Revisiting the "Swiss Cheese" model of accidents

Accidents in complex system occur through the accumulation of multiple factors and failures. 

J. Reason has famously developed a model based on the Swiss Cheese Metaphor that suggests multiple contributors (the holes in cheese slices) must be aligned for any adverse events to occur. Barriers in a system (the slices themselves) are intended to prevent errors that result in these adverse events. This Swiss cheese model is not without drawbacks, and is not accepted uncritically. With use over time even the author has acknowledged its limitations. Nevertheless it remains widely used and is employed as the main basis for new method development. The concept of barrier provides one of the few opportunities to model interactions and complexity in High Risk domains. A compilation of pro's and con's was needed to gain insight into the potential and limitations of this model for ATM application.

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Revisiting the "Swiss Cheese" model of accidents