From theory to practice: itinerary of Reasons’ Swiss Cheese Model

International audienceSince the early 1990s, the Swiss Cheese Model (SCM) of the English psychologist James Reason has established itself as a reference model in the etiology, investigation or prevention of organizational accidents in many productive systems (transportation, energy, healthcare …). Based on the observation that it’s still today widely used, this article intends to revert to the history and the theoretical background of the SCM. By doing so, the article focuses on the collaboration between the psychologist (James Reason) and a nuclear engineer (John Wreathall) who happened to be at the origin of the creation and evolution of SCM. The methodology is based on an exhaustive literature review of Reason's work and the 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 figure out whether the SCM still has a contemporary interest in accident prevention or explanatio

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

International audienceAfter 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

Théorie et pratique des modèles d’erreur humaine dans la sécurité des barrages hydroélectriques : le cas des études de dangers de barrages d’EDF

This thesis presents two different works: (1) an in-depth study of James Reason's work (Swiss cheese model) and (2) the engineering activity of a model (ECHO) of organizational and human factors in operation of EDF's dams. These works are articulated regarding the role, value and place of human error models in industrial safety management.A literature review shows that dams' safety is mainly based on technical issues. The considerations relating to human factors, although pervasively present in the accidents, seem to be lacking in practice. After its wide use, we present in detail the Reason's model. We highlight a double collaboration (poorly documented) between research and industry on the one hand, Humanities and engineering Sciences on the second hand. Based on this dual partnership as a success condition for efficient safety culture developments, we present the engineering process associated with the design and the implementation of a human factor model in EDF dams' hazards study. Finally, we try to measure and report the effects produced by ECHO on the representations and practices.The discussion focuses on the interest and modalities for double collaboration in industrial safety and, therefore hopes to contribute to reframe the debate on model's nature and value.Cette thèse présente des travaux de deux natures différentes ; (1) l'étude approfondie des travaux de James Reason (Swiss cheese model) et (2) l'activité d'ingénierie d'un modèle (ECHO) pour l'étude des facteurs organisationnels et humains dans l'exploitation des barrages d'EDF. Ces travaux sont articulés autour de la question du rôle, de la valeur et de la place des modèles d'erreur humaine dans la gestion de la sécurité industrielle.Une revue de littérature montre que les dispositions de sécurité dans les barrages sont essentiellement techniques. Les considérations relatives au facteur humain, bien que prégnantes dans l'accidentologie, semblent faire défaut dans les pratiques. Constatant sa très large utilisation, nous présentons en détail le modèle de Reason. Nous mettons en lumière une « double » collaboration (peu documentée) entre recherche et industrie d'une part, sciences humaines et sciences de l'ingénieur d'autre part. Partant de cette double collaboration comme une condition de réussite à des évolutions culturelles de sécurité, nous présentons le processus d'ingénierie qui a permis la conception puis la mise en place d'un modèle facteur humain dans les études de dangers de barrages d'EDF. Nous tentons enfin de mesurer et de présenter les effets produits par ECHO sur les représentations et les pratiques. La discussion porte sur l'intérêt et les modalités de double collaboration dans la sécurité industrielle et espère contribuer à un recadrage du débat sur la nature et la valeur des modèles

Huit idées reçues sur le(s) modèle(s) de l’erreur humaine de James Reason

International audienceThis paper directed to engineers, researchers and PhD students concerned one way or another by the issues of industrial safety and needing to use the theories or work of the English psychologist James Reason, theorist and practitioner of the global concept of human error. This paper, which requires additional reading of James Reason’s essential works, intends to provide evidence to exceed eight preconceived ideas about thework of the latter, mainly directed to the etiological model of accidents known as "Swiss cheese model".Ce court article est destiné aux personnes concernées de près ou de loin par les problématiques de sécurité industrielle et amenées à utiliser les théories et travaux du psychologue Anglais James Reason relatifs aux problématiques d’erreur humaine et de sécurité industrielle. Cet article propose des commentaires et critiques de huit « idées reçues » sur l'origine, les fondements théoriques et les utilisations du modèle étiologique d’accidents popularisé sous le nom de « modèle du fromage Suisse ». Il constitue une synthèse de travaux menés dans le cadre d’une thèse au Centre de Recherche sur les Risques et les Crises (CRC) de MINES ParisTech incluant notamment la rencontre de James Reason et de John Wreathall (ingénieur nucléaire ayant activement contribué à la formalisation du modèle et à ses évolutions) en 2014

Fonds bibliographique Sir James Reason - Une vie dans l’erreur

Ce papier de recherche présente la création d’un fonds bibliographique "Sir James Reason". Psychologue anglais, James Reason est mondialement célèbre pour sa taxonomie de l’erreur humaine et son modèle étiologique de l’accident connu sous le nom de Swiss Cheese Model (SCM). Ce Papier de Recherche propose une courte biographie et une explication des principaux fondements des modèles de Reason avant de présenter la liste exhaustive des travaux publiés par Reaso

Geology, Engineering & Humanities: 3 sciences behind the Malpasset dam failure (France, Dec. 2, 1959)

International audienceOn December 2, 1959, the Malpasset arch dam in southeast France suddenly failed, flooding the valley down to the sea, causing huge destruction and more than 400 casualties. Built from 1952 to 1954 for water supply and irrigation, filling of the reservoir was delayed five years and the failure occurred following a flash flood of the river the dam was closing. Post failure studies and expertise during a trial revealed poor field investigations on a micaschist rock foundation crisscrossed by faults, and poor management of construction of the structure. The failure was ascribed to uplift, moving a rock dihedron defined by a conspicuous fault and a tear along foliation. This paper shows that, in addition to the many traps listed by previous investigations (mostly geological and geotechnical), the human and organizational factors can also shed a new light on this catastrophe. Keeping lessons from Malpasset alive and increasing the knowledge about this case is relevant since worldwide, after the catastrophe, not only did new regulations on dams appear but also both fields of geological engineering and rock mechanics were developed. Thus, consciously or not, every geological engineer or rock mechanics specialists is somehow, a descendant of this case

Le modèle de l’erreur humaine de James Reason

Ce papier de recherche a pour objet de revenir en détail sur les travaux de recherche du psychologue anglais James Reason, mondialement célèbre pour sa taxonomie de l’erreur humaine et son modèle étiologique de l’accident immensément connu sous le nom de Swiss Cheese Model (SCM) ou Modèle du Fromage Suisse. Ce papier de recherche est une synthèse du parcours scientifique de Reason, il revient aussi sur la conception du modèle et ses évolutions, il traite de ses usages, apports et limites. Il offre enfin le recensement actualisé de l’ensemble de publications faites à ce jour par Sir Reason

Innovative and Immersive Crisis Management Training Device

International audienceAccidents such as Fukushima Daiichi demonstrates the limits of crisis management training. During a crisis, decision-makers may rely on their experience or the application procedures, but they often need creative skills. Indeed, a crisis is characterized by incomplete or contradictory information, changing goals, and time pressure. Thus, decision-makers must find solutions in an emotional context of stress and fatigue. Traditional crisis management training relies on return of experience and the drill procedures in pre-identified scenarios (theoretically explained or in serious games). This have contributed to reinforcing organizational response but it's not adapted to develop creativity. To do so, we designed and tested an immersive training device to disrupt learners' cognition, making them aware of the importance of their senses, emotions, and representations in the decision-making process. During the session, learners must make decisions based on what surrounds them. Before exiting the room, they must evaluate their performance (which is impossible since the sequence is designed to be meaningless). The debriefing showed how difficult it was for the learners to admit the absurdness of the exercise, as revealed by the strength and ingenuity of their rationalization mechanisms. Our ambition was to complement theoretical lessons. However, first results have inspired a 3-5-year research program to study the articulation between lived experience, feelings, memory, and self-narrative in the face of a crisis