In August 2022, tragedy struck a Sydney warehouse when a 56-year-old worker was crushed to death beneath two massive stone slabs, each weighing over 300 kilograms. He had been left alone to maneuver the slabs without a spotter and without proper safety protocols in place.
This wasn’t just human error. It was a textbook example of a Swiss Cheese model of error—a concept in safety science where multiple weaknesses in a system align, allowing a hazard to slip through every layer of defense. One weak policy, one missing spotter, one moment of risk—and the result was fatal.
Image 1: The same A-frame storage system involved in the incident.
What is the Swiss Cheese Model in Safety Science?
The Swiss Cheese Model, developed by psychologist James Reason in the 1990s, illustrates how accidents in complex systems are rarely caused by a single failure. Instead, they occur when multiple minor lapses (symbolized by holes in slices of Swiss cheese) line up across different layers of defense. The model is used for accident causation analysis, risk analysis, and risk management in several industries, including aviation, healthcare, manufacturing, and material handling.
Each slice of cheese represents a safety measure, such as equipment, procedures, training, or supervision. While each one helps reduce risk, no single layer is perfect. Over time, holes form due to wear, complacency, poor communication, or outdated systems. When these gaps align, hazards can pass through, leading to serious injury, property damage, or worse.
Why Warehouses Are Especially Vulnerable
Warehouses combine heavy equipment, moving personnel, inventory, and infrastructure in fast-paced environments. With these variables, systemic weaknesses can develop unnoticed.
⚠️ One critical but often overlooked layer? Pallet racking systems. Misaligned uprights, overloaded beams, or undetected damage can silently introduce massive risks.
Real Incidents Where the Swiss Cheese Holes Aligned
1. Topline Steel Fabrications NT, Darwin (2023)
The Incident
A contractor suffered severe injuries when a 1.2-ton steel bundle fell from a forklift operated by the company’s operations manager (who was unlicensed to operate it).
System Failures
- The operator lacked proper forklift certification.
- No formal forklift operating procedures were in place.
- The company had weak safety oversight and management systems.
Swiss Cheese Takeaway
This incident mirrors the Swiss Cheese Model exactly: each failure (unqualified operator, missing procedures, poor oversight) was a “hole.” When those holes aligned, they created a direct path to serious injury and legal consequences.
2. Avant Stone, Sydney (2022)
The Incident
A seasoned employee was fatally crushed by two large stone slabs while preparing for a client inspection. He was working alone at the time of the accident.
System Failures
- No documented procedure for safe slab handling.
- Inadequate supervision; he was left to operate solo.
- Lack of lifting equipment or protective infrastructure.
Swiss Cheese Takeaway
This was not a single-point failure; it was a cascade of vulnerabilities. These “holes” aligned to create a fatal outcome. The company was later fined $450,000 and made safety upgrades—but the loss of life was a sobering consequence of systemic breakdown.
3. Edwards Transport, England (2016)
The Incident
A forklift driver collided with a racking system while navigating a warehouse aisle. The impact caused an entire row of shelves to collapse, burying him under thousands of tons of cheese. Emergency crews spent nearly nine hours rescuing him.
System Failures
- Inadequate collision prevention strategies.
- Possible lack of supervision or enforcement of forklift operation protocols.
- No physical barriers or reinforced racking to contain the collapse.
Swiss Cheese Takeaway
In a somewhat ironic twist, this “Swiss Cheese” failure literally involved cheese. Yet the metaphor holds: multiple system weaknesses, from oversight to infrastructure, aligned to create a near-fatal scenario. This case starkly illustrates the need for reinforced racking systems and impact-resistant barriers, solutions that Damotech routinely implements to prevent such catastrophic collapses.
4. Qinghe Special Steel Corporation, China (2007)
The Incident
In one of the deadliest industrial accidents in recent history, a ladle carrying molten steel detached from an overhead crane, killing 32 workers on the factory floor.
System Failures
- Use of substandard hoisting equipment.
- No adherence to basic safety protocols.
- Disorganized and ineffective organizational oversight.
Swiss Cheese Takeaway
Even though this was a steel plant, not a warehouse, the parallels are chillingly clear. Latent failures across mechanical, procedural, and managerial domains aligned, and the result was catastrophic.
“When you repeat a mistake, it is not a mistake anymore: it is a decision.”
– Paulo Coelho
How to Translate the Swiss Cheese Model to Warehouse Risk Management
These cases highlight what happens in a fragmented safety culture, where systems don’t connect, leaders overlook frontline conditions, and fixes are reactive rather than strategic.
Your goal as a warehouse operator is to prevent alignment of these “holes” by:
- Implementing regular, expert inspections
- Making data-driven decisions
- Performing engineered repairs
- Installing impact protection
- Training employees across all roles
- Using rack safety software to track actions and improvements
From Model to Movement: The Safety Flywheel
To bring the Swiss Cheese Model to life in real-world operations, Damotech created the Rack Safety Flywheel—a systemized approach integrated into our DAMO CARE program.
1. Inspection – Expose the Holes
Certified engineers perform regular, in-depth inspections to uncover visible and latent issues in racking systems. They identify structural damage, code violations, and wear before they become dangerous.
2. Insight – Turn Observations into Action
Inspection data is uploaded to Damotech’s cloud-based platform, where it’s categorized by severity and tracked across locations.
3. Maintenance – Repair with Purpose
Engineered solutions, like DAMO PRO, restore load capacity, eliminate rack weakness, and avoid the need for full replacements.
4. Prevention – Create the Final Line of Defense
Protective equipment and human training can stop a small error from becoming a serious incident. DAMO GUARD and other protectors shield racks from forklift impacts. Additionally, Damotech’s training services reinforce the best practices and create a culture of vigilance.
💡 Learn more about DAMO CARE and the Rack Safety Flywheel →
Watch the video below to discover how the Flywheel can guide you in building a complete rack safety program from start to finish.
✅ Key Takeaways
- Warehouse safety isn’t about one perfect policy—it’s about layered defenses.
- The Swiss Cheese Model explains why relying on a single layer (training, signage, inspection) is risky.
- Implementing overlapping, trackable, and enforced systems dramatically reduces the chances of holes aligning.
- A structured program like DAMO CARE transforms this theory into practice, keeping people safe and warehouses compliant.
👇 Ready to Shrink the Holes in Your Safety System?
Contact a Damotech expert to build your own rack safety program.
Frequently Asked Question
What is the Swiss Cheese Model of safety in warehouses?
It’s a risk management framework showing that accidents happen when multiple safety lapses (or “holes”) align. Warehouses benefit from applying this model to reinforce racking, training, and inspections.
How can warehouse operators prevent “holes” from aligning?
By integrating multiple safety layers: regular inspections, engineered repairs, data tracking, protective equipment, and employee training.
What is the DAMO CARE program?
A full-service rack safety subscription that includes inspections, repairs, compliance support, and tools to build a resilient warehouse safety culture.
