Embry-Riddle Aeronautical University, NTSB Chairman, 2017-2021, CBS News Transportation Safety Analyst
I suspect everyone who reads this blog is familiar with the Swiss Cheese Model. Developed by Professor James Reason in the early 1990, this model depicts in very simple terms how various layers of defense (depicted as cheese in his model) are used to create a robust system of safety. However, when these layers are breached, as depicted by the holes in cheese, an accident trajectory can penetrate each layer, and we have a bad outcome. I believe he also first coined the term Just Culture, another term we hear at safety conferences across the world, whether the topic is aviation, medicine, nuclear power, and any other high consequence industry. Sadly, Jim passed away yesterday at the age of 86 at his home outside of London. In 2018, I wrote the below-linked National Transportation Safety Board "Safety Compass" blog to commemorate Jim's 80th birthday. In 1998, when I was an airline pilot doing safety work, Jim promised me that he would speak at our internal safety meeting. Living up to his promise, he boarded a flight in Manchester, England before dawn, connected in London and flew to Pittsburgh to speak the next morning. Right after his speech, we rushed him to the airport so he could fly back to UK. All this for a 45-minute keynote and because he made a promise to me. I have such fond memories of having dinner in London several years ago with his daughter, Paula, at one of his favorite restaurants. It was a magical evening. In addition to writing several books, Jim had many awards, including being bestowed the honorable title of Commander of the British Empire (CBE). Paula bragged about her dad, saying he has been "touched by the Queen." Goodbye, Jim. Until we meet again. Thank you doing so much to improve safety through your writings and teaching. https://lnkd.in/eYzgrY_u
Few people in the world know his name or his work, but everyone alive today (all 8 billion of us) are safer as a result of what he wrote and spoke about.
Reason’s work was foundational to our industry’s exceptional safety record. While he will be missed by many, his memory will live on with every safety professional who has studied, utilized or incorporated his research into their safety programs. Safe travels, Dr. Reason.
Well said, Robert, thank you. What a legacy he leaves for keeping a diligent watch that safety is always paramount. Just Culture actually began in the late 70s and 80s for aviation following the TWA accident that led to the NASA reporting system. Professor Reason brought it all together with his research and writing to fully develop the "culture" necessary throughout our system. We are so much better for his insight, brilliance, and stewardship. My sincere sympathies.
Professor James Reason’s Swiss Cheese Model has been a cornerstone of aviation safety, helping us understand how accidents happen and, more importantly, how to prevent them. His work has shaped safety management systems, improved training, and ultimately saved countless lives by identifying and closing gaps in our defenses before failures align. His legacy lives on in every briefing, checklist, and safety discussion that incorporates his insights. The aviation community owes him a great debt—blue skies and tailwinds, Jim.
The Swiss Cheese Model, originally developed in aviation, has proven crucial in enhancing safety and risk management also in shipping. By illustrating layers of defense, it shows how multiple safeguards can effectively prevent accidents. In the shipping industry, this model emphasizes proactive decision-making and the continuous identification of vulnerabilities. By prioritizing training, regular audits, and a strong safety culture, we can close the gaps and ensure the vessels can operate safely and efficiently. Embracing the Swiss Cheese Model is essential as we strive for excellence in shipping safety!
🙏 He will continue to live on with his successful works and ideas he created. May he rest in peace.💐 Although the Swiss cheese model has been widely adopted by flight and cabin crew, it’s been a successful tool that enabled the aviation industry stakeholders to predict possible weak points in each separate branch, including production, MRO, aircraft operations, flight operations to enhance flight safety.
Fabulous story about a man with such a significant impact in Aviation. Of course, him travelling to the US speaks volumes about you as well.
I too have a fond memory of having dinner with Jim when he came to Vancouver after accepting my invitation to speak at CASS. I proposed a modification to his Swiss Cheese model with drip tray to collect information on the operations that made it through some holes before getting stopped. He lit up like a kid. It was the dawn of SMS and that visual helped us simply get the SMS message out. James Reason was a leader that brought safety into operations. Thank you Jim.
Professor Reason's impact on aviation safety (and safety in other industries) cannot be overstated. The Swiss Cheese model has been a foundational concept in understanding how accidents happen and, more importantly, how they can be prevented! Rest in peace, Professor Reason.
Managing Principal at Sine Rivali, LLC
2wMy first collaboration with James was as part of the project team performing the technical investigations into the Kings Cross Underground fires as part of Mr. Justice Fennel's, QC Public Inquiry starting November 1987. James was brought into the team to assist with investigating the human factors associated not only with London Underground Ltd. and as well the London Fire and Civil Defence Authority and the interactions between those organizations. In 1988 after being appointed by Lord Cullen to direct his technical investigations into the Pipe Alpha offshore installation explosions and fires as part of the Public Inquiry into that disaster, we retained James to look into the myriad and complex HF issues of Occidental, various contractors and subcontractors as well as host of emergency services. The last time we caught-up was sharing a pint at a small pub in Liverpool in 2019. James had been invited to give a lecture at Liverpool University and I was working on a project in Liverpool at the time. Interestingly he somewhat lamented how he felt the swiss cheese model was, in his view, moving in a direction of being used as a "crutch" to explain away the occurrence of an incident or incidents.