude. In one sense, this setting makes sense; at a lower altitude the need for supplemental oxygen is lower. In another sense, there’s no risk in providing too much oxygen, so why not provide a simpler system which only delivers 100% oxygen and has less risk of error?

The best designs add minimal friction while providing value to the users. For example, a maintenance system which pre-fills documentation when the user scans a part. The user prefers it because it simplifies their job, documentation is more complete/accurate, and the system can automatically double-check that the part is compatible.

This is always going to be easiest to accomplish during initial design rather than added after the fact. Software engineering has made a big step forward in this regard with DevSecOps, baking security right in rather than trying (usually with little success) to force it on the system later. Resiliency should be incorporated into every step of an engineering project.

Analyze and accept risk

Finally, there’s never going to be a 100% safe and secure system. We must quantify the risks as best as possible, control them as much as practicable, and eventually accept the residual risk.

How have you applied the Swiss cheese model in your work? Do you have any criticisms of it or perhaps an alternative perspective? Share your thoughts in the comments.

• On the other hand, imagine how close you may have been to disaster throughout your life if not for 1-2 layers of cheese.

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Swiss Cheese and Safety

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French onion soup, the Cuban sandwich, process safety. Just a few recipes that wouldn't be the same without the crater-infused cheese: Swiss.

Beyond being a staple for comfort foods, Swiss cheese plays an important role in adopting a safety-oriented cultural mindset, which is essential for students working in Michigan Tech labs, and workers on oil tankers and at milling plants. The campus steward of the Swiss cheese for safety mindset—known formally as process safety—is Professor of Chemical Engineering and Herbert H. Dow Chair in Chemical Process Safety, Andre Da Costa.

Applying Swiss Cheese to COVID-19

Not a weird home remedy. As we look at ways to prevent the spread of COVID-19 , many have turned to the Swiss cheese model . It helps explain how masking, quarantine, vaccines and handwashing work together.

Put simply, his interest is in preventing the injuries, fatalities and damage that can potentially result from human error in hazardous environments, including but not limited to research labs. Da Costa brings more than 20 years of experience developing, promoting, disseminating and supporting implementation of process safety in industry and academia to Michigan Tech. But it is his compassion for humanity and the environment that drives him and his mission to thread process safety into our campus DNA.

Everything's Better with Cheese

Enter the Swiss cheese model of process safety, which illustrates, through layers in a block of Swiss cheese, the processes that can both prevent and cause safety concerns. According to Da Costa, we should think of a potential safety hazard as a beam of light. Swiss cheese is punctured with holes—the vulnerabilities in a system that can lead to an incident. The light—the hazard—could potentially shine through the gap in the cheese, the system's hole can result in an incident-like an explosion, a chemical spill and resulting skin burn or worse. Da Costa wants us to move beyond the single slice of Swiss, or the system without a process safety mindset.

More Cheese Please

The model he's pushing is comprised of multiple slices of Swiss. After all, more cheese is preferable.

The theory is that the multiple layers of cheese represent a process safety system. If several slices of cheese are stacked on top of each other, the hypothesis is that the holes would not align, which would shield the beam of light, preventing a hazard from passing through the layers (and resulting in catastrophe).

"In the case of process safety incidents, the cheese slices can be compared to barriers or layers of protection. Layers of protection may be: engineering controls (safe design), administrative controls (safe procedures) and behavioral controls (safe actions/safety culture."  Andre Da Costa

Elaborating further, he says that with proper process safety protocols in place—multiple layers of Swiss—the openings "may be plugged by understanding what can go wrong and designing systems with inherently higher safety. Other holes may be plugged by building a culture that promotes people’s safe actions."

Will be Safe for Cheese

Before entering a lab, not only does Da Costa hope his students and colleagues have a carefully crafted safety plan, he also hopes they value safety above all else. Safety as a value can foster safe behaviors and prevent incidents. Da Costa explains that a safety process mindset entails awareness of the multiple, potential vulnerabilities we can face working in dangerous environments. He hopes that the students and faculty who work in labs will always be cognizant of the holes (weaknesses) in the process.

Essentially, our collective actions can be the slices in the block of Swiss cheese to make sure everyone goes home safely.

"In a strong culture that values process safety, everyone maintains a sense of vulnerability and understands that bad things can happen and our actions make a difference," Da Costa says. "Before performing an activity ask, 'Are safeguards or layers of protection (Swiss cheese slices) in place to prevent an accident?'"

Da Costa's work in process safety is essentially asking people to create a recipe for preventing accidents. That recipe is a strategic mindset, which includes careful consideration of the situation's potential for incidents. Collaboratively, participants in the environment must compile a host of ingredients, which include accounting for all possible hazards, consequences, the degree of incident likelihood, safeguards and safety recommendations. Moving from raw ingredients to action plan, participants develop a process safety model steeped in efficiency, productivity and human safety.

Michigan Technological University is a public research university founded in 1885 in Houghton, Michigan, and is home to more than 7,000 students from 55 countries around the world. Consistently ranked among the best universities in the country for return on investment, Michigan’s flagship technological university offers more than 120 undergraduate and graduate degree programs in science and technology, engineering, computing, forestry, business and economics, health professions, humanities, mathematics, social sciences, and the arts. The rural campus is situated just miles from Lake Superior in Michigan's Upper Peninsula, offering year-round opportunities for outdoor adventure.

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SWISS CHEESE MODEL

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HAL is a multi-disciplinary open access archive for the deposit and dissemination of sci-entific research documents, whether they are pub-lished or not. The documents may come from teaching and research institutions in France or abroad, or from public or private research centers. L’archive ouverte pluridisciplinaire HAL, est destinée au dépôt et a ̀ la diffusion de documents scientifiques de niveau recherche, publiés ou non, émanant des établissements d’enseignement et de recherche français ou étrangers, des laboratoires publics ou privés.

jean-christophe le coze

This article provides a historical and critical account of James Reason’s contribution to safety research with a focus on the Swiss cheese model (SCM), its developments and its critics. This article shows that the SCM is a product of specific historical circumstances, has been developed over a ten years period following several steps, and has benefited of the direct influence of John Wreathall. Reason took part in intense intellectual debates and publications in the 1980s during which many ideas circulated among researchers, featuring authors as influent as Donald Norman, Jens Rasmussen, Charles Perrow or Barry Turner. The 1980s and 1990s were highly productive from a safety research point of view (e.g. human error, incubation models, high reliability organisation, safety culture) and Reason has considerably influenced it with a rich production of models, based on both research and industrial projects. Historical perspectives offer interesting insights because they can question research, the conditions of its production, its relevance and, sometimes, its success, as for the SCM. But, because of this success, critics have vividly argued about some of the SCM limitations, including its simplistic vision of accidents and its degree of generality. Against these positions, the article develops a ‘critique of the criticism’, and the article concludes that the SCM remains a relevant model because of its systematic foundations and its sustained use in high-risk industries; despite of course, the need to keep imagining alternatives based on the mix of collective empirical, practical and graphical research which was in the SCM background.

Dani Rabinowitz

A number of epistemologists have recently defended a necessary condition for knowledge that has come to be labeled as the “safety” condition. Timothy Williamson, Duncan Pritchard, and Ernest Sosa are the foremost defenders of safety. According to these authors an agent S knows a true proposition P only if S could not easily have falsely believed P. Disagreement arises with respect to how best to capture the notion of “safe belief.” Unlike Pritchard and Sosa who have gone on to incorporate the safety condition into a virtue account of knowledge, Williamson distances himself from the project of offering reductive analyses of the concept “knowledge.” Williamson’s project can best be thought of as an illumination of the structural features of knowledge by way of safety. The recent maneuvers of Pritchard and Sosa into the domain of virtue epistemology are not discussed here. This article is a treatment of the different presentations and defenses of the safety condition for knowledge. Special attention is paid to an elucidation of the various aspects of the safety condition. Problems for safety are then discussed before concluding by way of a short demonstration of how the safety condition handles some rather tough Gettier-like cases in the literature.

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Nowadays, certification of safety-critical software systems requires submission of safety assurance documents, often in the form of safety cases. A safety case is a justification argument used to show that a system is safe for a particular application in a particular environment. Different argumentation strategies are applied to derive the evidence for a safety case. They allow us to support a safety case with such evidence as results of hazard analysis, testing, simulation, etc. On the other hand, application of formal methods for development and verification of critical software systems is mandatory for their certification. In this paper, we propose a methodology that combines these two activities. Firstly, it allows us to map the given safety requirements into elements of the formal model to be constructed, which is then used for verification of these requirements. Secondly, it guides the construction of a safety case demonstrating that the safety requirements are indeed met. Con...

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How Swiss Cheese Can Help Visualize Medication Safety Risks

Learning from medication safety incidents and near misses is an important part of reducing the risk of patient harm. And one of the best ways to identify and address the root causes of medication errors in a pharmacy is through a process of continuous quality improvement (CQI).

When a medication safety incident occurs, it often has multiple causes—a series of mistakes, oversights or system failures that combine to create risk for a patient. This type of medication error can be visualized with the Swiss cheese model of system accidents [1] .

Imagine several slices of Swiss cheese, each representing a different layer of human, technological or system safeguards in your pharmacy. Each layer has holes that reflect the inherent weaknesses in that particular safeguard. Normally, if one hole is penetrated, another slice (or safeguard) stops an error in its tracks. But what if the holes suddenly lined up? Now it’s as though there are no safeguards at all.

The point is, no matter how many protections are put in place, there still exists the potential for a medication incident to occur. This highlights the need for continuous evaluation of a pharmacy’s risk mitigation processes to ensure safeguards and systems are effective and adaptive.

Assurance and Improvement in Medication Safety (AIMS)

To support its mandate to serve and protect the public, the College’s Assurance and Improvement in Medication Safety (AIMS) Program sets expectations for pharmacy professionals regarding the assessment of potential areas of risk in a pharmacy’s workflow, along with tools to assist in extracting actionable learnings from incidents or near misses that do occur.

Through the AIMS Program, registrants have access to their own pharmacy-level medication incident data recorded in the AIMS Pharmapod platform, information that can help practitioners learn from medication incidents and near misses, and better understand why they happen and how they can be prevented. The College has posted an e-learning module on its website to help pharmacy professionals access and understand the information in the data warehouse.

Access the AIMS e-learning module

In addition to the local pharmacy data, the College has developed an interactive tool that allows pharmacy teams and other stakeholders to view aggregate, anonymous medication safety data from across the province to help identify trends or opportunities for continuous quality improvement.

View the interactive data tool

As part of AIMS, all community pharmacies are required to complete the Pharmacy Safety Self-Assessment (PSSA) by December 31, 2021. A pharmacy’s PSSA can only be accessed through the Designated Manager’s Pharmapod account; to login please follow this link: https://www.pharmapodhq.com . The PSSA is an informative quality improvement tool that helps a pharmacy track their efforts to enhance patient safety over time. It can be used to proactively identify areas of potential risk, enabling pharmacy teams to plan improvement activities effectively and demonstrate system improvements. While completing the PSSA is a mandatory component of the AIMS Program, pharmacies are not required to share the PSSA with the College.

Each of these resources—the AIMS Pharmapod platform, the interactive tool and the PSSA—are designed to support pharmacies in meeting the expectations of the Supplemental Standards of Practice (sSOP) and to do so in a consistent and standardized manner across the province.

Quality Indicators

AIMS is just one way for pharmacy professionals to identify potential continuous quality improvement opportunities. Another important source of information comes from community pharmacy quality indicators.

To better understand the impact of pharmacy care on patient outcomes, the College, in partnership with Health Quality Ontario (HQO), established the first set of publicly reported Quality Indicators (QI) for community pharmacy in Canada. These indicators provide a clearer picture of the overall quality of pharmacy care in Ontario and support quality improvement efforts by pharmacy professionals and the College.

The purpose of these indicators is to improve the quality of pharmacy care and to increase transparency about the impact of pharmacy through aggregate level public reporting. Pharmacy professionals, like other healthcare professionals, play an active part in providing quality and safe care to patients while contributing to solutions to address common quality challenges experienced throughout our health system. Safe transitions of care, the opioid crisis, and medication-related hospital visits are just a few examples where pharmacy can play an increasingly valuable role in our health system, while continuing to contribute directly to a patient’s health goals.

The first set of Quality Indicators is posted on the OCP website, measuring the appropriateness of dispensed medications, medication-related hospital visits and transitions of care.

Has your pharmacy made improvements to enhance medication safety? Share your successes with the College at [email protected]

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117770 / ↑

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The objectives of Pharmacy Connection are to communicate information about College activities and policies as well as provincial and federal initiatives affecting the profession; to encourage dialogue and discuss issues of interest to pharmacists, pharmacy technicians and applicants; to promote interprofessional collaboration of members with other allied health care professionals; and to communicate our role to members and stakeholders as regulator of the profession in the public interest.

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James Reason’s Swiss Cheese Model

Oct 28, 2019

440 likes | 839 Views

Control Room Management API Control Room Forum April - 2019 Byron Coy PE Sr. Technical Advisor Pipeline & Hazardous Materials Safety Administration US Department of Transportation. James Reason’s Swiss Cheese Model. It usually takes several concurrent conditions,

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• control room team training

Presentation Transcript

Control Room ManagementAPI Control Room ForumApril - 2019Byron Coy PESr. Technical AdvisorPipeline & Hazardous Materials Safety AdministrationUS Department of Transportation

James Reason’sSwiss Cheese Model It usually takes several concurrent conditions, before a serious incident or accident occurs

Swiss Cheese Model • It usually takes several concurrent conditions before a serious incident or accident occurs • If the work you do on Control Room Management removes just one errant condition… • The chance of another event like Bellingham, WA will be reduced • 20 Year Anniversary of Bellingham • Where (3) lives were lost : June 10, 1999

Authority to Direct or Supersede • (b)(5), The roles, responsibilities and qualifications of others with the authority to direct or supersede the controller • FAQs, January-2018 • B.07, Procedures to account for occasions when the controller disagrees • B.08, Qualifications for area of responsibilities • B.09, Roles & Responsibilities established by the time of implementation • B.10, Written Policy to allow (or disallow) • FAQ D.02, Hours of service for on-duty time • Web: PHMSA PRIMIS Control Room

Team Training • (h)(6), Control room team training and exercises for controllers and other individuals • FAQs, January-2018 • H.05, Participants, including (b)(5) • H.06, Content • H.07, Training Techniques • H.08, Deadlines & Frequency • H.09, Controller Participation • Web: PHMSA PRIMIS Control Room

Interstate Control RoomsTop 10 States • There is currently no requirement for Operators to report the number or location of their of Control Rooms • All jurisdictional Control Rooms should be in compliance with the Regulations

More inspections to be scheduled in 2019

PHMSAControl Room Inspections2012-2014163 Inspections

PHMSAControl Room Inspections2012-2016203 Inspections

PHMSAControl Room Inspections2012-2018220 Inspections

Compliance Cases from Inspections Web Search: cpf 192.631 cpf 195.446

Notice of Amendment Items

Top 5 : Notice of Amendment Items In 2018, (a) is 3rd highest cited violations in all of 192 & 195

Non-Notice of Amendment Items Penalties from Inspections $168,500

Inspection Questions • Original Full-Program Inspection Form • March 01, 2012, Rev-3 • 100+ questions covering all aspects of CRM Regulations • Integrated Inspection • CRM Screening Questions • 6-10 CRM Overview Questions • Full-Program Inspection Form maintained for targeted use • Previously uninspected control rooms • Newly established operator or control room • Just cause after incident/accident with CRM affiliation

Accident/Incident : Causal & Severity

Alarm Management ProblemsIncrease Accident/Incident Severity

NTSB Recommendation P-11-009 • Issued September 26, 2011 • Require operators of natural gas transmission and distribution pipelines and hazardous liquid pipelines to ensure that their control room operators immediately and directly notify the 911 emergency call center(s) for the communities and jurisdictions in which those pipelines are located when a possible rupture of any pipeline is indicated. • Control Room operator or delegated representative • San Bruno, CA, Natural Gas Incident (9/9/2010) • Carmichael, MS, Propane Accident (11/1/2007)

NTSB Recommendation P-11-009 • PHMSA Advisory Bulletin ADB-12-09 • Communication between pipeline facility operators and local emergency responders • §§ 192.615, 193.2509 and 195.402 • Promptly notify 9–1–1 emergency call centers, or the local equivalent • Inquire if there are any other reported indicators of possible pipeline emergencies such as odors, unexplained noises, product releases, explosions, fires, etc. • Early coordination will facilitate a more timely and effective response

NTSB Recommendation P-11-009 • Status : Open – Acceptable Response • PHMSA Rulemaking in progress for 192 & 195 • RIN 2137-AF06, Line Segmenting & Rupture Detection • https://www.transportation.gov/regulations/march-2019-significant-rulemakings-report

Deploying new technology, does not guarantee Improvements Be aware of your system limitations

Byron Coy PESr. Technical [email protected] Search : PHMSA Primis Control RoomPipeline & Hazardous Materials Safety AdministrationUS Department of Transportation

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Swiss Cheese Model - PowerPoint PPT Presentation

Swiss Cheese Model

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