Science
James Reason, Who Used Swiss Cheese to Explain Human Error, Dies at 86

The story of how James Reason became an authority on the psychology of human error begins with a teapot.
It was the early 1970s. He was a professor at the University of Leicester, in England, studying motion sickness, a process that involved spinning his subjects round and round, and occasionally revealing what they had eaten for breakfast.
One afternoon, as he was boiling water in his kitchen to make tea, his cat, a brown Burmese named Rusky, sauntered in meowing for food. “I opened a tin of cat food,” he later recalled, “dug in a spoon and dolloped a large spoonful of cat food into the teapot.”
After swearing at Rusky, Professor Reason berated himself: How could he have done something so stupid?
The question seemed more intellectually engaging than making people dizzy, so he ditched motion sickness to study why humans make mistakes, particularly in high-risk settings.
By analyzing hundreds of accidents in aviation, railway travel, medicine and nuclear power, Professor Reason concluded that human errors were usually the byproduct of circumstances — in his case, the cat food was stored near the tea leaves, and the cat had walked in just as he was boiling water — rather than being caused by careless or malicious behavior.
That was how he arrived at his Swiss cheese model of failure, a metaphor for analyzing and preventing accidents that envisions situations in which multiple vulnerabilities in safety measures — the holes in the cheese — align to create a recipe for tragedy.
“Some scholars play a critical role in founding a whole field of study: Sigmund Freud, in psychology. Noam Chomsky, in linguistics. Albert Einstein, in modern physics,” Robert L. Sumwalt, the former chairman of National Transportation Safety Board, wrote in a 2018 blog post. “In the field of safety, Dr. James Reason has played such a role.”
Professor Reason died on Feb. 4 in Slough, a town about 20 miles west of London. He was 86.
His death, in a hospital, was caused by pneumonia, his family said.
A gifted storyteller, Professor Reason found vivid and witty ways to explain complicated ideas. At conferences, on TV news programs and in consultation with government safety officials around the world, he would sometimes deploy slices of cheese as props.
In one instructional video, he sat at his dining room table, which was set for a romantic dinner, with a bottle of wine, two glasses and a cutting board layered with cheese.
“In an ideal world, each defense would look like this,” he said, holding up a slice of cheese without holes. “It would be solid and intact.”
Then he reached for another slice, one with quarter-size cutouts. “But in reality, each defense is like this,” he said. “It has holes in it.”
The metaphor was easy to understand.
“All defenses have holes in them,” Professor Reason continued. “Every now and again, the holes line up so that there can be some trajectory of accident opportunity.”
To explain how the holes develop, he put them in two categories: active failures, or mistakes typically made by people who, for example, grab the cat food instead of the tea leaves; and latent conditions, or mistakes made in construction, written instructions or system design, like storing two scoopable substances near each other in a cabinet.
“Nearly all organizational accidents involve a complex interaction between these two sets of factors,” he wrote in his autobiography, “A Life in Error: From Little Slips to Big Disasters” (2013).
In the Chernobyl nuclear accident, he identified latent conditions that had been in existence for years: a poorly designed reactor; organizational mismanagement; and inadequate training procedures and supervision for frontline operators, who triggered the catastrophic explosion by making the error of turning off several safety systems at once.
“Rather than being the main instigators of an accident, operators tend to be the inheritors of system defects,” he wrote in “Human Error” (1990). “Their part is that of adding the final garnish to a lethal brew whose ingredients have already been long in the cooking.”
Professor Reason’s model has been widely used in health care.
“When I was in medical school, an error meant you screwed up, and you should just try harder to not screw up,” Robert Wachter, the chairman of the department of medicine at the University of California San Francisco, said in an interview. “And if it was really bad, you would probably get sued.”
In 1998, a doctor he had recently hired for a fellowship said he wanted to specialize in patient-safety strategy, to which Dr. Wachter replied, “What’s that?” There were no formal systems or methods in his hospital (or most others) to analyze and prevent errors, but there was plenty of blame to go around, most of it aimed at doctors and nurses.
This particular doctor had trained at Harvard Medical School, where they were incorporating Professor Reason’s ideas into patient-safety programs. Dr. Wachter, who began reading Professor Reason’s journal articles and books, said the Swiss cheese model was “an epiphany,” almost “like putting on a new pair of glasses.”
Someone given the wrong dose of medicine, he realized, could have been the victim of poor syringe design rather than a careless nurse. Another patient could have died of cardiac arrest because a defibrillator that was usually stored in the hallway had been taken to a different floor to replace one that had malfunctioned — and there was no system to alert anyone that it had been moved.
“When an error happens, our instinct can’t be to look at this at the final stage,” Dr. Wachter said, “but to look at the entirety of the system.”
When you do, he added, you realize that “these layers of protection are pretty porous in ways that you just didn’t understand until we opened our eyes to all of it.”
James Tootle was born on May 1, 1938, in Garston, a village in Hertfordshire, northwest of London. His father, Stanley Tootle, died in 1940, during World War II, when he was struck by shrapnel while playing cards in the bay window of his house. His mother, Hilda (Reason) Tootle, died when he was a teenager.
His grandfather, Thomas Augustus Reason, raised James, who took his surname.
In 1962, he graduated from the University of Manchester with a degree in psychology. He received his doctorate in 1967 from the University of Leicester, where he taught and conducted research before joining the faculty at the University of Manchester in 1977.
He married Rea Jaari, an educational psychologist, in 1964. She survives him, along with their daughters, Paula Reason and Helen Moss, and three grandchildren.
Throughout his career, Professor Reason’s surname was a reliable source of levity.
“The word ‘reason’ is, of course, widely used in the English language, but it does not describe what Jim is rightly famous for, namely ‘error,’” Erik Hollnagel, the founding editor of the International Journal of Cognition, Technology and Work, wrote in the preface to Professor Reason’s autobiography. “Indeed, ‘error’ is almost the opposite of ‘reason.’”
Still, it made sense.
“Jim has certainly brought reason to the study of error,” he wrote.

Science
F.D.A. Scientists Are Reinstated at Agency Food Safety Labs

Federal health officials have reversed the decision to fire a few dozen scientists at the Food and Drug Administration’s food-safety labs, and say they are conducting a review to determine if other critical posts were cut.
A spokesman for the Department of Health and Human Services confirmed the rehirings and said that several employees would also be restored to the offices that deal with Freedom of Information requests, an area that was nearly wiped out.
In the last few months, roughly 3,500 F.D.A. jobs, about 20 percent, were eliminated, representing one of the largest work force reductions among all government agencies targeted by the Trump administration.
The H.H.S. spokesman said those employees called back had been inadvertently fired because of inaccurate job classification codes.
The decision to rehire specialists on outbreaks of food-related illnesses and those who study the safety of products like infant formula follows contradictory assertions made by Dr. Marty Makary, the F.D.A. commissioner, in media interviews this week.
“I can tell you there were no cuts to scientists or inspectors,” Dr. Makary said Wednesday on CNN.
In fact, scientists had been fired from several food and drug safety labs across the country, including in Puerto Rico, and from the veterinary division where bird flu safety work was underway. Scientists in the tobacco division who were dismissed in February — including some who studied the health effects of e-cigarettes — remain on paid leave and have not been tapped to return, according to employees who were put on leave.
How many fired employees will be permitted to return remained unclear.
About 40 employees at the Moffett Lab in Chicago and at a San Francisco-area lab are being offered their jobs back, the department spokesman said. Scientists in those labs studied a variety of aspects of food safety, from how chemicals and germs pass through food packaging to methods for keeping bacteria out of infant formula. Some scientists in Chicago reviewed the work and results of other labs to ensure that milk and seafood were safe.
Dr. Robert Califf, the F.D.A. commissioner under President Joseph R. Biden, said the terms “decapitated and eviscerated” seemed fitting to describe the steep loss of expertise at the agency. He said the F.D.A. was already falling behind on meetings meant to help companies develop safe products — and to design studies that give clear answers about their effectiveness.
“Most of it is really at this level of fundamental, day-to-day work that has a huge impact overall, but it’s not very controversial,” he said. “It’s just that it takes work, and they have to have people to do the work.”
Dr. Makary has also said the layoffs did not target product reviewers or inspectors. But their work has been hampered by voluntary departures, the elimination of support staff and the broader disruption at an agency where many are fleeing for the exits, according to former staff members.
Hundreds of drug and medical device reviewers, who make up about one-fourth of the agency work force, have recused themselves from key projects, Dr. Scott Gottlieb, a former agency commissioner, said on CNBC. Under F.D.A. ethics rules, staff members who are interviewing for jobs cannot do agency review work on products by companies where they are seeking employment — or for a competitor.
Dr. Gottlieb also said cuts to the office of generic drug policy wiped out employees with expertise in determining which brand-name drugs are eligible to be made as lower-cost generics, calling those job eliminations “profound.” Approving generic drugs can save consumers billions of dollars.
Support staff for inspectors investigating food and drug plants overseas were also cut, raising security concerns. Dozens of workers who lost their jobs attended to security monitoring to ensure that inspectors were safe, especially in hostile nations.
Science
Can $1,000 a month help more students land nursing careers? An L.A. pilot effort says yes

Community colleges play a critical role in addressing California’s persistent demand for healthcare workers, preparing students to become the state’s next generation of nurses, medical assistants and physical therapy aides.
But in the Los Angeles Community College District, where more than half of all students report incomes near or below the poverty line, many people struggle to complete their degrees while also holding down jobs to pay rent, buy groceries and cover child-care costs.
A pilot program at the L.A. district — the state’s largest, with nine colleges and 194,000 students — aims to address these seemingly intractable challenges with a targeted remedy: $1,000 a month in guaranteed income.
Late last year, the district launched an initiative that provides cash payments for 12 months to 251 students with a demonstrated financial need who are pursuing health careers. The funding is unrestricted, so participants can use the money however they see fit.
The goal of the effort, dubbed Building Outstanding Opportunities for Students to Thrive, or BOOST, is to eliminate financial insecurity so that students can focus on achieving their academic goals and the college system can deliver a diverse, multilingual healthcare workforce to serve L.A. in the process.
The Times followed one student through the first months of the new initiative to learn how a guaranteed basic income might influence the lives and choices of L.A. community college students.
“I want to give him opportunities, and in order to do that, I have to get ahead,” Adriana Orea, a single mom, says of her decision to pursue a career as a registered nurse.
Adriana Orea, 32, has known for years that she wanted to pursue a career in nursing. She had worked for a time as a licensed vocational nurse, and found the experience rewarding. But after giving birth to a son two years ago, she set her sights on a higher-paying position as a registered nurse, which generally requires a bachelor’s degree from an accredited nursing program.
“I want to give him opportunities, and in order to do that, I have to get ahead,” said Orea, a single mother. “I don’t want him to feel like he’s missing out on something because I’m not able to provide it for him.”
She had recently returned to school, enrolling at L.A. City College in the prerequisite courses she’ll need to get accepted into a nursing school, when she was selected for BOOST. She received her first cash payment on Thanksgiving.
“I feel very blessed to have been picked,” she told The Times a few days later. “At the same time, I feel like I want to be very responsible with this, because it’s not something to be taken lightly.”
Orea lives with her parents and her curly-haired 2-year-old, Kevin, in a rent-controlled building near MacArthur Park. In early December, she was taking three classes and working eight hours a week at the front desk of the college counseling department — a position she got through the state’s welfare-to-work program.

Adriana Orea says her parents, both Mexican immigrants who work night shifts as janitors, are crucial partners in helping raise her son, Kevin.
She is quick to express gratitude for her parents, who are crucial partners in helping raise her son. Her parents, both Mexican immigrants who work night shifts as janitors, watch Kevin while Orea is on campus. She covers most of the family’s food expenses with her CalFresh benefits, spending between $500 and $600 a month on groceries, and also pitches in for rent.
“It’s just been living on a budget, which is definitely doable, because I have so much support,” she said.
Of the first $1,000 payment, she spent about $600 on outstanding bills for Kevin’s newborn check-ups that had resulted from a lapse in health insurance. She also used some of the money to buy Christmas gifts for her family and a holiday outfit for herself. She received the second payment in mid-December, and was determined to not dip into it.
“I’m just treating it like I’m not receiving it,” she said.
By January, she already felt more financially secure, having squirreled away $1,000 and knowing more would be coming.
“I might actually have something in the back pocket,” she said. “It’s not just a paycheck-to-paycheck thing.”

Adriana Orea says the $1,000 a month she gets through BOOST has made a world of difference in her stress levels: “I can literally just concentrate on studying for my classes.”
More than 150 guaranteed income pilot programs have launched nationwide in recent years, but BOOST is one of the first focused on community college students.
Proponents tout unconditional cash as a way to provide greater stability to vulnerable community members. But as the concept has gained steam, it has also spurred backlash. Several Republican-led state legislatures are banning or trying to preempt cities and counties from launching direct cash initiatives, arguing publicly funded programs are a waste of taxpayer resources.
The BOOST program is privately funded with more than $3.1 million from the Eli and Edythe Broad Foundation, and $867,500 from the California Community Foundation’s Young Adults Forward Fund. It represents a rare philanthropic investment in California community college students, who number 2.1 million statewide. Typically, more than half of California high school graduates start at a community college.
There is a “massive mismatch of where private philanthropic dollars go and where students in California go to school, particularly if we think about low-income, first-generation and students of color,” said Kelly King, executive director of the Foundation for the Los Angeles Community Colleges. “This level of investment in community college students is very unusual, unfortunately, but it’s very much needed.”
To be eligible for BOOST, students must have selected a health-related major and express interest in pursuing a health career, as well as have a demonstrated financial need and be considered low-income for L.A. County. Participants in the pilot were selected by lottery, with 251 receiving the monthly payments and an additional 370 enrolled in a control group.
Of the total participants, 72% are female, 65% are Hispanic or Latino, and 29% report that the primary language in their household is Spanish, according to data provided by the community college district. The average annual household income is $31,853, and 47% report having children in the household.
Like other pilots, BOOST is designed as a research study. In this case, the Center for Guaranteed Income Research at the University of Pennsylvania is analyzing how the unrestricted payments effect the well-being of students and what role it might play in keeping them on track in completing their healthcare degrees.
“Lack of basic needs, food insecurity and unexpected financial shocks create barriers for students that often push them out of education,” said Amy Castro, the center’s co-founder and faculty director. “Dreaming about your future should be a feature of young adulthood that is open to all — not just the wealthy or those with the good fortune to have ironclad access to higher education.”

Among other benefits, Adriana Orea says the money she is saving through BOOST has allowed her to start an emergency fund in case she or her son falls ill and she can’t work.
By mid-February, the guaranteed payments had made a big difference in Orea’s life.
Determined to take advantage of the financial support, she enrolled in four classes for the spring semester. She felt as if her momentum was snowballing, and realized that with better time management, she could also take on a few more hours at work and make a bit more money.
Despite having more on her plate, Orea seemed less stressed. Knowing she didn’t need to hold down a full-time job, or a second part-time gig, to support her son was in itself a huge relief.
“I can literally just concentrate on studying for my classes,” she said.
She had started amassing an emergency fund in case she or Kevin gets sick and she’s unable to work.
She was also feeling more comfortable spending the money. She bought her family a Valentine’s Day lunch at Sizzler, treating her mom to the buffet and her dad to his favorite steak and shrimp dish. She took Kevin to Big Bear to see snow. And if she ran out of time to pack a lunch from home, she didn’t stress about grabbing a sandwich at a doughnut shop near campus.
“I see my bank account going up — I feel like I’m saving,” she said. So, she’s able to tell herself: “This is not a big splurge, I can treat myself.”
By early April, Orea had received $5,000 through BOOST.
She opened a high-yield savings account, with the goal of using her money to make money. She purchased Disneyland tickets to celebrate her mom’s 60th birthday. She had recently received two parking tickets, and while she said she was disappointed to lose money, it wasn’t the crisis hit to her budget that it would have been in the past.
She said receiving the cash — and knowing it was temporary — has made her “laser-focused” on her goals: Finish her prerequisite courses this spring; work part-time as a licensed vocational nurse this summer while studying for her nursing school entrance exam; then apply to schools in the fall and start a nursing program next spring.
“Having this opportunity made me take a hard look at myself and be like, ‘This is what you want. How are you going to get there? Take advantage that you have this,’” she said.
At the same time, her horizons have expanded. Receiving the guaranteed income had freed her from the suffocating sensation of constantly worrying about money.
“Once you feel like there’s one less thing stressing you out, you just feel this relief,” she said. “It clears your mind a little more and you just feel less stressed about everything else.”
Orea said she expects the money she has saved through BOOST will smooth her transition to nursing school. She hopes to receive financial aid to attend a nursing program at L.A. City College or a Cal State university, but said she would take out loans if needed to attend a more expensive private school. She plans to live at home and pick up a couple of shifts each week as a licensed vocational nurse while in school, but said her savings from this year should help ensure she isn’t stretched thin during the two-year program.
She will likely remain in L.A. County after nursing school, she said. She worked in geriatrics previously, but is interested in exploring work in a birthing or neonatal unit. No matter where she works, she will use her Spanish fluency to communicate with patients and their families.
This article is part of The Times’ equity reporting initiative, funded by the James Irvine Foundation, exploring the challenges facing low-income workers and the efforts being made to address California’s economic divide.
Science
The Trump Administration Wants Seafloor Mining. What Does That Mean?

Life at the bottom of the Pacific Ocean is slow, dark and quiet. Strange creatures glitter and glow. Oxygen seeps mysteriously from lumpy, metallic rocks. There is little to disturb these deep-ocean denizens.
“There’s weird life down here,” said Bethany Orcutt, a geomicrobiologist at Bigelow Laboratory for Ocean Sciences.
Research in the deep sea is incredibly difficult given the extreme conditions, and rare given the price tag.
On Thursday, President Trump signed an executive order that aims to permit, for the first time, industrial mining of the seabed for minerals. Scientists have expressed deep reservations that mining could irreversibly harm these deep-sea ecosystems before their value and workings are fully understood.
What’s down there, anyway?
Seafloor mining could target three kinds of metal-rich deposits: nodules, crusts and mounds. But right now, it’s all about the nodules. Nodules are of particular value because they contain metals used in the making of electronics, sophisticated weaponry, electric-vehicle batteries and other technologies needed for human development. Nodules are also the easiest seafloor mineral deposit to collect.
Economically viable nodules take millions of years to form, sitting on the seafloor the whole time. A nodule is born when a resilient bit of matter, such as a shark tooth, winds up on the ocean floor. Minerals with iron, manganese and other metals slowly accumulate like a snowball. The largest are the size of a grapefruit.
Life accumulates on the nodules, too. Microbial organisms, invertebrates, corals and sponges all live on the nodules, and sea stars, crustaceans, worms and other life-forms scuttle around them.
About half of the known life in flat, vast expanses of seafloor called the abyssal plain live on these nodules, said Lisa Levin, an oceanographer at the Scripps Institution of Oceanography. But “we don’t know how widespread species are, or whether if you mine one area, there would be individuals that could recolonize another place,” she said. “That’s a big unknown.”
How do you mine the sea?
Two main approaches to nodule mining are being developed. One is basically a claw, scraping along the seabed and collecting nodules as it goes. Another is essentially an industrial vacuum for the sea.
In both, the nodules would be brought up to ships on the surface, miles above the ocean floor. Leftover water, rock and other debris would be dropped back into the ocean.
Both dredging and vacuuming would greatly disturb, if not destroy, the seafloor habitat itself. Removing the nodules also means removing what scientists think is the main habitat for organisms on the abyssal plain.
Mining activities would also introduce light and noise pollution not only to the seafloor, but also to the ocean surface where the ship would be.
Of central concern are the plumes of sediment that mining would create, both at the seafloor and at depths around 1,000 meters, which have “some of the clearest ocean waters,” said Jeffrey Drazen, an oceanographer at the University of Hawaii at Manoa. Sediment plumes, which could travel vast distances, could throw life off in unpredictable ways.
Sediment could choke fish and smother filter-feeders like shrimp and sponges. It could block what little light gets transmitted in the ocean, preventing lanternfish from finding mates and anglerfish from luring prey. And laden with discarded metals, there’s also a chance it could pollute the seafood that people eat.
“How likely is it that we would contaminate our food supply?” Dr. Drazen said. Before mining begins, “I really would like an answer to that question. And we don’t have one now.”
What do mining companies say?
Mining companies say that they are developing sustainable, environmentally friendly deep-sea mining approaches through research and engagement with the scientific community.
Their research has included basic studies of seafloor geology, biology and chemistry, documenting thousands of species and providing valuable deep-sea photos and video. Interest in seafloor mining has supported research that might have been challenging to fund otherwise, Dr. Drazen said.
Preliminary tests of recovery equipment have provided some insights into foreseeable effects of their practices like sediment plumes, although modeling can only go so far in predicting what would happen once mining reached a commercial scale.
Impossible Metals, a seafloor mining company based in California, is developing an underwater robot the size of a shipping container that uses artificial intelligence to hand pick nodules without larger organisms, an approach it claims minimizes sediment plumes and biological disturbance. The Metals Company, a Canadian deep-sea mining company, in 2022 successfully recovered roughly 3,000 tons of nodules from the seafloor, collecting data on the plume and other effects in the process.
The Metals Company in March announced that it would seek a permit for seafloor mining through NOAA, circumventing the International Seabed Authority, the United Nations-affiliated organization set up to regulate seafloor mining.
Gerard Barron, the company’s chief executive, said in an interview on Thursday that the executive order was “not a shortcut” past environmental reviews and that the company had “completed more than a decade of environmental research.”
Anna Kelly, a White House spokeswoman, said the United States would abide by two American laws that govern deep-sea exploration and commercial activities in U.S. waters and beyond. “Both of these laws require comprehensive environmental impact assessments and compliance with strong environmental protection standards,” she said.
What are the long-term risks?
Many scientists remain skeptical that enough is known about seafloor mining’s environmental effects to move forward. They can only hypothesize about the long-term consequences.
Disrupting the bottom of the food chain could have ripple effects throughout the ocean environment. An extreme example, Dr. Drazen said, would be if sediment diluted the food supply of plankton. In that case they could starve, unable to scavenge enough organic matter from a cloud of sea dust.
Tiny plankton are a fundamental food source, directly or indirectly, for almost every creature in the ocean, up to and including whales.
Part of the challenge in understanding potential effects is that the pace of life is slow on the seafloor. Deep-sea fish can live hundreds of years. Corals can live thousands.
“It’s a different time scale of life,” Dr. Levin said. “That underpins some of the unknowns about responses to disturbances.” It’s hard for humans to do 500-year-long experiments to understand if or when ecosystems like these can bounce back or adapt.
And there are no guarantees of restoring destroyed habitats or mitigating damage on the seafloor. Unlike mining on land, “we don’t have those strategies for the deep sea,” Dr. Orcutt said. “There’s not currently scientific evidence that we can restore the ecosystem after we’ve damaged it.”
Some scientists question the need for seafloor mining at all, saying that mines on land could meet growing demand for metals.
Proponents of deep-sea mining have claimed that its environmental or carbon footprint would be smaller than traditional mining for those same minerals.
“There has been no actual recovery of minerals to date,” said Amy Gartman, an ocean researcher who leads the United States Geological Survey seabed minerals team, referring to commercial-scale mining. “We’re comparing theoretical versus actual, land-based mining practices. If and when someone actually breaks ground on one of these projects, we’ll get a better idea.”
Eric Lipton contributed reporting.
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