SWISS CHEESE MODLE

Swiss cheese model is the risk causation model. The model was developed by James Reason,
a British psychologist and expert in human error. It provides a visual representation of
multiple layers of defences and their potential for failure, leading to an incident.

Each slice of Swiss cheese has its own unique set of holes. These holes represent
shortcomings, or areas where there is potential for failure. Some slices may have more holes
than others. When all of a given organization’s slices are stacked together, they represent the
organization’s defence against risk as a whole. If the holes overlap then there is a high chance
of accident i.e. a weak point in the defence system. And the holes don’t overlap and the hole
gets covered by the slice(the defence barrier) represents the successful implementation of the
swiss cheese model.

Example:

A refinery process plant experiences a fire incident in one of its processing units.

1. Latent Conditions (System Vulnerabilities):

 Inadequate fire detection system maintenance.
 Lack of proper training for operators on fire safety protocols.
 Inadequate communication channels for reporting and responding to fire emergencies.
 Aging equipment with potential ignition sources.

2. Active Failures:
 An operator accidentally leaves a valve open, causing a flammable substance to leak.
 The fire detection system fails to detect the leak due to maintenance issues.
 Operators nearby fail to notice the leak due to insufficient training and awareness.
 Communication breakdown between the operator who notices the leak and the central
control room.

3. Defenses and Mitigation:

 Fire suppression systems are installed throughout the plant.
 Fire extinguishers are available at strategic locations.
 Emergency response team is trained to handle fire incidents.
 Standard operating procedures (SOPs) exist for fire safety.
 4. Alignment of Failures:
 The open valve and leak go unnoticed due to lack of proper training and awareness.
 The fire detection system, which should have detected the leak, is not functioning
correctly due to maintenance issues.
 Communication breakdown hinders the timely reporting and response to the leak.

5. Incident Occurrence:
 The flammable substance ignites, and the fire spreads rapidly, causing significant
damage and potential harm to personnel.

In this example, the Swiss Cheese Model helps us understand how multiple failures and
vulnerabilities in the system align, allowing the incident to occur. The holes in the cheese
slices represent the weaknesses or failures at various levels, including maintenance, training,
communication, and equipment. When these failures align, they create a pathway for the
incident to unfold, leading to the fire.

PHYSICAL, SYSTEM AND HUMAN:

Physical, system, and human errors can contribute to accidents in various industries. Here are
examples of each type of error and potential controls to help prevent them:

1. Physical Errors:

 Equipment malfunction or failure: Regular maintenance, inspection, and testing of

equipment can help identify and address potential issues before they lead to accidents.
Implementing redundancy and backup systems can also minimize the impact of
equipment failures.
 Hazards in the physical environment: Conducting thorough risk assessments and
implementing appropriate safety measures, such as proper signage, barriers,
ventilation systems, and personal protective equipment (PPE), can mitigate physical
hazards.
 Fire and explosions: Installing fire detection and suppression systems, ensuring proper
storage and handling of flammable materials, and providing training on fire safety
protocols can help prevent and manage fire and explosion incidents.

2. System Errors:

 Design flaws or inadequate safety systems: Employing thorough engineering design

processes that consider safety and reliability principles, conducting hazard
assessments, and adhering to relevant standards can help identify and address design
flaws and ensure the implementation of robust safety systems.
  Inadequate maintenance and inspection programs: Implementing comprehensive
maintenance and inspection programs that include regular inspections, testing, and
preventive maintenance can help identify and rectify potential system failures before
they lead to accidents. Using computerized maintenance management systems
(CMMS) can assist in managing maintenance activities effectively.
 Communication breakdowns: Establishing clear communication channels, utilizing
standardized procedures, conducting effective training on communication protocols,
and fostering a culture of open and effective communication can reduce the likelihood
of misunderstandings and errors.

3. Human Errors:

 Lack of training and competence: Providing comprehensive training programs that

cover both technical skills and safety awareness can help employees understand their
roles, responsibilities, and potential risks. Regular refresher training and ongoing
competency assessments are essential to ensure employees maintain their knowledge
and skills.
 Fatigue and stress: Implementing fatigue management programs, scheduling adequate
rest periods, and encouraging a supportive work environment that promotes work-life
balance can help mitigate the effects of fatigue and stress on human performance.
 Complacency and shortcuts: Establishing a strong safety culture that emphasizes the
importance of following procedures, providing incentives for safe behavior, and
conducting regular safety meetings and audits can help address complacency and
discourage shortcuts.

It's important to note that controls should be tailored to the specific industry, work
environment, and associated risks. A comprehensive approach to accident prevention
includes a combination of physical safeguards, system enhancements, and human factors
considerations to minimize the likelihood and impact of errors leading to accidents.