FOOD MANUFACTURING ROOT CAUSE ANALYSIS Lockout/Tag Out TECHNICAL PAPER PAGE | 28
APPENDIX 4
THE SWISS CHEESE MODEL OF ACCIDENT CAUSATION
Adapted © 2013 Industrial Safety Integration
Simultaneous failure/absence of risk
controls could cause a "catastrophic
event"
Failure/absence of risk
controls
Examples that could lead to
increased risk
Training
material not
current
Shortage of
key skillset
Fatigue
Design
issues
LATENT FAILURE
LATENT FAILURE
LATENT FAILURE
Unsafe act
ACTIVE FAILURE
LATENT FAILURE
Risk Assessment: The Swiss Cheese Model of Accident Causation
9
Pictured above: The "Swiss Cheese" model of simultaneous failure or absence of risk controls that could
cause a "catastrophic event." In this model, when there are latent failures in design, gaps in regulation,
outdated training material, shortage of skillsets, and an unsafe act, all the "holes" in the system line-up to
potentially cause a critical injury or fatality.
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