The Swiss Cheese Model of Health and Safety

and how to use it to plug the holes in your safety program

Hello and welcome to this week’s edition of the Safety First Journal.

Hope you had a great long weekend with a chance to get away and recharge.

Let’s dive in.

Established companies generally have some form of safety program in place. This may be a few basic policies and checklists or maybe you’ve got a fully established ISO 45001 compliant system in place. And yet, you still have accidents and incidents. What has gone wrong?

Let’s look at a simple example. Say you have a forklift daily inspection checklist that employees complete daily to protect against mechanical problems. Yet despite this an employee reports a back injury due to excessive vibration on the machine because one of the wheels is badly worn and damaged. You’ve put a plan in place (the inspection checklist) to guard against that very problem yet somehow it fell through the cracks. The first thing to do is thoroughly review the incident to find the root cause.

In this case, the root cause could be any number of things:

· The employee was just checking the boxes without doing a thorough inspection.

· The employee wasn’t trained properly on the inspection, saw the damage but thought it was minor.

· The damaged tire was identified but not communicated to the supervisor.

· The supervisor knew about the damage, but hadn’t called for service and repairs.

· The replacement tire was deemed too expensive so there was a delay in getting it fixed.

And so on …

While you might think that the daily inspection is enough to prevent injuries like this, even the best policies and procedures have holes, which brings us to the Swiss Cheese Model of health and safety.

What Is the Swiss Cheese Model?

The Swiss Cheese Model was originally proposed by British psychologist James Reason in his book, Human Error, published in 1990. The model’s core thesis is that accidents happen not as a result of a single failure, but of multiple failures combining to create a catastrophic error.

The sinking of the Titanic is a tragic example of multiple failures aligning and illustrates the Swiss Cheese Model well.

The sinking and loss of life that ensued wasn’t the result of a single failure, it was a combination of many unfortunate circumstances, such as:

· Design and construction weaknesses. Insufficient water-tight bulkheads, some weak rivets in the bow section which may have popped under pressure, and lack of lifeboat capacity.

· Human and organizational errors. Iceberg warnings from other ships were downplayed or ignored, the captain’s decision to maintain speed through an iceberg zone.

· Operational and communications failures. The lookouts didn’t have binoculars, evasive action was delayed and many of the lifeboats that were available were launched half full because the crew was concerned about overloading them.

· Rescue system gaps. The nearby ship, the Californian, didn’t respond due to miscommunication, the Titanic’s communication crew didn’t properly escalate incoming warnings.

Each of these failures was like a hole in a slice of Swiss cheese. Each one was not fatal on its own, but when the holes lined up, they allowed disaster to strike.

What are the Common “Holes” in Workplace Safety Programs?

Reason’s theory (and common sense) would tell us that every workplace safety system has holes somewhere along the line. For example, does your business struggle with one of these common errors?

· Training that isn’t retained or reinforced.

· Procedures that exist on paper but aren’t communicated or followed.

· Workers who “improvise” when under time pressure.

· Supervisors who don’t model good safety behaviour.

· Important things get missed when someone goes on vacation or isn’t available.

· Workload is such that safety gets left behind or ignored.

How to make the Swiss Cheese Model work for you.

So, having established that even the best safety plans have vulnerabilities, how do you flip the script and make the Swiss Cheese Model work for you?

· Map the layers in your safety program. First, you have to understand your current state. Take a hard look at your safety programs, policies and procedures and look for vulnerabilities in each. Ask yourself how each could possibly fail and, to continue the metaphor, poke holes in your plan to see where the problems exist.

· Look for patterns of weakness. Do most of your incidents involve new or young workers? Is there something in your program that is consistently not getting done? For example safety meetings, inspections, overdue training. It’s rarely a single event that leads to an accident, but a series of gaps over time.

· Strengthen or add layers. Look for ways to improve your process and add backups and redundancies where it makes sense. If one aspect fails, how can you ensure other systems act as a backup.

· Involve your team. Your workers know if shortcuts are being taken and how they can get around the systems you have in place. Establish honest and repercussion free dialogue. Front line workers know their job better than anyone else in the organization and can be an excellent resource if you’re able to establish a sense of trust and shared goals.

· Learn from incidents and near misses. Thorough incident investigations are critical to searching out potential weaknesses in your approach. The deeper and more extensive you go in your investigations, the greater the chance that you find information that will be truly useful in preventing similar incidents in the future.

You can’t make every layer of your safety program perfect, but by doing your best to understand the potential weaknesses and creating back up plans and support systems to limit those weaknesses, you reduce the chance of all the “holes” lining up to lead to an accident. Even small improvements across multiple layers have a substantial impact on reducing the chance of an accident occurring.

Well, that’s it for this week, I hope you found this concept helpful. Let me know one thing you can do this week to use the Swiss Cheese Model to improve your safety program.

If you enjoyed this article, I also ghostwrite thought leadership articles for health and safety professionals to help them build their personal brand and attract more opportunity in their careers. Feel free to reach out to see how I can help or just to say hi and discuss a problem you might be having with workplace safety. I’m always happy to help.

The Safety First Journal is published every Tuesday on LinkedIn and Substack.

Cheers,

Dan

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