Human Error and Defense in Depth: From the “Clambake” to the “Swiss Cheese”

Abstract

After the Fukushima accident, a new concept of nuclear safety arouse: engineering thinking facing extreme situations. One of the specificity of emergency situations being a rise of social demand on engineering process, safety scientist have to make an anti-dualist move in order to improve collaboration between social scientists and engineers. In this aim, this article studies a case of efficient collaboration: the Swiss Cheese Model (SCM) of accidents. Since the early 1990s, SCM of the psychologist James Reason has established itself as a reference in the etiology, investigation or prevention of accidents. This model happened to be the product of the collaboration between the psychologist and a nuclear engineer (John Wreathall). This article comes back on the journey of the SCM and its fathers. It is based on an exhaustive literature review of Reason’s work and interviews of Reason and Wreathall carried out in 2014. The study suggests that the success of the model is not so much due to appropriation of the work of the psychologist by the industrial community but to a complex process of co-production of knowledge and theories. To conclude, we try to highlight ways that should encourage, in the future, such collaborative ways of working.