SWISS CHEESE MODEL
Figure 1 (below) is a Swiss Cheese model showing the main causes of the accident.
(22)
Label the different parts of the diagram, giving an
explanation of the label, including an example from
the scenario where required.
Note: You must use Table 1 in the answer template to structure your answers. The number of examples
required are indicated by the instructions included in the table column ‘Relevant example(s) from
scenario’.
ANSWER SHEET
Box
number
1
2
3
4
Label
Hazard
Layers of protectionDefences
Leadership &
Commitment
Active Failure
Explanation of label
“The potential to cause harm.
Harm including ill health and
injury, damage to property, plant,
products or the environment,
production losses or increased
liabilities.”
(Source; hse.gov.uk.)
Layers of Protection Analysis
(LOPA) is a method used to
evaluate high-consequence
scenarios determining if the
combination of probability of
occurrence and severity of
consequences meets a company’s
risk tolerance.
Relevant example(s) from
scenario
reversing of the lorry which was
driven by the truck driver was
done without competent
banksman
Hit by causation.
Instruction: provide 1 example
1. Pathways beside the bay area
was provided separate but it
was not restricted with a hard
barricading
Instruction: provide 1 example
Leadership is called effective when
a leader or the Top Management
thinks Morally, Socially and
Financially for its organisation &
Instruction: no example required
workers managements.
Leadership barrier was effective as
the M.D wanted to “do the right
thing” LINK WITH SC LITTLE
1. The Apprentice:
The human errors that includes
skill based error, mistakes and
violations are considered as active
failures
The apprentice took the decision
with over confidence that the job can
situation with the truck driver bay
lead to the accident such behaviour
will be considered as Rule based
mistake.
SWISS CHEESE MODEL
Box
number
Label
Explanation of label
Relevant example(s) from
scenario
2. The Lorries were reversing with
a blind spot area, but such
information from the truck driver
was not identified or
communicated to put a control
measure of such hazard while
driving.
3. reverse alarm of the lorry failed
& got hit and having injuries.
Instruction: provide 4 examples
1. the process of safe working it is
also a latent failure factor that
contributed the accident due to
self-way to perform the task.
2. Closing eyes during walking on
a vehicle movement zone is also
an exceptional violation.
Latent failures
5
Latent failures are a cause of a
multiple connected conditional
failures and human failures. There
are multiples latent failures that
are aligned together and a
personal injury, property damage,
environmental effects happen.
3. Lack of supervision &
monitoring: The reversing was
performed by the new apprentice
as there were no supervisor of
work for the guidance and
monitoring
4. Lack of training and
awareness; The new apprentice
itself can be considered as a
latent failure as the presence of
any new untrained person at
work is mobilized
SWISS CHEESE MODEL
Box
number
Label
Explanation of label
Relevant example(s) from
scenario
5. Poor planning- competency to
carry out such critical job , as
there was no system of permit to
work when carrying out reversing
activity, it is a site management
failure
Instruction: provide 5 examples
6
7
8
Inadequate Site
management
There was no empowerment to
stop policy as no intervention was
done when the warehouse worker
was wearing headphone for
listening song, as it was
prohibited to do such act.
Hazard Progression
Residual Risk
After arranging controls measures
as barriers there are still holes not
mitigated or completely controls,
such residual gaps are considered
as residuals risks.
Incident
A hazard which has surpassed all
the barriers with active failures
and latent conditions and has
caused damage to person, object
or environment can be considered
as incidents.
Instruction: no example required
Active failure -
Instruction: no example required
Instruction: no example required
SWISS CHEESE MODEL