James Reason developed the “Swiss cheese model” illustrating how major accidents and catastrophic system failures actually uncover multiple, smaller failures leading up to an actual hazard. In the model, each slice of cheese represents a safety barrier for a particular hazard and that no single barrier is foolproof, each having ”holes”. When the holes align, which thankfully doesn’t happen often, catastrophic failures occur, typically resulting in serious consequences.
Failure prevention can only come with discipline to process, in doing our own little part in the process, and in not becoming complacent in anything we do, because our little part is, in fact, integral to the process. We need risk control systems for the plant, for the process and of course most importantly for the people that drive the process.
Managing risk is everyone’s job. We need to remind ourselves of this. Whether we recognize it or not, our decisions and actions have a direct bearing on the level of risk within the company. So we have to be active in managing these risks. We need to understand:
- What is the range and nature of failures that I can effect?
- How can I control the risk of asset failure?
- How can things go wrong around me?
- What are the likely consequenses of failure?
People are the weakest link in terms of process safety and asset management. So for our own good, we cannot become complacent in our actions to care for the assets that drive our business.