By John Geracitano
In the 1930s, a crane in a Philadelphia railyard dropped a steel track onto my grandfather’s leg, injuring it so badly it had to be amputated. Accidents happen, especially in dangerous occupations. But after reading Jessie Singer’s There Are No Accidents, my perspective shifted. Singer’s research reveals a startling truth: “accidents” are often preventable and predictable. What happened to my grandfather was not an accident; it was likely the result of a series of identifiable and unmitigated gaps in the system. And at the rate at which accidents occur in the military, it is worth the investment to identify and address weaknesses in your organization.
A (very) Brief History of Accidents
Workplace injuries and fatalities, like my grandfather’s, were commonplace during the Second Industrial Revolution. The U.S. Bureau of Labor Statistics estimates that workplace accidents claimed over 30,000 lives each year, and more than 75,000 railroad workers died from work-related injuries before 1920. Efforts to reduce these alarming numbers began in 1935 when the Wagner Act empowered workers to participate in decisions about work hours and conditions. While this made a difference, the National Safety Council reports that workplace incidents still kill more than 14,000 Americans and permanently injure 2.5M people annually.
Beyond the workplace, consumers are subject to corporations’ poor leadership, especially in the auto industry. In 1956, Ford customers had to pay extra for vehicular safety mechanisms that would save their lives. Marketed as the Lifeguard Package, these features included seatbelts, collapsible steering wheels, and padded dashboards. Despite the apparent benefits, regulators did not mandate that these be installed in every vehicle. Similarly, airbags have been around since the 1960s, yet they were not mandatory for vehicles until 1998.
These marketing practices continue today. If you want the best safety features, such as auto-emergency brakes and lane detection technology, you must pay for them. Statistics show this technology saves at least 360 lives annually, yet it will not be mandated in standard cars until 2029.
In another example of Ford’s sterling leadership, they decided not to fix the fuel tank of the 71’ Pinto after it ruptured in every one of its 40+ crash tests, creating an extremely high risk for fire. This video shows how quickly a fire erupted when a Pinto was struck from behind. Engineers had a solution that would cost $8 per vehicle. However, as internal documentation shows, leadership wanted to meet production deadlines and were willing to spend more on legal fees and consumer payouts than implement the fix. The result was upwards of 900 burn-related deaths in Pinto-involved crashes. Car accidents did not cause these deaths. All resulted from poor design and even worse leadership. All were preventable.
The Swiss cheese model
Singer expertly recounts several historical tragedies that resulted from a series of oversights, including the 1911 Triangle Shirtwaist Factory fire, the Titanic and Eastland shipwrecks, the Three Mile Island nuclear disaster, and the design flaws of the DC-10 cargo door. Using frameworks like the Swiss cheese model of accident causation and Normal Accident Theory, Singer highlights how these catastrophic events were not only the result of individual errors but also systemic vulnerabilities.
The Swiss cheese model depicts human systems as cheese slices stacked together, representing a system’s defenses against failure as a sequence of imperfect barriers. Each hole is a vulnerability, varying in size and position over time. A failure occurs when holes in all slices temporarily align, referred to as the “trajectory of accident opportunity” by the model’s founder, James Reason. Holes can range from tangible hardware failure to intangible vulnerabilities stemming from racism, social determinants of health, and socioeconomic status. Therefore, some populations inherently have more “holes” simply based on who they are or where they live.
Applying this model to modern examples unveils a similar alignment of warning signs, neglected actions, and conditions ripe for mishap. The Titan submersible implosion, the water crisis in Flint, Michigan, two Boeing 737 Max crashes due to software issues, and the train wreck that spewed toxic chemicals into East Palestine, Ohio, were all preventable tragedies. The key takeaway is recognizing and addressing the “holes” in our systems—whether they involve personal decisions, organizational practices, or societal structures—to prevent future tragedies and strengthen resilience across all levels.
Relevance to the Military
This systemic perspective is particularly relevant to military operations, where complex systems, high-stakes environments, and diverse vulnerabilities intersect to create significant risks. Some military sectors and units are considered High-Reliability Organizations (HROs), where failures can have catastrophic consequences. These organizations anticipate and mitigate risks through rigorous training and effective communication while cultivating a culture of mindfulness and continuous improvement. Reflecting on how the Swiss cheese model applies to military contexts illuminates the unique challenges of preventing failures.
For example, thanks to reporting from the Military Times, we know that vehicle accidents most commonly occur in safe conditions rather than maneuvering in a training or combat scenario. Furthermore, they happen more frequently during the summer months: April-June for ground accidents and July-September for aviation accidents. This timing is mainly attributed to the significant leadership transitions formations endure during the summer movement cycle. Leaders are aware of formation transitions and the risks they present. However, it takes deliberate effort to affect change and eliminate these known vulnerabilities.
Accidents will still happen no matter how many safeguards are put into place. However, this doesn’t mean that a majority cannot be prevented. Below are two takeaways for leaders at any level to consider.
- Recognize and mitigate systemic vulnerabilities. Leaders must acknowledge that failures often stem not from a single error but from systemic vulnerabilities that align under certain conditions, as depicted in the Swiss cheese model. Using the previous example, personnel transitions introduce risks as new personnel acclimate to their roles, leading to disruptions in cohesion and oversight. Proactively addressing these known vulnerabilities will fill some “holes” and improve operational readiness.
- Strengthen leadership through reflection. As the Swiss cheese model highlights, failures occur when overlooked vulnerabilities accumulate and align. Leaders should make time to reflect. This can take several forms. First, reviewing past after-action reviews (AARs) as a team can bring various perspectives to implementing lessons learned during upcoming events. Second, emphasizing and rewarding open reporting and accountability can uncover hidden risks in daily operations, fostering a culture in which hazards are addressed early. Lastly, mandating continuity plans to mitigate the effects of transitions and conducting feedback sessions at echelon are two other tools for building strong organizations. Leading with this proactive mindset will instill a culture of awareness, resilience, and increased readiness within formations.
An underlying theme throughout Singer’s book is empathy. Assigning blame after an accident is not productive and detracts from the opportunity for prevention. Nothing changes if proper mitigation efforts go undone, leaving the current conditions unaltered and assuring another “accident” will happen. Therefore, it is up to leadership to establish a culture of awareness, reflection, and proactivity to understand their weaknesses, implement mitigation strategies, and grow stronger together.
These lessons drawn from historical tragedies and frameworks like the Swiss cheese model emphasize that most failures are not inevitable but preventable. For leaders, particularly in complex environments like the military, this means proactively identifying and addressing systemic vulnerabilities while fostering a culture of accountability and reflection. By implementing these principles, leaders will reduce the likelihood of accidents while building more resilient systems that protect both lives and missions.
John Geracitano is a U.S. Army Signal officer currently serving as a doctoral student at the University of North Carolina at Chapel Hill. Formerly an Armor officer, John’s most recent positions include Deputy G6, Brigade S6, and Task Force Operations Officer.
