Reason's Swiss Cheese Model Dofonoee Accident UnsafeActs Window of Opportunity Preconditions Line Management Decision Makers Unsafe Acts and L建ent Unsafe Conditions Latent Unsafe Conditions Assumes accidents are random events coming together accidentally-"High- consequence,low probability events." Ignores common cause failures of defenses(systemic accident factors). Does not include migration to states of high risk. Assumes some(linear)causality or precedence in the cheese slices. CLGO System Engineering by J.J.Gao 15+ - System Engineering by J. J. Gao 15 Reason’s Swiss Cheese Model