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Swiss cheese model

The Swiss cheese model is a conceptual framework in risk analysis and safety management, developed by psychologist James Reason in 1990, that illustrates how accidents occur in complex socio-technical systems through the metaphor of multiple layers of defense represented as slices of Swiss cheese, each containing randomly positioned holes symbolizing weaknesses or potential failure points; a hazard penetrates the system only when these holes temporarily align across all layers, allowing an error trajectory to pass unimpeded.^[1] Central to the model is the distinction between active failures—immediate, unsafe acts committed by individuals at the "sharp end" of operations, such as pilots or surgeons—and latent failures, which are dormant weaknesses embedded in the system due to earlier decisions by designers, managers, or regulators, such as inadequate training protocols or flawed equipment design.^[1] These latent conditions create the "holes" in the defensive layers, which vary in size and position over time, emphasizing that no single failure is sufficient to cause an accident but rather a rare conjunction of contributing factors.^[1] Originally articulated in Reason's seminal paper on latent human failures in complex systems, the model shifted focus from blaming individual errors to examining organizational and systemic vulnerabilities, influencing safety investigations by promoting proactive barrier strengthening rather than reactive fault-finding.^[1] In aviation, it informs incident analyses by mapping aligned failures in procedural, technical, and human defenses to prevent recurrence.^[2] The framework has broad applications beyond aviation, including healthcare, where it informs root cause analyses for patient safety incidents by identifying how latent risks—such as understaffing or poor communication protocols—combine with active errors like medication misadministration to breach safeguards.^[3] It has also been applied to public health, notably in layered prevention strategies during the COVID-19 pandemic.^[4] In engineering and nuclear industries, it guides risk assessments for high-hazard environments, underscoring the need for redundant, independent defenses to minimize alignment probabilities.^[5] Despite its enduring influence, critics note limitations in addressing non-linear interactions or adaptive human behaviors, prompting refinements like the 2006 "Revisiting the Swiss Cheese Model" to incorporate trajectory variability.^[6]

Overview and History

Definition and Purpose

The Swiss cheese model is a metaphorical framework in risk analysis and risk management that depicts complex socio-technical systems as a stack of Swiss cheese slices, each representing a sequential layer of defense, barrier, or safeguard against potential hazards. The irregular holes in these slices symbolize weaknesses, such as human errors, organizational flaws, or technical vulnerabilities, which vary in size and position across layers. In normal circumstances, the non-alignment of these holes prevents any adverse trajectory—such as an error or hazard—from propagating through the entire system, thereby maintaining safety. The primary purpose of the model is to illustrate that accidents emerge not from isolated, single-point failures but from the uncommon linear alignment of multiple weaknesses across all defensive layers, enabling a clear path for the hazard to reach its harmful outcome. This conceptualization shifts focus from individual blame in a "person approach" to a "system approach," emphasizing how active errors at the operational level interact with latent conditions embedded in organizational structures, procedures, and culture. By promoting this holistic view, the model aids in accident prevention by underscoring the need for robust, multi-layered defenses in high-reliability industries.^[7] A key benefit of the Swiss cheese model lies in its encouragement of proactive risk management, where organizations systematically identify and address latent conditions—such as poor design, inadequate training, or resource gaps—that create or enlarge holes in the defenses, thereby reducing the likelihood of hazardous alignments. This approach fosters a culture of continuous improvement in safety protocols without relying solely on reactive measures after incidents occur.^[8] Originating in the 1990s, the model was developed by psychologist James Reason as a core element of human error theory and organizational accident analysis.^[8]^[9]

Development by James Reason

James Reason, a British psychologist born on May 1, 1938, served as a professor of psychology at the University of Manchester, where he focused on human error research particularly during the 1980s and 1990s, with continued contributions into the 2000s.^[10]^[11] His studies emphasized the cognitive and organizational aspects of errors in complex systems, building on earlier experimental work in psychology.^[11] Reason first introduced the Swiss cheese model in his 1990 book Human Error, using the analogy of Swiss cheese slices to represent layered defenses in safety systems, with holes symbolizing potential weaknesses that could align to allow failures.^[12] This framework drew from his development of the Generic Error-Modelling System (GEMS), also detailed in the same publication, which categorized error types based on skill, rule, and knowledge-based behaviors.^[13] The model evolved through Reason's subsequent work, particularly in his 1997 book Managing the Risks of Organizational Accidents, where he elaborated on its application to systemic risk management.^[8] Reason died on February 4, 2025. Post-1990s, it was adapted for practical safety audits and investigations, influencing standards such as those from the International Civil Aviation Organization (ICAO), which adopted a similar conceptual framework in the early 1990s.^[14]

Core Components

Slices and Holes

The Swiss Cheese Model, developed by James Reason in 1990, employs the metaphor of stacked slices of Emmental cheese to depict the multilayered defenses inherent in complex sociotechnical systems. Each slice represents a sequential layer of protection, such as engineered safeguards, administrative procedures, training protocols, or supervisory oversight, which collectively form a robust barrier against hazards despite individual imperfections. These layers are designed to provide redundancy, ensuring that no single point of failure compromises the entire system.^[15] The holes within each slice symbolize specific weaknesses or gaps in those defensive layers, manifesting as procedural oversights, equipment malfunctions, design flaws, or instances of human error. These vulnerabilities differ in size, shape, and position across slices, reflecting the unique characteristics and limitations of each protective measure—for example, a small hole might indicate a minor training deficiency, while a larger one could represent a systemic equipment issue. Under normal conditions, the irregular placement of holes prevents any straight path through the stack, maintaining overall system integrity.^[3] Unlike fixed barriers, the holes in the model are inherently dynamic, capable of appearing, enlarging, or shifting due to factors such as organizational adaptations, gradual wear and tear, or evolving operational demands. This variability underscores the need for ongoing monitoring and reinforcement of defenses to address emerging gaps. Holes may also arise from active errors at the operational level or latent conditions embedded within the system, further emphasizing the model's focus on systemic resilience.^[12]

Active and Latent Failures

Active failures, also referred to as active errors or violations, are unsafe acts committed directly by individuals at the frontline of operations, often termed the "sharp end" of the system. These include slips, lapses, mistakes, or deliberate rule violations by operators such as pilots, surgeons, or maintenance technicians, which occur immediately and are typically short-lived and detectable upon investigation. For instance, a pilot misreading an altitude instrument during a critical phase of flight exemplifies an active failure, as it stems from an individual's action in direct contact with the process.^[16]^[17] Latent failures, conversely, encompass hidden or dormant deficiencies embedded within the organizational system, originating from upstream decisions by designers, managers, regulators, or policymakers. These conditions arise from factors such as flawed system design, insufficient training programs, inadequate supervision, or resource constraints like understaffing that foster fatigue among personnel. Unlike active failures, latent conditions are insidious, persisting over time and potentially remaining undetected until they combine with other elements to precipitate an incident; an example is organizational understaffing in an airline that leads to chronic pilot exhaustion, eroding overall vigilance.^[16]^[17] Within the Swiss cheese model, active failures manifest as transient holes in the innermost defensive layer, directly impacting immediate operational safeguards, whereas latent failures generate or exacerbate persistent holes across multiple outer layers, weakening the system's overall resilience. This distinction highlights how accidents rarely result from isolated frontline errors but from the alignment of these failure types. Reason's analyses of accidents in high-reliability sectors like aviation and nuclear energy highlight the significant contribution of latent conditions to many incidents, emphasizing the need to target systemic vulnerabilities for effective risk mitigation.^[16]^[8]

Operational Mechanism

Alignment of Defenses

In the Swiss cheese model, alignment of defenses refers to the rare circumstance in which the holes—representing weaknesses or potential failure points—in multiple successive layers of protection temporarily coincide, permitting a hazard or error trajectory to traverse the entire system. This alignment creates a clear pathway akin to sighting through aligned apertures in stacked slices of Swiss cheese, where each slice symbolizes a defensive barrier such as procedures, equipment safeguards, or supervisory oversight. James Reason introduced this dynamic in his framework to illustrate how isolated vulnerabilities become consequential only when they synchronize across layers.^[18] Several factors can precipitate this alignment by dynamically repositioning or enlarging the holes within defensive slices. Triggering events, including acute stress on operators, unforeseen operational conditions, or sequences of interdependent errors, may cause latent weaknesses to shift into congruence with active lapses, thereby opening a conduit for hazards. Active failures at the operational forefront, influenced by immediate circumstances, interact with pre-existing latent conditions to facilitate such synchronization in a single sentence.^[18]^[1] To counteract alignment, preventive strategies focus on fortifying individual slices and promoting persistent misalignment of holes. Approaches include bolstering redundancy through duplicate safeguards, incorporating error-proofing mechanisms like fail-safes in design, and enforcing procedural tools such as checklists to shrink potential failure windows and add resilient barriers. These measures collectively reduce the opportunities for coincidental overlaps.^[18] Although the random distribution of holes across independent slices renders full alignment statistically improbable under normal conditions, systemic pressures can elevate this risk by systematically widening holes or inducing correlations between layers. Examples of such issues encompass chronic under-resourcing, inadequate training protocols, or deferred maintenance, which erode defensive integrity and heighten vulnerability to breach.^[8]^[1]

Path to Accident

In the Swiss Cheese Model, the path to an accident commences with the initiation of a hazard, which may arise from external threats or internal errors entering the system at its periphery. This hazard represents a potential trajectory that seeks to traverse the stacked defensive layers, starting with the outermost slice. If the hazard aligns with a hole in this initial layer—stemming from either active failures at the operational level or latent conditions embedded in organizational processes—it successfully penetrates and advances toward the next defense.^[3] The propagation of the hazard occurs as it navigates through successive slices, requiring precise alignment of holes across multiple layers to avoid being halted by intact cheese. Each layer functions as a barrier with variable weaknesses, and the hazard's progression depends on the dynamic positioning of these holes, which can shift due to evolving system conditions. This step-by-step breaching continues, potentially reaching the "sharp end" of the system—where frontline operations interface with critical assets, people, or outcomes—only if the trajectory remains unobstructed throughout.^[19] Full penetration of all defensive layers culminates in an accident, manifesting as tangible loss, harm, or system failure at the sharp end. Conversely, misalignment at any single layer can intercept and mitigate the hazard, reducing the incident's severity or preventing it entirely by redirecting or containing the threat.^[20] Central to the model is the understanding that such accidents constitute "organizational accidents," arising not from isolated errors but from the rare convergence of multiple aligned weaknesses across defenses, underscoring the need for robust, multi-layered risk management to disrupt potential paths.^[5]

Applications and Extensions

Healthcare and Patient Safety

The Swiss cheese model gained significant traction in healthcare following the 1999 Institute of Medicine report "To Err Is Human: Building a Safer Health System," which popularized a systems-based approach to analyzing medical errors and advocate for safer practices beyond individual blame.^[21] The report highlighted how errors often result from organizational and environmental factors rather than solely frontline actions, aligning with the model's depiction of multiple defensive layers where weaknesses can align to permit harm.^[22] This adoption shifted patient safety efforts toward identifying latent conditions, such as inadequate training or resource shortages, that create vulnerabilities across system defenses.^[3] In healthcare contexts, the model illustrates patient safety incidents like surgical errors, where active failures—such as miscommunication between team members during handoffs—combine with latent issues like chronic understaffing to bypass safeguards.^[23] For instance, in wrong-site surgery cases, holes in slices representing protocols (e.g., site verification checklists), alarms (e.g., electronic alerts), and supervision (e.g., senior oversight) may align if a rushed procedure due to staffing shortages leads to overlooked confirmations.^[5] These examples underscore how the model's layers, adapted to clinical environments, reveal pathways to adverse events when defenses fail collectively.^[24] The model's influence prompted the development of tools like the World Health Organization's Surgical Safety Checklist, introduced in 2008, which adds redundant defensive layers to misalign potential holes and enhance team communication.^[25] By standardizing pre-, intra-, and postoperative verifications, the checklist addresses both active errors (e.g., procedural oversights) and latent ones (e.g., poor coordination), thereby strengthening the overall system.^[26] Implementation of such interventions has yielded measurable outcomes, with studies showing reductions in adverse events by 30-50% in surgical settings, including lowered complication rates and mortality.^[27] These improvements emphasize fostering a just culture in healthcare, where errors are reported without punitive repercussions to encourage learning and hole-plugging, rather than scapegoating individuals. This approach has reinforced the model's role in promoting proactive safety enhancements across medical institutions.^[5]

Aviation and Other Industries

The Swiss cheese model has been prominently applied in aviation to analyze major accidents, such as the 1977 Tenerife airport disaster, where a collision between two Boeing 747 aircraft resulted in 583 fatalities due to the alignment of multiple failures, including air traffic control miscommunications, pilot fatigue from a bomb threat diversion, and inadequate adherence to takeoff procedures.^[28] In this incident, latent conditions like organizational pressures and active errors such as misunderstood radio transmissions created a trajectory through defensive layers, as illustrated by James Reason's framework.^[8] The model's emphasis on layered defenses influenced the development of the Human Factors Analysis and Classification System (HFACS), which extends Reason's concepts to systematically identify causal factors in aviation mishaps.^[29] Regulatory bodies have integrated the Swiss cheese model into aviation safety protocols, particularly through crew resource management (CRM) training. The Federal Aviation Administration (FAA) incorporates the model in its human factors guidelines for maintenance and operations, using it to train personnel on recognizing how holes in procedural, supervisory, and organizational slices can align to cause errors.^[30] Similarly, the International Civil Aviation Organization (ICAO) endorses CRM programs that draw on the model to enhance threat and error management, with guidelines updated in the 2000s to emphasize non-technical skills like communication and decision-making in high-risk environments.^[31] These adaptations, formalized in FAA Advisory Circular 120-51D (2004), have contributed to a decline in aviation accident rates by promoting proactive identification of latent failures.^[32] Beyond aviation, the model has been adapted in the nuclear industry to dissect events like the 1986 Chernobyl disaster, where latent design flaws in the RBMK reactor, combined with procedural violations during a safety test and inadequate emergency responses, allowed a steam explosion and fire to breach multiple safety barriers.^[8] Reason applied his model to incidents like Chernobyl, where organizational and regulatory weaknesses—such as insufficient training and suppressed safety reporting—aligned with active operator errors to escalate the catastrophe.^[33] In manufacturing, particularly chemical processing, the model informs risk assessments for incidents involving procedural gaps, as seen in analyses of plant leaks where failures in equipment maintenance, operator oversight, and emergency protocols create aligned vulnerabilities.^[34] The American Institute of Chemical Engineers promotes its use in process safety management to evaluate layered protections against hazards like toxic releases.^[34] The Swiss cheese model has also extended to cybersecurity, where it conceptualizes layered defenses—such as firewalls, intrusion detection, and user training—as cheese slices with inherent weaknesses that must overlap imperfectly to prevent breaches.^[35] In this domain, HFACS adaptations apply the model to human error in security operations, identifying how latent issues like outdated policies align with active mistakes, such as phishing susceptibility, to enable attacks.^[35] Industry standards from organizations like the International Society of Automation incorporate it for industrial control systems, emphasizing multiple barriers to mitigate cyber-physical risks in critical infrastructure.^[36] During the COVID-19 pandemic (2020–2023), the model was adapted to public health to illustrate multilayered defenses against virus transmission, including masks, social distancing, ventilation, and vaccination, emphasizing that no single measure is foolproof but combinations reduce risk.^[37]

Criticisms and Limitations

Critics have argued that the Swiss cheese model oversimplifies accident causation by portraying failures as linear sequences of aligned weaknesses, thereby neglecting the nonlinear dynamics and feedback loops inherent in complex socio-technical systems.^[38] This sequential perspective, as highlighted by Erik Hollnagel in his development of the Functional Resonance Analysis Method (FRAM), treats accidents as epidemiological outcomes of failure combinations rather than emergent results of performance variability and functional resonances.^[19] Hollnagel (2012) critiques the model for ignoring adaptive behaviors and interactions that can amplify or dampen risks in real-time, proposing FRAM as an alternative that models how system functions resonate to produce both successes and failures.^[39] Similarly, Sidney Dekker (2006) and Nancy Leveson (2012) describe it as inadequately capturing systemic interactions, where holes in defenses do not remain static but evolve through ongoing processes.^[40] A key limitation of the model lies in its focus on linear failure paths, which underemphasizes system resilience and the capacity for adaptation to prevent incidents.^[14] It assumes defenses as independent layers, yet in practice, these are interdependent, with alignments influenced by dynamic factors like organizational culture and environmental changes, making empirical quantification of "hole sizes" or alignment probabilities challenging.^[14] The model's weakly predictive nature further restricts its utility, as it offers qualitative insights into potential accident trajectories but struggles to specify timing, location, or likelihood without additional tools.^[14] This has led to calls for supplementation with methods like the Cognitive Reliability and Error Analysis Method (CREAM) to better account for human and organizational variability.^[14] In response to these critiques, the Swiss cheese model has been integrated with frameworks such as the Human Factors Analysis and Classification System (HFACS), which expands its layers to include detailed categories of unsafe acts, preconditions, supervision, and organizational influences, enhancing its applicability in aviation.^[29] Post-2010, it has evolved within broader systems thinking approaches, such as STAMP (Systems-Theoretic Accident Model and Processes), to incorporate nonlinear constraints and feedback, allowing for more robust analysis of complex interactions.^[38] These adaptations address some oversimplifications while preserving the model's value as a foundational metaphor for multilayered defenses.^[38] The model exhibits gaps in addressing rare, black-swan events, where unpredictable, high-impact incidents arise from non-linear confluences beyond simple hole alignments, as these defy the probabilistic assumptions of layered defenses.^[41] It is also less effective for highly automated systems, where failures stem from rigid programming and emergent software interactions rather than human latent conditions, requiring complementary models that emphasize systemic control structures.^[41]

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