A temporal perspective for incident analysis: Extending Reason's Swiss Cheese Model to the post-incident analysis of the Costa Concordia disaster

Abstract

According to error prevention literature, Reason's Swiss Cheese Model marked a paradigm shift by providing a psychosocial and systemic perspective on understanding workplace errors. Previous research has primarily adopted this model as a tool for analyzing errors and preventing incidents. The present paper aims to extend the application of the Swiss Cheese Model beyond the prevention phase to also include post-incident analysis by adopting a dual perspective that considers prevention and management as interconnected phases of a unitary flow. To illustrate this approach, the Costa Concordia incident is examined as an example case to apply the Swiss Cheese Model, examining psychosocial and technical factors across two temporal phases: before and after the incident. The analysis highlights the temporal interplay among factors and the significance of the intermediate phase –the period between the occurrence of the incident and its management– in determining the severity of the consequences of errors and the effectiveness of mitigation strategies. Overall, this research offers a more nuanced understanding of errors and incidents, advocating for a broader adoption of the Swiss Cheese Model, not only as a model for error prevention but also for incident management. The findings offer insights for both theory and practice.