This document discusses the Swiss Cheese Model, which views accidents as the result of multiple factors aligning in unfortunate ways, similar to how holes in slices of Swiss cheese might occasionally line up to create a pathway. The model is used to understand how isolated components within complex systems can sometimes interact to potentially create accidents or failures.

19. Isolated Components

21. The Swiss Cheese Model

22. The Swiss Cheese Model

23. The Swiss Cheese Model

24. The Swiss Cheese Model

25. The Swiss Cheese Model

26. The Swiss Cheese Model

27. The Swiss Cheese Model