James reason 1990!
- James Reason Swiss Cheese Model.
James reason human error model
- James reason human error model
- James reason model
- James reason 1990
- James reason safety culture
- He views safety as a system, and accidents as the result of any individual's mistakes in combination with other failings in the system.
Source: BMJ, 2000 Mar 18:320(7237): 768-770
A while ago I was part of the Cardiff pilot of Practical Strategies for Learning from Failure (#LFFdigital). My job was to explain the James Reason Swiss Cheese Failure Model in 300 seconds (5 minutes).
This is what I did.
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 the graphic I’ve used here.
The Swiss Cheese Model, my 300 second ex