The Swiss cheese model for disasters

No more human errors should be allowed to break through the system barriers and lead to major disasters in this country.

WI MOON-HEEThe author is a national 2 team reporter of the JoongAng Ilbo. Mountainous areas make up 70 percent of Switzerland. Dairy farming has long developed in the country, taking advantage of the mountain regions. As a result, diverse kinds of cheese using cow milk have been produced. According to the website of the Swiss Embassy in Korea, there are more than 450 kinds of cheeses in Switzerland. In 2019, about 195,000 tons of cheese were produced, and more than 20 kilograms (44 pounds) of cheese is consumed per person each year.

Emmental cheese in particular is the most well-known Swiss cheese, notably characterized by the holes called “cheese eyes.” It is Jerry’s favorite cheese in the cartoon “Tom and Jerry.” The cheese eyes are said to produce the flavor. Emmental cheese is made with milk from the cows that live in alpine areas. Emmental is a name made by combining the Emmen area in Berne and “tal,” meaning valley.

In his book “Human Error,” published in 1990, James Reason, a psychologist at the University of Manchester, presented the Swiss cheese model for disasters. In fact, it is the Swiss “Emmental” cheese model. This model compares potential flaws that can cause a safety accident to the holes in Emmental cheese. When you overlay multiple layers of Emmental cheese, a linear gap can emerge through the holes on all layers of cheese. This “trajectory” can cause a major accident, he argued. The case of the accident should be expanded from human negligence to organizational factors, he maintained.

As all the holes lurking in the police, fire departments and local governments overlapped at once in the Itaewon disaster before Halloween, it caused devastating damages. There were 11 emergency calls warning of an imminent risk of crush from four hours before the disaster. Halloween festivities peak up until around midnight, but the fire department only planned safety operation plans until 10 p.m. At a meeting among the police, officers at Itaewon Station, the merchants’ association and the Yongsan District office only sent two officials from the waste management team.

There is no organization without holes. But each organization must try to reduce the number of holes or at least cut the size. Let’s start from around us. No more human errors should be allowed to break through the system barriers and lead to major disasters in this country.