The Swiss Cheese Model

On Friday, I was at the airport and had a chat with a colleague of mine while waiting for a delayed flight. We started talking about safety and industrial accidents, and I promised him I would write a post and share with my network about the Swiss Cheese Model and how it relates to accident prevention in industries.

So here we are.

Imagine an industrial plant as a fortress designed to prevent accidents. Each layer of this fortress is a defense: safety training, equipment maintenance, risk assessments, and protocols. But the truth is, real safety doesn’t rely on piles of paperwork or strict procedures—it’s about leaders setting an example and creating a culture where safety is a natural part of daily operations.

The Swiss Cheese Model shows how these layers of defense aren’t perfect. Think of each layer as a slice of Swiss cheese—there are always gaps, or holes, in every safety measure. These holes could be anything: a tired worker overlooking a safety step, machinery not maintained properly, or a miscommunication between teams. Usually, these holes don’t align, because another layer of defense catches the mistake. For example, if a worker misses a step during machine operation, another worker might notice and prevent an incident.

But sometimes, when the holes in several layers line up, they create a path for an accident to slip through. Imagine a situation where a piece of equipment hasn’t been properly maintained, a manager hasn’t prioritized safety checks, and an operator is too focused on meeting a deadline to notice something's off. If no one stops the work, an accident—like a machinery breakdown or hazardous spill—becomes inevitable.

This is where Stop Work Authority (SWA) becomes crucial. SWA empowers every worker, regardless of rank, to immediately halt operations if they perceive a safety risk. It’s a powerful tool that gives workers the confidence to stop work without fear of consequences if something feels unsafe. But this tool is only effective if leadership leads by example and encourages its use.

Take machinery inspections, for example. In a culture where safety is driven by bureaucracy and the need to avoid downtime, workers may hesitate to stop work, even if they spot something concerning. But in a workplace where leadership shows that safety always comes first, the story changes. If a supervisor actively stops work themselves when they see a potential risk, it sends a message that safety isn’t just about following rules—it’s about doing the right thing to protect people.

This is where the concept of distributed leadership comes into play. Safety cannot rely on a single person or department; it must be embedded at every level of the organization. Every team member, from operators to middle management, must take ownership of safety. In a truly effective organization, distributed leadership empowers everyone to be a leader in their area of responsibility, whether it's ensuring proper maintenance of equipment or pausing operations when something seems off. This approach ensures that safety is woven into the fabric of everyday operations, making the organization more resilient and adaptable.

In such an environment, workers feel empowered to use Stop Work Authority. Imagine a worker hearing a strange noise from a conveyor belt and deciding to stop the machine, knowing they won’t be reprimanded for halting production. This proactive attitude catches small issues before they become big accidents, keeping the holes in the Swiss cheese from lining up.

For instance, punitive legal frameworks can create unintended consequences. When companies face legal pressures and the fear of heavy penalties for accidents, obviously, they focus more on protecting themselves from liability than on genuinely learning from errors. This can lead to an organizational culture where mistakes are hidden instead of addressed, and safety investigations become shallow or rushed, leaving deeper problems unsolved. The external legal environment, in this case, becomes a hole in the system, making it harder for the organization to improve safety effectively.

Additionally, stakeholders like environmental groups, local communities, and regulators often pressure companies to address concerns that, while important, can sometimes distract from the plant’s primary safety objectives. If the organization prioritizes managing these external pressures over maintaining robust internal safety practices, the holes in its defenses might start to align. This misalignment between internal focus and external expectations can lead to preventable accidents, as the organization becomes more reactive than proactive.

Achieving true organizational effectiveness in safety means finding the balance between external pressures and internal safety protocols. It also involves building a culture of distributed leadership, where safety ownership is shared across the organization, rather than centralized in one department or leader. This way, safety issues are identified and addressed early, making the organization more agile and less vulnerable to accidents.

To navigate this complex ecosystem successfully, companies need to balance stakeholder concerns without losing focus on their core safety responsibilities. This means leaders must communicate openly with stakeholders, educating them on the critical role of safety measures like flaring or controlled emissions in preventing larger disasters. By bringing stakeholders into the conversation and setting realistic expectations, organizations can create a more supportive environment that helps prevent accidents rather than distracts from them.

A successful safety culture isn’t just about what happens within the company’s walls—it’s about how well the company integrates with its external ecosystem. Whether it’s legal pressures, environmental expectations, or community concerns, every external factor influences how safety is managed. But leadership’s role is to ensure that these external influences don’t overshadow the primary goal of keeping people and the environment safe.

Ultimately, true safety comes from leadership that practices what they preach, but it also depends on how the organization embraces distributed leadership and interacts with its entire ecosystem. It’s about more than ticking boxes or filling out forms. When leaders show that safety matters by using SWA, reinforcing a safety-first mentality, and navigating external pressures responsibly, they create an environment where both internal practices and external expectations align toward the same goal. A successful safety culture requires not just internal commitment, but a balance with the external ecosystem—engaging with stakeholders, regulators, and communities in a way that strengthens safety rather than distracts from it.

So, to everyone reading this: safety isn’t just about internal procedures—it’s about leadership, responsibility, and understanding the role of the broader ecosystem in empowering everyone to act when something seems wrong.

Distributed leadership and organizational effectiveness are key to preventing those Swiss cheese holes from aligning and ensuring that accidents stay rare, rather than inevitable.