TheSwissCheeseModelofaccidentcausationiswidelyusedinindustriesthroughouttheworld,includingmining,inriskanalysisandriskmanagement.Itusescheeseslicesinadiagramtoshowhowaccidentscanoccurunexpectedlywhencertainevents,conditions,orhazards“lineup”atthesametimeinanunprotectedsystem.*ModifiedfromReason,1991Copyright1991,JamesReasonReason,J.,1990,Humanerror.CambridgeUniversityPress,UK,316pp.MineSafe,Dept.OfConsumerandEmploymentProtection,GovernmentofWesternAustralia,2006."Whatarelatentconditions?”–www.constructionlawmadeeasy.com–MinterEllison,2015“Encounteringlatentconditions”–www.miningaustralia.com.au–DanielHall,March30,2009Sources:WhatAretheHoles?Theholesrepresentweaknessesinindividualpartsofthesystem.Theycontinuallyvaryinsizeandpositionacrosstheslices.Theriskofapotentialaccidentbecomingarealityislessenedwhendiferentbarriersordefensesare“layered”behindoneanother.Still,thereisalwaysachanceforfailure,meaningthatanaccidentmightresult.ACTIVE&LATENTFAILURESWhenDoesa“Failure”Occur?Whenaholeineachslicemomentarilyaligns,thereisanopportunityforanaccidenttohappen.That’swhenahazardpassesthroughholesinalloftheslicesandcanleadtoafailure.WhatCanLeadtoFailure?1.Organizationalinfluences2.Unsafesupervision3.Preconditionsforunsafeacts4.TheunsafeactsthemselvesWho’stoBlameforFailure?It’sinevitablethathumanswillmakemistakes.ButintheSwissCheeseModel,mosterrorsarecausedbyanorganizationhavingincompletelayersofprotection,whichallowerrorstolineupand“passthroughthecheese”untilanaccidentoccurs.WhoCreatedtheSwissCheeseModel?JamesReasondevelopedtheconceptandfirstdescribeditinhis1990book“HumanError.”HeiscurrentlyProfessorEmeritusofPsychologyattheUniversityofManchester,England.Tolearnmore,visitwww.coresafety.com010203040506Activefailuresoccurimmediatelyandareoftencausedbyapersonorpersons’actionsorinactions.Thesefailurescanbedirectlylinkedtoanaccident.Latentfailuresincludeconditionsthatmaybe“hidden”forlongperiodsoftimeuntil,oneday,theycontributetoanaccident.TheSwissCheeseModelconsidersbothtypesoffailures.Mostaccidentscanbetracedtooneormoreofthesefourfailure“domains.”MultipleSlices,StackedSidebySideWhatDoesSwissCheeseHavetodoWithMiningAccidents?
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