【Sea and River Safety Discussion】A038 – The application of the “Cheese Principle” is not limited to safety management
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There is an important Swiss cheese model in security management; it essentially involves several layers of cheese stacked on top of each other, with holes in each layer. Light can pass from the first layer to the last layer only when the holes in each layer align precisely with one another. Each hole in the cheese slice can be seen as a safety hazard, while each piece of cheese represents the safety controls in our various processes. When the vulnerabilities in all control mechanisms combine, they penetrate through all layers of security protection; in other words, all control mechanisms cease to function, and an accident becomes inevitable.
The four main components of the cheese model are: 1. Human error: Human error is the most common element in an accident chain, and it is also the element that is easiest to control and improve. This includes factors such as employees’ lack of focus, fatigue, personal preferences, and improper behavior. 2. Management system: The management system includes the organization’s policies, processes, and procedures, as well as the training and supervision of employees. Management systems can reduce human errors by improving processes and providing better training and supervision. 3. Physical environment: The physical environment includes factors such as equipment, tools, and workplace layout. A well-designed physical environment can reduce the occurrence of accidents, for example by properly arranging equipment and improving its usability and reliability. 4. External environment: The external environment includes factors such as politics, economy, and society, which may have an impact on security management. Managers need to pay attention to and adapt to changes in the external environment to prevent accidents.
Management and sharing: It is necessary to minimize the number of \"holes\" in each piece of cheese. This implies that in safe production practices, potential hazards and violations must not be ignored; the system of thorough verification must be implemented rigorously, without any slackness or reliance on luck in its execution. Be adept at identifying safety hazards and effectively addressing deficiencies, while strengthening risk warnings for specific positions and risk control in key areas. Do not blindly trust that the previous step or earlier process was error-free; instead, thoroughly verify it and insist on starting from scratch.
The cheese theory offers us three key insights: First, once a hidden danger emerges, if it is not addressed in time, an accident will inevitably occur； Secondly, regulators at each stage must not assume that those in other regulatory stages have done their duty; instead, they need to ensure that they carry out their own responsibilities properly ； Third, to ensure that the outcome is 100% under control, it is first necessary to achieve 100% compliance with the process standards. Therefore, the goal of management is to identify and seal every hole in each piece of cheese. In practical work, an effective tool for sealing the “cheese holes” is a “list”. Before carrying out any work, list in detail all the potential problems that may arise, create a list of these issues, and develop specific measures to address them. During the execution process, verify the implementation of each of these measures one by one until it is confirmed that all problems have been resolved. Production and operation units shall establish and improve a dual-prevention mechanism to truly ensure that safety risk management takes precedence over potential hazards, and that the identification and resolution of such hazards come before accidents occur. By implementing layered safeguards and carrying out closed-loop rectification of hazards in accordance with the requirements of the five implementation aspects, accidents can be avoided.
【Sea and River Safety Discussion Thread】A compilation post; updates will be made regularly – feel free to discuss! https://bbs.hcbbs.com/thread-5497581-1-1.html (Source: Haichuan Chemical Industry Forum)
【Sea and River Safety Discussion】A039 – How to Apply the “Bathtub Curve” in Safety Management? ? ? https://bbs.hcbbs.com/thread-5500950-1-1.html (Source: Haichuan Chemical Industry Forum)