Human Error and Defense in Depth: From
the “Clambake” to the “Swiss Cheese”
Justin Larouzée
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.
Keywords Swiss cheese model Á James Reason Á John Wreathall Á Coproduction Á
Collaboration
1 Introduction
The Fukushima nuclear accident that occurred in Japan, March 2011, and its aftermath reinforced the need of theoretic and pragmatic studies over industrial and social
resilience. Since there is no end in sight to the accident, it also raised the issue of
engineering thinking facing extreme situation [1]. Defined as “engineering activities
J. Larouzée (&)
Centre for Research on Risks and Crises (CRC), MINES Paristech/PSL Research University,
Sophia Antipolis, France
e-mail: Justin.larouzee@mines-paristech.fr
© The Author(s) 2017
J. Ahn et al. (eds.), Resilience: A New Paradigm of Nuclear Safety,
DOI 10.1007/978-3-319-58768-4_22
257
the “Clambake” to the “Swiss Cheese”
Justin Larouzée
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.
Keywords Swiss cheese model Á James Reason Á John Wreathall Á Coproduction Á
Collaboration
1 Introduction
The Fukushima nuclear accident that occurred in Japan, March 2011, and its aftermath reinforced the need of theoretic and pragmatic studies over industrial and social
resilience. Since there is no end in sight to the accident, it also raised the issue of
engineering thinking facing extreme situation [1]. Defined as “engineering activities
J. Larouzée (&)
Centre for Research on Risks and Crises (CRC), MINES Paristech/PSL Research University,
Sophia Antipolis, France
e-mail: Justin.larouzee@mines-paristech.fr
© The Author(s) 2017
J. Ahn et al. (eds.), Resilience: A New Paradigm of Nuclear Safety,
DOI 10.1007/978-3-319-58768-4_22
257