Figure 1: Swiss Cheese Model
The Swiss Cheese model (figure 1) the model describes the chain of an accident opportunity as many little deviances or omitted checks that, by themselves, are small but if all those little ‘holes in the “Swiss Cheese” line up then an unforeseen problem or accident can occur.
The holes in the cheese slices represent individual weaknesses in individual parts of the system or process and are continually varying in size and position in all slices. The process fails when holes in all the slices momentarily align, permitting "a trajectory of accident opportunity", so that a hazard passes through holes in all the defences (checks), which can lead to a problem or accident.
This Swiss Cheese Model is directly applicable to marine surveying in particular:
• the process and associated checklists used in marine surveying
• errors by the practitioner that can occur.
In the diagram (figure 2), as part of the survey process, we are carrying out inspections or checks which could alert us to the potential for a possible problem / accident.
Used under the Creative Commons Attribution-Share Alike 4.0 International license. Figure 1: Swiss Cheese Model
From the diagram (figure 2) it is clear that Oversight / Accident Opportunity 1 would not be seen (caught) by our process and checklists.
Used under the Creative Commons Attribution- Share Alike 4.0 International license.
It is also errors in the execution of the process and violations that could create the potential for a possible problem / accident which in the marine surveying discipline could include:
Errors which Include:
• Decision Errors: Goal-directed behaviour that proceed as intended, yet the plan proves inadequate or inappropriate for the situation. These errors typically result from a lack of information, knowledge or experience.
• Skill-based Errors: These “doing” errors occur frequently during highly practiced activities and appear as attention failures, memory failures, or errors associated with the technique with which one performs a task.
• Perceptual Errors: Errors that occur during tasks that rely heavily on sensory information, which is obscured, ambiguous or degraded due to impoverished environmental conditions or diminished sensory system.
Figure 2: Swiss Cheese Model applied to checklists
Used under the Creative Commons Attribution- Share Alike 4.0 International license annotated by the author.
THE REPORT | DEC 2024 | ISSUE 110 | 73
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