Use Swiss Cheese Thinking Before A Barrier Fails
Use the Swiss Cheese Model to identify when multiple weak controls are aligning into an operational hazard.
Barrier thinking asks what else is supposed to catch this if one control fails. Layers, Not Heroes Railways are designed so safety does not rely on one perfect human. Signals, rules, procedures, supervision, read-back discipline, track protection, and local knowledge all share the load. Holes Are Normal A tired signaller, noisy radio, unclear notice, or moved worksite marker does not mean failure is inevitable. It means one layer has a hole today. The danger rises when other layers around the same task are also weak. Intervene On Alignment When holes align, add a control before the move continues: slow the…
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