#coachlearninginsport: critical incidents and Swiss cheese



The first four lines Rudyard Kipling’s poem ‘If‘ have been a recurring background to my thinking about coach learning.

If you can keep your head when all about you
Are losing theirs and blaming it on you,
If you can trust yourself when all men doubt you,
But make allowance for their doubting too …

I like, in particular, the “make allowance” part. It encapsulates a maturity of a world view that tends come to late in our careers rather than early.
I have been wondering about how discussing critical incidents and Swiss cheese might support early career coaches to develop this allowance.

Critical Incidents

John Flanagan developed his thoughts on critical incidents in the 1940s. One of his first investigations analysed the reasons for failure to learn to fly in the United States Army Air Forces in 1941. In that year, 1.000 pilot candidates left flight training schools without qualifying. Three years later he looked at combat leadership “to gather specific incidents of effective or ineffective behaviour with respect to a designated activity” (1954:328). His investigations led him to identify “critical requirements” of combat leadership.
As he developed his interest in these critical requirements, he noted:

The principal objective of job analysis procedures should be the determination of critical requirements. These requirements include those which have been demonstrated to have made the difference between success and failure in carrying out an important part of the job assigned in a significant number of instances. (1954:329)

What has attracted me to John’s work is his focus on critical incidents as “extreme behavior, either outstandingly effective or ineffective with respect to attaining the general aims of the activity”.(1954:338)
He developed his critical incident technique as “a set of procedures for collecting direct observations of human behaviour in such a way as to facilitate their potential usefulness in solving practical problems and developing broad psychological principles” (1954:327).
There are some interesting accounts of John’s work and the critical incident technique (see, for example, Hilary Hughes (2007), Helen Spencer-Oatley (2013)).
I have enjoyed David Tripp’s application of critical incident methods in education (1994):

The primary benefit of this type of research needs to be improvements to teachers’ professional lives, an outcome that is best achieved, not by producing holistic biographies, but through a piecemeal examination of teachers’ current practice to uncover professionally formative experiences. This means one cannot employ traditional biographical methods to produce continuous chronological accounts of whole lives, but should utilize a critical incident method that produces an ongoing and discontinuous account of fragments of the past. This approach is illustrated using an incident in the author’s own biography.

I see enormous benefit in reflecting on and sharing our own and others’ experiences in becoming a coach. We have a great deal to learn from each others’ performances of understanding of critical requirements.I am hopeful that this sharing enables us to contemplate the blame and doubt explicit in ‘If’.
I think we need to discuss failure and ways to deal with it if we are “to make allowance for doubting” too.

Swiss Cheese?

I have not looked at Swiss cheese of late without thinking about my Advanced Firefighter training that uses James Reason’s work on risk analysis.
In a paper written in 2000, James observes of his Swiss cheese model of system accidents:

In an ideal world, each defensive layer would be intact. In reality, they are more like slices of Swiss cheese, having many holes—although, unlike in the cheese, these holes are continually opening, shutting, and shifting their location. The presence of holes in any one “slice” does not normally cause a bad outcome. Usually this can happen only when the holes in many layers momentarily line up to permit a trajectory of accident opportunity—bringing hazards into damaging contact with victims. The holes in the defenses arise for 2 reasons: active failures and latent conditions.

James defines active failures as “the unsafe acts committed by people who are in direct contact with the patient or system”. Latent conditions are “the inevitable “resident pathogens” within a system. They arise from decisions made by designers, builders, procedure writers, and top-level management”. (2000:np)
The New South Wales Rural Fire Service uses the Swiss cheese model to discuss better practice in crew resource management. The aim is to bring a systems approach to the management of risk whilst recognising that individuals need support and training too.
Catastrophic failure in this approach looks like this:

Source: http://ed-informatics.org/2011/07/06/color/
Source: http://ed-informatics.org/2011/07/06/color/

Stopping it requires early action to misalign the holes:
Source: http://blogs.esa.int/astronauts/2013/01/10/capsule-ressource-management/

This is where I see enormous opportunities in coach education contexts to explore critical requirements and to develop our use of scenarios to prepare coaches for those moments when “you can keep your head when all about you, Are losing theirs and blaming it on you”.


Whilst I was researching this post, I became interested in David Tripp’s approach to critical incidents. I enjoyed David’s observation that:

radical and lasting change in practice is always the result of personal change, whereas institutional change is generally the result of personnel change in the leadership. (2012:xi)

I found Chantal Amade-Escot’s (2005) discussion of critical didactics of interest too. Her work has encouraged me to think about the theory and practice of a didactic contract:

The key element to understanding the concept of the didactic contract is to consider that it is not a formal contract but an implicit attempt to find a common meaning about what is at stake in the teaching–learning process. Consequently, when there is a mismatch between teacher and students regarding the nature and purpose of the instructional task, the didactic contract is breached and observable. (2005:134)

I have been thinking about performance reviews for some time now. I am profoundly interested in how we might use incidents and contracts as triggers for conversations about performance. John and James have moved me closer to thinking about how I might use a critical requirement of a coach’s performance to transform conversations about key performance indicators and key performance areas. Chantal has helped me focus on the didactic part of the relationship.
Imagine starting your review with the line … “At last year’s World Championships I was saved by thoughts of Emmental …” and then drawing upon a critical incident methodology to share your story.

Photo Credits

Gare Montparnasse (RV1864, CC BY-ND 2.0)
Cheese making (Switzerland Tourism, CC BY-NC 2.0)
Piano’s Wake (Daniel Hoherd, CC BY-NC 2.0)


  1. I like the notion of critical incidents and the relationship of the Swiss Cheese model. To some degree this is a variation of ‘Murphy’s Law’; in that if there are two or more ways to do something, someone will always attempt a task ‘the wrong way’.
    I was able to be part of a presentation earlier this year by Jas Hawker a former Red Arrows pilot who along with Justin Hughes runs ‘Mission Excellence’ (http://www.missionexcellence.com/). Jas makes the point about feedback. This from Ian Pettigrew (http://www.kingfishercoaching.com/hrevent15-how-the-red-arrows-develop-a-high-performing-team/) gives a very concise overview of Jas’s message.
    In the context of sport, I’m trying to increase the sense of ownership within the team. Preparing for the new season I came across this from The Harvard Business Review:

    • Hello, Gordon. Thank you for finding the post and sharing such excellent resources. I hope the new season goes well. My fire training has encouraged me to think a great deal about ownership, responsibility and accountability. Your reply has prompted me to think about consequences in training … something that the Red Arrows can help us with.
      I hope you are well and as busy as ever.
      Best wishes


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