SH151: When the holes line up...

SH151: When the holes line up...

In this episode, we explore Professor James Reason's Swiss Cheese Model, which helps explain how incidents occur when multiple safety barriers fail at different levels within a system. We discuss how organizational, supervisory, and individual errors can combine to create accidents, and how the holes in these barriers move and shift over time. Using dynamic models, we highlight that safety is an emergent property of a system, where small errors accumulate and can lead to larger, more significant failures. We also examine the role of human error, risk management, and attention to detail in preventing accidents and emphasize the complexity of real-world systems, where multiple factors often lead to a critical mass of failure before an incident happens.

Original blog: https://www.thehumandiver.com/blog/when-the-holes-line-up

Links: Animated simple Swiss Cheese model: https://vimeo.com/326723142

Big Hole model: https://vimeo.com/326723122

Little Hole model: https://vimeo.com/326723109

Tags: English, Gareth Lock, Human Factors, Incident Investigation

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Avsnitt(315)

SH315: The Insurance Illusion

SH315: The Insurance Illusion

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17 Okt 10min

SH314: 5. Human Factors as an Operating System

SH314: 5. Human Factors as an Operating System

In this episode, Brent Webb explores the idea that Human Factors should be more than a collection of concepts or courses—it can become the “operating system” of an organisation. Drawing on his experie...

14 Okt 7min

SH313: 4. Am I Enough?

SH313: 4. Am I Enough?

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10 Okt 9min

SH312: Your Body Can't Cash the Cheque Your Ego Is Writing

SH312: Your Body Can't Cash the Cheque Your Ego Is Writing

We explore how capable, motivated divers can gradually push beyond safe limits when their environment rewards risk-taking and treats near misses as successes. Using the story of a young technical dive...

7 Okt 16min

SH311: 3. Don’t Wait - Learn From Everyday Work Using HOP Principles

SH311: 3. Don’t Wait - Learn From Everyday Work Using HOP Principles

This episode explores Human and Organizational Performance (HOP), an approach to safety that starts with the idea that people will always make mistakes, so we should focus on understanding why decisio...

3 Okt 6min

SH310: 2. More Than a Deep Dive: What a WWII Bomber Recovery Can Teach Us About Human Factors

SH310: 2. More Than a Deep Dive: What a WWII Bomber Recovery Can Teach Us About Human Factors

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30 Sep 8min

SH309: Change around Safety Culture is Really Hard

SH309: Change around Safety Culture is Really Hard

In this episode, Gareth Lock reflects on why improving diving safety requires more than telling people to follow the rules. Drawing on his experience in aviation, diving, and safety science, he explai...

23 Sep 14min

SH308: We Know, and We Say Nothing

SH308: We Know, and We Say Nothing

This episode explores why experienced divers still die in situations that seem predictable, using the tragic 2026 Maldives cave accident as a starting point. It looks at how outcome bias, the normalis...

16 Sep 17min

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