I recently read a New York Times article discussing the Swiss Cheese Model of Pandemic Defense. The article discussed James Reason’s Swiss Cheese model of human error to describe the concerted response to the COVID-19 pandemic.
The model uses the analogy of the swiss cheese to exemplify the number of possible defenses against possible threats, there being human error in transportation or a global pandemic.
Each slice represents a possible line of defense. But, like the swiss cheese, each layer has holes and each hole introduces a new vulnerability to the system.
This framework can easily be applied to human interaction with complex systems in virtually any Human Factors application.
In healthcare, for example, the fatal administration of the wrong drug could be caused by a chain of failures wherein two different drugs have a similar packaging and the healthcare professional administering the drug was distracted or poorly trained to notice the differences between the two, winding up administering the wrong one to the patient.
In autonomous vehicles, because of the poor operational design of the system (a hole), combined with the poor HMI (another hole), the driver is unsure about the capabilities of the system (yet another hole), and winds up misusing the system (error).
This model is a useful Human Factors tools when identifying everything that can go wrong in human-machine interaction. It also offers a model to help shrink the size of the holes or remove them altogether.
