Catastrophic failures can happen in any industry. While industrial hygienists and environmental health and safety (EHS) professionals are concerned with protecting the health and safety of our work force, other professionals have more abstract concerns, such as protecting the financial solvency, reputation, or marketability of their companies. Our corporate institutions are ultimately concerned with protecting all of these interests; however, catastrophic failures can be made in any of these spheres.

In February, the U.S. witnessed what amounted to a catastrophic failure in the pronouncement of an incorrect winner of the Best Picture award at the 89th Academy Awards ceremony. In the days following the event, the public relations department of PricewaterhouseCoopers (PwC), the accounting firm responsible for tabulating the Oscars results, struggled to redeem the company’s reputation, which is built on accountability. “You had one job!” echoed across the internet, but what many failed to acknowledge is that human error is a built-in feature. Good risk management of a system accounts for human error, and builds many barriers of protection to prevent accidents from occurring in spite of human error. A system that relies solely or heavily on a single human’s perfect performance is a system that will certainly fail. The “Swiss Cheese” model of accident causation helps to illustrate how various barriers of protection against accidents can fail.

The “Swiss Cheese” model is attributed to James Reason, who proposed that the defenses of human systems can be compared to a series of barriers with holes (or weaknesses) in them, which can be envisioned as a series of slices of Swiss cheese. An accident or failure occurs when the holes temporarily align to create a “trajectory of accident opportunity.” What we witnessed at the Oscars was an alignment of these holes: duplicate envelopes; excitement backstage that was distracting to the handler of the envelopes; small lettering on the award card that was difficult for the announcers to read; and a Hollywood-typical attitude that “the show must go on!” which pushed the announcers to go ahead with what one suspected to be a faulty announcement.

Industrial hygienists and EHS professionals have valuable lessons to learn from this event. We have an important role to play in preventing catastrophic failures in our sphere, made even more critical by the reality that our failures can result in lives lost. We must help to design systems that have more barriers in place, or smaller holes within those barriers.

We can accomplish this by working to promote safety culture within our organizations. We can help ensure that supervisors are part of a positive safety culture and have the resources they need to provide safe oversight and direction to workers. We can thoroughly evaluate the preconditions in the work environment that might present risks to the work force and implement controls to reduce or eliminate those risks. And we can empower workers to prevent active failures by working safely and stopping work when they perceive a risk is present that might lead to a catastrophic failure. Finally, awareness of the systematic controls that exist in a robust risk management program directs an organization’s energy toward continuous improvement of all barriers, and away from a blaming attitude that focuses only on the last layer of “Swiss cheese,” its valued workers.