Monday, November 1, 2021

The Swiss Cheese

 The Swiss Cheese

By Catalina9

The other day when I was on my way to the store to buy swiss cheese and it was raining. I had opened my umbrella inside, walk under a ladder and a black cat crossed in front of me by the time I got to my car. My day was off to an unpredictable day. I purchased a block of swiss cheese and a package of sliced. I could not see the swiss cheese holes in the block, but I could see them in the sliced cheese, and all the holes were lined up. An unavoidable incident seems to be on the march in my direction today. I had opened an umbrella inside, walked under a ladder, black cat crossed in front of me and now all the holes in the swiss cheese lined up. And to make things worse, I embrace the principle that more is less and less is more. 


Umbrellas are attainable and measurable goals to be used for
a purpose.
An effective Safety Management System (SMS) is expected to run smoothly, and that safety will come by itself if we just do the right tings. The right thing is to find the holes in the swiss cheese and to stop the flow of accidents by plugging or diverting holes. If we make safety objectives and goals, we will be safe, or if we just remain vigilant, observant and follow the rules, we will also be safe. Accidents are built from a blueprint for a system to fulfil an undesired purpose, or aim, and the swiss cheese analogy is an imaginary description to simplify how integrated micro-systems builds accidents.


They key to a successful SMS is to accept that there are micro-systems within larger systems. These micro-systems are defined as at random, since there is no obvious logic to how they form or are placed within its own system. The definition of at random in the Marriam-Webster dictionary is without definite aim, direction, rule, or method, and lacking a definite plan, purpose, or pattern. Applying these micro-systems as random and unpredictable is how they must be applied within an SMS enterprise.  


A latter is a tool to reach new goals, so don’t walk
under it.
The swiss cheese principle is an exceptional good description of at random, or of how accidents are built and the many interactions of events that must take place to build up to the accident itself. However, this principle is only effective as a reactive tool for analysis after an accident, since when arriving at one hole, there is no road map or directions as what turn to take next to avoid lining up another swiss cheese hole. The swiss cheese analysis is non-directional, it is operating within a dark space and each hole in the cheese are individually and specifically placed within its own micro-system and without connections to current events. Holes in the swiss cheese may appear to be randomly placed, but they are systematically placed within its own micro-system produced by carbon dioxide. Each hole in the swiss cheese is a result of a cause which creates the effect. The cause is its own system within the swiss cheese creating these pockets of gas. From outside the swiss cheese, these holes may appear to pop-up randomly, while within the dark spaces of the micro-system itself their location placing becomes predictable


Conventional wisdom is that more is less, and less is more. Professional organizations are rigidly applying this principle in their decision-making process. When applied correctly, simplifying processes is a tool to achieve more. However, simplifying processes does not include a reduction in level of service, or removal of regulatory compliance processes. When more is less, and less is more, there is much more work, research, design, and project planning needed to produce a simplified system output on the front line.  


Looking for the black cat is active hazard identification
Safety in aviation is beyond being a miracle, a matter of luck or dreams come true. Everything happens for a reason, good or bad, positive, or negative. Accepting that at random are micro-systems affecting your goals, and that this system appears as at random is vital to the goal achievement process. If at random is without definite aim, direction, rule, or method, and lacking a definite plan, purpose, or pattern, then accidents are meaningless. A meaningless event has no purpose or reason. An accident is emotionally meaningless since there is no reason or purpose for people to be harmed or loss of life due to unexpected events. However, when applying meaningless, or without definite aim in an SMS organization it becomes impossible to establish cause and integrated factors of occurrences and unexpected events. That everything happens for a reason does not imply that events magically occur, is a statement that there are micro-systems affecting operations which cannot be determined, recorded, or predicted. In an SMS world, these systems are also defined as special cause variations.


A Regulator is responsible for the development and regulation of aeronautics and the supervision of all matters connected with aeronautics. When a new regulation comes into force, an airport or airline operator only have one choice to continue operations, which is to maintain compliance with the new regulation. Public opinions, political environment and aviation incidents are all triggers for new regulations. Over time these regulations add up to an overwhelming task for both airlines and airports. In addition, the regulations require an SMS enterprise to run a safety management system that is adapted to the size, nature and complexity of the operations, activities, hazards, and risks associated with the operations. More regulation and a scaled down SMS system are two opposing regulatory requirements.  



Scaling down an SMS enterprise is not to remove or decline specific regulations, but to combine operational tasks applicable to each regulatory requirement. Scaling down is to make your job as the Accountable Executive userfriendly and manageable for the SMS Manager. When regulations are performance based, an operator is obligated to demonstrate how their activities conform to the regulations. Demonstrating compliance is more than demonstrating compliance with one regulation, but to demonstrate how each task maintain compliance, and how any of these separate tasks does not interfere or causing non-compliance with other regulations.


The swiss cheese principle is a valuable analogy to describe actions, reactions and results of a micro-hazard travelling through the cheese and setting the main system up for failure by travelling through each hole in the swiss cheese. However, if an SMS enterprise establish a safety goal to avoid the swiss cheese holes and objectives are to navigate safely around the holes, they are doing the right thing, but operating with unmeasurable goals since the distance and directions to the holes are not measurable.  

 

Applying the principle that less is more and more is less gives the same output as the swiss cheese principle. Both principles come with a valuable application, but it is impossible to establish measurable goals from these principles. On the other hand, opening an umbrella inside, walking under a ladder or the black cat crossing, are all events that can be used to establish measurable goals. Find the umbrella, ladder, and black cat within your SMS enterprise micro-systems to build a portfolio of safety. 


Catalina9




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