Road Transport Accident Analysis from A System-Based Accident Analysis Approach Using Swiss Cheese Model
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Summary
This study addresses the persistent rise in road transport accidents in Ghana, arguing that traditional "person-based" accident analysis, which blames individual errors, is insufficient for understanding systemic safety failures. Motivated by the high economic and social costs of road crashes and the lack of adoption of system-based approaches in the region, the authors aim to demonstrate the utility of James Reason’s Swiss Cheese Model (SCM) in analyzing road transport incidents. The research seeks to identify latent organizational conditions and active errors that collectively contribute to accidents, thereby informing more effective intervention strategies. The methodology involved a case study of a specific accident that occurred at a driving school in Accra, Ghana, in July 2018. Data were collected through interviews with the school manager, the driving instructor, the learner driver, and two eyewitnesses. The researchers applied the Swiss Cheese Model to categorize identified factors into latent errors (organizational weaknesses) and active errors (immediate unsafe acts). This system-based approach allowed the team to map how failures in different defensive layers aligned to create an accident trajectory, rather than isolating a single cause. The analysis identified four distinct failure layers that contributed to the crash. Two latent errors were attributed to management: the employment of an uncertified and untrained driving instructor, and the absence of supervisory measures to monitor instructor performance. Two active errors were identified at the operational level: the instructor exited the vehicle, leaving the learner driver alone without the ability to intervene via dual controls, and the learner driver proceeded with lessons despite being severely fatigued from working night duty the previous day. The study found that these four weaknesses aligned to breach the system’s defenses, resulting in the learner driver accidentally accelerating into a wall. The significance of this study lies in its demonstration that system-based accident analysis provides a more comprehensive understanding of road safety failures than person-based approaches. By revealing how latent organizational conditions interact with active human errors, the SCM highlights the need for structural interventions rather than individual blame. The authors conclude that policymakers and safety regulators should adopt system-based frameworks to address root causes, such as enforcing strict certification for instructors and implementing supervisory protocols. This approach is recommended to improve safety management and reduce the high incidence of road accidents in Ghana and similar contexts.
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| Stage | Outcome | Tool | Model | Prompt | Attempts | Completed |
|---|---|---|---|---|---|---|
| discover | success | Crossref | — | — | 1 | 2026-06-19 |
| archive | success | canonical_url | — | — | 1 | 2026-06-26 |
| extract | success | cached | — | — | 2 | 2026-06-26 |
| clean | success | clean | — | — | 1 | 2026-06-20 |
| chunk | success | chunk | — | — | 1 | 2026-06-20 |
| embed | success | embed | Qwen/Qwen3-Embedding-8B | — | 1 | 2026-06-20 |
| promote | success | — | — | — | 1 | 2026-06-19 |
| summarize | success | llm | qwen3.6-27b-prismaquant | summ-v5 | 1 | 2026-06-26 |
| tag | success | vector_similarity | — | — | 6 | 2026-06-20 |
| verify | success | — | — | — | 1 | 2026-06-26 |
Summary generated by qwen3.6-27b-prismaquant on 2026-06-26; verification: verified.
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