Chapter 9 discusses how the Swiss cheese model became an important icon of the idea that problems experienced at the sharp end (or frontline) of an organization are not created there, but are inherited from imperfect upstream processes and parts.By this time, a strong consensus had already formed: human performance at the sharp end is shaped by local workplace conditions and distal organizational factors.The Swiss cheese model is a defenses-in-depth or barrier model of risk, which suggests (as did Heinrich) that risk should be seen as energy that needs to be contained or channeled or stopped. The chapter explains why this makes it difficult for Swiss cheese to be a true ‘systemic’ model, since it is not capable of explaining or portraying the complex emergence of organizational decisions, the erosion of defenses, drift, and a normalization of deviance.Swiss cheese conceptually aligns with safety management systems. These direct safety efforts and regulation at the administrative end of an organization, where assurance that safety is under control is sought in management systems, accountabilities, processes, and data.The gradual shift to ‘back-of-house,’ to organizational and administrative assurance of safety, had been long in the making. It is now intuitive that all work is shaped by the engineered context and workplace conditions and upstream organizational factors. If we want to understand or change anything, then that is where we need to look. This trend has also given rise to large safety bureaucracies and cultures of compliance. It has left us with a safety profession that broadly lacks purpose and vision in many industries, and with regulators whose roles have in certain cases been hollowed out and minimized.