FIGURE 5.3. Reason’s Swiss Cheese Model of Accidents. Accidents usually have multiple causes, whereby had any single one of those causes not happened, the accident would not have occurred. The British accident researcher James Reason describes this through the metaphor of slices of Swiss cheese: unless the holes all line up perfectly, there will be no accident. This metaphor provides two lessons: First, do not try to find “the” cause of an accident; Second, we can decrease accidents and make systems more resilient by designing them to have extra precautions against error (more slices of
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