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
Why new dads shouldn’t panic about low testosterone
Three months after his son was born, Kevin Maguire felt alone.
It was 2019. He had recently moved to Barcelona with his wife and daughter and was working on marketing projects for Fortune 500 companies. The birth of his son, Bodhi, should have been a joyous event. But Maguire, now 43, became sad and irritable, and didn’t want to be around his newborn. He withdrew from family and friends, often playing video games late into the night or finding excuses to get out of the house.
“I would take the dog out for a walk,” Maguire said. “I wanted to get far away enough that I wouldn’t bump into anyone I knew and I would just sit and cry.”
Desperate for answers, he entered his symptoms online. Maguire, author of the recently published book “The New Fatherhood: Why Everything They Told You About Being a Dad Is Wrong, and How Embracing It Will Transform Your Life,” knew to look for signs of the “baby blues” in his wife. But he was surprised by articles that said men could experience postpartum depression too. The diagnosis resonated and he began writing about his condition and the trials of fatherhood on Substack.
New dads face psychological pressures, from sleepless nights to sky-high bills, which can contribute to postpartum depression. So can shifting hormone levels.
“One thing I found in my lab’s research is that when new dads have really low levels of testosterone, they might report more symptoms of postpartum depression,” said Darby Saxbe, a professor of psychology at USC and author of the recently published “Dad Brain: The New Science of Fatherhood and How It Shapes Men’s Lives.”
While hormonal shifts can create challenges, they also help men adapt to fatherhood, Saxbe explained. Several hormones can spike in men when they become dads, including oxytocin, linked to better relationship quality; vasopressin, associated with emotional bonding; and prolactin, which promotes lactation in women and caregiving behavior in guys.
New dads can also experience a decline in testosterone. According to a 2011 paper from University of Notre Dame professor Lee Gettler, part of the largest study on fatherhood and testosterone ever conducted, men averaged around a 25% drop in testosterone after becoming fathers.
While dads have reasons to be concerned by plummeting levels of testosterone, a modest dip isn’t necessarily a disaster — in fact, it can make men better parents and partners.
“We often get invested in the idea that men should always have the highest possible levels of testosterone,” Saxbe said. “What the research tells us is a little more nuanced. You really want flexibility. You want a hormonal system that can adapt to the different demands of your life.”
The prospect of a decline might scare soon-to-be fathers, especially those on TikTok and Instagram, where accounts push the idea that having “high T” is the key to being a “real man,” according to a recent study in the journal Social Science & Medicine.
Influencers stand to profit persuading men there’s a widespread “masculinity crisis,” the researchers found, noting that 72% of the accounts they analyzed had a stake in testosterone supplements and treatments.
But studies show more testosterone isn’t always better. “We found that when dads have higher testosterone, even before birth, they’re less invested [than men with lower testosterone] in co-parenting a few months after birth,” Saxbe said. High T fathers were more stressed from parenting than their lower T counterparts, and had partners who were less satisfied in their romantic relationships.
This jibes with the challenge hypothesis, which says, in multiple species, testosterone levels rise when males battle for attention from potential mates and go down when it’s time to take care of the young.
While a small decline can be adaptive, dads face mental health risks when their testosterone drops too low.
There is no “normal” level of testosterone, said Dr. Jesse Mills, director of the Men’s Clinic at UCLA Health. Experts recommend that men should consider treatment if their levels dip below 300 nanograms per deciliter (ng/dL). But men metabolize testosterone in different ways, meaning a healthy level for one might be low for another.
“If a new dad comes to me and his testosterone is 298 [ng/dL], he’s below the threshold,” Mills said. “But if he has zero symptoms and everything else is going great — he’s over the moon with his new child, he’s so happy — that’s not somebody I’m going to treat with testosterone.”
He notes that the drop in testosterone fathers experience can partly be attributed to the stresses that come with a new kid: less sleep, a poor diet and fewer trips to the gym. That means there are precautions that expectant fathers can take that don’t involve testosterone replacement therapy (TRT).
Still, while some guys with low testosterone levels might not need TRT, others in the “normal” range could benefit from treatment. (Dads who want another kid soon, beware. Mills notes that testosterone replacement therapy can take a man’s sperm count to zero.)
Both Mills and Saxbe stress that men should be paying attention to symptoms of low testosterone — such as depression and low libido — rather than trying to reach or maintain an ideal number. They also agree that tending to mental health concerns is hugely important for new fathers.
Eventually, after Maguire researched his condition, he recovered after time spent meditating, exercising and bonding with his son.
“A lot of new dads don’t realize how much they’re struggling because they feel ashamed or because they don’t realize it’s common shortly after the birth of a baby,” Saxbe said.
When they struggle, fathers can fixate on testosterone because that’s what modern culture tells them will make them feel better. And sometimes testosterone replacement therapy works. But Saxbe stresses a lot of men could use psychotherapy or support groups that bring dads together, as well as more time bonding with loved ones in general.
“The thing that predicts a man’s well-being and longevity is the quality of his relationships with other people,” said Saxbe. “You can be the world’s best weightlifter. You can have a low body-fat percentage. You can be killing it at work. Those things don’t predict how happy you’re going to be at 80.”
Science
Video: NASA Announces Artemis III Crew
new video loaded: NASA Announces Artemis III Crew
transcript
transcript
NASA Announces Artemis III Crew
NASA announced the crew of Artemis III mission, which will fly to low-Earth orbit to test rendezvous and docking maneuvers with one or two lunar landers.
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“I am excited to welcome you as the next crew in the Artemis journey to successfully return to the moon — this time to stay.” “I’m honored by the role that I’ve been given. I’m also very humbled by the task in front of us. But first and foremost, I’m grateful.” “So with that, the Artemis II crew, comrade, hands you the baton. You got the controls.” “As you know, we had a significant anomaly at our Launch Complex 36A on May 28. We’ve redoubled our efforts and are moving forward.”
By Alisa Shodiyev Kaff
June 9, 2026
Science
Santa Monica Mountains’ last steelhead trout survived the Palisades fire — and even had babies
Scientists feared the Santa Monica Mountains’ last remaining steelhead trout were dead, smothered by debris flows unleashed by the Palisades fire.
But the endangered fish surprised them: A team of biologists recently spotted 30 of the rare trout — and 21 babies — in Topanga Creek.
“There was a lot of happy dancing in the creek,” said Rosi Dagit, principal conservation biologist for the Resource Conservation District of the Santa Monica Mountains, which works with public and private landowners to conserve natural resources.
That’s because the steelhead here are endangered, at both the state and federal levels. Once, they swam in most streams of the Santa Monicas, but their numbers plummeted amid overfishing and coastal development. Increasingly frequent wildfire has further stressed their habitat. Topanga Creek, a biodiversity hot spot, is home to their last known population in the mountains that stretch from the Hollywood Hills to Point Mugu in Ventura County.
The trout that were spotted, including this one, are part of a distinct Southern California population that’s listed as endangered at the state and federal levels.
(RCDSMM Stream Team)
The California Department of Fish and Wildlife spearheaded a complex mission to rescue trout threatened by the Palisades fire that sparked in January 2025.
Time was of the essence. The fire hadn’t yet been fully contained. But rain was on the way, which would sweep massive amounts of sediment from the denuded hillsides into the water. Fish are often killed this way.
Crews stunned the fish with electricity, scooped them up in buckets, trucked them to a hatchery and ultimately moved them to Arroyo Hondo Creek in Santa Barbara County.
Within days, Topanga Creek was choked with mud. Some assumed the fish left behind were goners.
But in March, the conservation district’s team found four. The following month, when water conditions were clearer, they saw more.
“These fish continue to amaze me,” said Kyle Evans, environmental program manager for the state Department of Fish and Wildlife, who had seen the damage to the creek. “I had seen populations get wiped out in similar situations. So when I heard, I was thrilled.”
Evans surmises the fish that survived were in an area of the creek where less charred material and sediment were swept in.
“These fish likely hunkered down, were hiding under some rocks or places to try to get away from the main concentration of flow,” he said. “And luckily they weren’t buried.”
The ones that were spotted were fairly small, around 6 to 14 inches. Rainbow trout and steelhead trout are the same species, but with different lifestyles. If the fish remain in freshwater, they’ll be considered rainbows. However, they can migrate to the ocean and become steelhead, where they typically grow larger before returning to their natal waters to spawn.
Topanga Creek hasn’t fully recovered from the damage it sustained, but scientists say it’s looking better. Surveys last year were “so depressing,” Dagit said, with very few animals, and stretches that were essentially transformed into flat roads from all the sediment buildup. Some of the riparian canopy burned right down to the creek.
Then came 32 inches of rain over the last nine months, scouring out and moving sediment, creating deeper pools. Dagit said they recently found newt egg masses for the first time in years, as well as a few adult newts and many frogs. Plants that provide cover are starting to recover.
She provided photos comparing certain pools last year and this year, some dramatically transformed. In September 2025, the Shrine Pool could have been an overgrown hiking trail. This April, it was filled with shallow water.
The Shrine Pool in September 2025, left, and the same location in April 2026, right, with RCDSMM’s Isaac Yelchin donning a wetsuit.
(RCDSMM Stream Team)
Topanga Creek is home to another endangered fish, the small but hardy northern tidewater goby, often described as cute. Not long before the trout operation, Dagit led a rescue of hundreds of these fish too. Many were repatriated to the lagoon at the mouth of the creek in a moving ceremony last June.
There’s still the matter of what to do with the trout that were moved to Santa Barbara County last year. Evans would like to bring them home to the Santa Monicas at some point, but isn’t sure if it will happen. On one hand, they could bolster the small, genetically isolated surviving population. On the other, they might inadvertently bring in a disease or bacteria. There is some time to decide. Evans estimates the creek still needs to recover for two to three more years.
For now, the fish are functioning fine in their adopted creek. Experts worried the trauma wrought by the move would disrupt their spawning process, but they had babies that spring. This year, they spawned again.
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