Applying the Swiss Cheese Model of Accident Causation


This paper shows how utilizing the Swiss Cheese Model of accident causation can aid engineering managers in understanding how errors might occur and how they can be prevented. Human error is an issue of concern for every system. Engineering managers need a structured approach to identify system gaps that fail to address potential human errors. The model considers different levels of human error including unsafe acts, preconditions for unsafe acts, unsafe supervision, and organizational influences. Examples of past incidents including the Space Shuttle Challenger and the Exxon Valdez oil spill that resulted in catastrophic outcomes will be analyzed using the Swiss Cheese Model to identify potential hazards, safeguards, and shortcomings that resulted in loss of human lives, financial ruin, environmental damages and other impacts.

Meeting Name

Annual International Conference of the American Society for Engineering Management (2011: Oct. 19-22; Lubbock, TX)


Engineering Management and Systems Engineering

Second Department

Psychological Science

Keywords and Phrases

Accident causation; Engineering managers; Environmental damage; Exxon Valdez oil spill; Human errors; Human lives; Potential hazards; Structured approach; Accidents; Management; Managers; Oil spills; Space shuttles; Errors

International Standard Book Number (ISBN)


Document Type

Article - Conference proceedings

Document Version


File Type





© 2011 American Society for Engineering Management, All rights reserved.

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