When the holes line up...

Many of my readers will have heard about me talk about Professor James Reason's Swiss Cheese Model and how it can be used to show how incident develop because of holes in the barriers and defences which are put in place to maximise safety.

Professor Reason's research showed that at different levels within a system, there are different barriers or defences present. e.g. organisational, supervisor and individual. However, these defences can have holes in them because the organisations, supervisors and operators are all fallible and therefore the defences cannot be perfect.

  • At the Organisational level, these failures might be poor organisational culture, inadequate diver and instructor training programmes, flawed equipment certification systems e.g. CE or ISO, or misunderstood/misused reward or punishment systems e.g. QC/QA or certificates for the number of certifications completed.
  • At the Supervisor level, these gaps might be inadequate supervision dealing with inexperienced...
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