Document

Author
Barry Kirwan, Ben Wood & Beatrice Bettignies-Thiebaux
Abstract
For two decades, Swiss Cheese theory has been an influential metaphor in safety science and accident prevention. It has made barrier theory and the impact of safety culture on operational safety more understandable to the upper echelons of high-risk organisations in many industrial sectors. Yet sometimes the Swiss Cheese model is used to focus on the operational ‘sharp end’ and unsafe acts, like a magnifying glass that acknowledges organizational influence, but still targets the human operator. It is time to ‘turn this lens around’, and allow organisations to focus on the upstream factors and decision-making that can engender these unsafe acts in the first place. This paper reports on an approach to do this, under development in the Maritime sector, called Reverse Swiss Cheese.