James Reason’s Swiss Cheese Model of safety is a remarkably simple way to think about how organizational culture and climate turn into injuries and incidents. Imagine four parallel slices of Swiss cheese, each one with holes randomly located around the slice. Each slice represents a layer of protection intended to prevent injuries and incidents. Each layer is also embedded in the organization’s safety culture.
This is the proximate cause of the incident. Which employee engaged in what behavior that led to what injury? Or what machine malfunctioned? Often, we can identify contributions to this behavior from the safety culture on the shop floor. Peer pressure can promote or prevent safe behavior.