No this is not some cheesy comment but a serious look at the Swiss Cheese Accident Causation Model. This seems to have come up in my reading in multiple different areas recently.
Whilst these models I have seen recently have primarily been non-automotive in areas such as industrial accidents, scuba diving accidents, aircraft accidents and military, they apply equally to accidents in almost every sphere.
These could be accidents to staff in your business, failures after repairs of vehicle accidents.
The basic premise is that usually there is no single cause for an accident rather that multiple failures added together are the cause. In pretty much any sphere of activity we look for a layered defence against accidents (in military terms, defence in depth) to avoid single cause accidents. In the Swiss cheese model, this is modelled by having multiple layers of cheese, each layer of cheese (defence) will have some flaws (holes) because people and systems are imperfect. If these flaws line up (yhe holes in the Swiss cheese layers), then the accident will happen. If the holes don’t line up it will be prevented.
These holes tend to be dynamic so may not line up today but may line up tomorrow. Failure to maintain systems, tiredness and many other factors can affect the number and size of hole at any given times.
For instance, worn tyres on a car might be fine for 99 percent of driving conditions, but in combination with sudden rain, a tired or inattentive driver and a child running into the road, then the combination of the four holes (tyres, rain, inattention, child) resulting in: an accident – remove any one of the holes and the accident won’t happen. If our systems work, then we should remove all four of the hazards and even if one or two still slip through, we can be safe as we have defence in depth.
A big factor in these flaws appearing, even in well managed systems, is human nature. People will look to cut corners to make the job easier, but this will compromise safety. Management needs to constantly keep an eye out for this and enforce the systems.
