ABSTRACT
The book that really started the study of organizational accidents wasTurner (1978). The three models presented ten to fifteen years ago by Moray (1994), Rasmussen (1997) and Reason (1997) have shaped recent thinking (the existence of Reason (1990) is acknowledged, but Reason (1997) was the influential publication). The lack of attention given to Moray (1994) and Rasmussen (1997) represents a missed opportunity to take a systems approach, but that seems to be the situation. The dominant model has been the Reason (1997) Swiss Cheese Model, shown
in Figure 1 below (situated outside Gruyere). It has been very widely adopted and
Figure 1. Swiss Cheese Model.
