Categories: a-port-information, Business, Port ServicesPublished On: 18.01.2023309 words1.6 min read


Ref No:     SB/2022/13 

Date:         02 December 2022 


How many things need to go wrong for an accident to happen?

The well-known “Swiss Cheese” model of accident causation (set out by James T. Reason) likens systematic barriers to multiple slices of Swiss Cheese stacked side by side. The theory is simple, the more ‘slices’ the less likely there will be ‘holes’ in the barriers aligned through the stack and the more likely the threat will be blocked/prevented.

Signal Cheese Image 14 Nov 2022

This video follows a day in the life of a worker at a fictional port terminal:

When We Look Away (MT) (

The port has procedures in place to prevent accidents, but tiredness, heat, the need to get the job done and several lapses in safe systems of work can lead to the worst of outcomes.

The video considers actions and decisions by others and how multiple factors in combination, not just those of the individual can contribute to increased risk. It shows that by committing to protection at all levels, people get to go home safe.

The video can be freely used as part of training, induction, toolbox talks and team briefings and is available within the Vimeo platform for free download.

With thanks to ICHCA for communicating this bulletin and to Signal Mutual for allowing the sharing of the learning material.

PSS Safety Bulletins 

The PSS Safety Bulletin process intends to share information with our members relating to new developments or changes in the industry which may be of interest. These Safety Bulletins are in addition to PSS Safety Alerts which relate to a specific accident or incident and the related learning outcomes which may help members prevent a repeat event.


Safety Bulletin SB-2022-13_0 PDF (200.39 KB) Download (200.39 KB)

Port Skills and Safety website: