Systems thinking, the Swiss Cheese Model and accident analysis: A comparative systemic analysis of the Grayrigg train derailment using the ATSB, AcciMap and STAMP models

• Published in: Accident analysis and prevention Vol. 68; pp. 75 - 94
• Main Authors: Underwood, Peter, Waterson, Patrick
• Format: Journal Article
• Language: English
• Published: England Elsevier Ltd 01.07.2014
• Subjects: Accident analysis; Accident Prevention; Accidents; Accidents, Traffic - statistics & numerical data; AcciMap; ATSB; Causality; Causation; Cheese; Derailments; Forensic engineering; Humans; Railroads - statistics & numerical data; Safety Management; STAMP; Swiss Cheese Model; Systems Analysis; Systems Theory; Systems thinking; Trains; United Kingdom; Swiss Cheese Model; STAMP; Systems thinking; ATSB; AcciMap; Accident analysis
• ISSN: 0001-4575; 1879-2057; 1879-2057
• DOI: 10.1016/j.aap.2013.07.027

•A debate exists over the validity of the Swiss Cheese Model (SCM).•The efficiency-thoroughness trade-off may make STAMP more suitable for use in research.•This study suggests that the SCM still offers a systems thinking approach. The Swiss Cheese Model (SCM) is the most popular accident causation model and is widely used throughout various industries. A debate exists in the research literature over whether the SCM remains a viable tool for accident analysis. Critics of the model suggest that it provides a sequential, oversimplified view of accidents. Conversely, proponents suggest that it embodies the concepts of systems theory, as per the contemporary systemic analysis techniques. The aim of this paper was to consider whether the SCM can provide a systems thinking approach and remain a viable option for accident analysis. To achieve this, the train derailment at Grayrigg was analysed with an SCM-based model (the ATSB accident investigation model) and two systemic accident analysis methods (AcciMap and STAMP). The analysis outputs and usage of the techniques were compared. The findings of the study showed that each model applied the systems thinking approach. However, the ATSB model and AcciMap graphically presented their findings in a more succinct manner, whereas STAMP more clearly embodied the concepts of systems theory. The study suggests that, whilst the selection of an analysis method is subject to trade-offs that practitioners and researchers must make, the SCM remains a viable model for accident analysis.