Exploring Why Accidents Happen: The Swiss Cheese Accident Causation Model

Very few accidents are caused by a single point of failure. Instead, most safety incidents stem from a chain of related errors that end up being catalyzed by a mistake, mishap or similar incident. With day-to-day operations becoming more complex and demand for efficiency skyrocketing, organizations are facing mounting pressure to align and coordinate processes across multiple departments. For example, strategies such as just-in-time inventory management depend on cohesion between warehouse workers and production teams to ensure the exact raw materials necessary for a specific order make it to the production line at the right time. This type of cross-departmental work highlights the safety challenges facing businesses. The complexity means that anything happening in one part of the business can impact safety in another, with small issues potentially aligning to create major accidents. This is the central theme of the Swiss Cheese Accident Causation Model. 


What is the Swiss Cheese Accident Causation Model?
Swiss cheese stands out because of its small holes. To start thinking about this accident causation model, imagine you have a bunch of pieces of cheese that are fully intact. Each slice represents a part of your business. One may be management, another operational support, another your safety program. In the Swiss Cheese Model, a flaw in any one of those areas of your business is a hole in the perfect piece of cheese. Over time, all it takes is to have a few of those holes intersect and a business is left with the kind of major safety emergency in the form a total recordable incident, days away restricted incident or similar event.

For example, consider front-line supervisors within your organization. These members of the management team are among the most influential workers in terms of safety. If a manager is consistent about wearing personal protective equipment and reminding employees to do so, then your front-line managers would be represented as a whole piece of cheese, at least for that area of safety operations. However, if your manager isn’t wearing PPE when necessary, lets workers get away with poor safety practices and pushes productivity over protection by skipping safety briefings to get people into the field faster, then that slice of cheese will have a big hole in it.

If a couple of holes from other parts of your business align – perhaps a supply chain gap leading to a contaminated raw material and a poor maintenance inspection of a production line, you could be left with safety gaps that align with one another and erupt in the form of a disaster event.

Avoiding cascading problems
At its core, the Swiss Cheese Accident Causation Model highlights the simple fact that every part of the business can end up influencing employee safety. Organizations that neglect to create a culture around protecting workers set themselves up to have more pieces of hole-filled Swiss Cheese. With a growing number of potential organizational gaps, the risk of a major safety emergency are higher. Excellence in protecting employees depends on a complete culture of safety, as any shortcuts or points of failure can be the catalyst that leads to an accident.

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