Document Type : Original Article


Social Determinants of Health Research Center, Saveh University of Medical Sciences, Saveh, Iran


BACKGROUND: The Swiss cheese model of accident causation is a model used in risk analysis
and risk management, including aviation safety, engineering, healthcare, and emergency service
organizations, and as the principle behind layered security, as used in computer security and defense
in‑depth. This study aimed to develop and weight the occupational health leading indicators using
the Swiss cheese model.
MATERIALS AND METHODS: The present study was a descriptive, cross‑sectional study;
occupational health performance assessment indicators were classified into five main groups of
chemical, physical, ergonomic, psychosocial, and biological harmful agents. In addition, potential
hazards and their prevention methods were identified using the Swiss cheese model. The leading
performance measurement indicators (n = 64) were developed based on preventive methods and
were weighted and rated by fuzzy analytic hierarchy process.
RESULTS: Thirty‑six out of 64 indicators were related to the management measures, 25 indicators
were related to exposure to harmful occupational agents, and the remaining indicators were
occupational‑related illnesses and diseases rate. Considering the importance and frequency of
indicators, psychological agents were the most important indicators (40%) and physical agents had
the greatest frequency (59%).
CONCLUSIONS: Process of indicators’ development has demonstrated that the major occupational
health prevention measures in the oil and gas industry are concentrated on physical, psychological,
and chemical agents, respectively. Thus, to provide protection for employees against occupational
diseases and improve health performance indicators, paying special attention to mentioned agents
is essential in the oil and gas industry.


1. Falahati M, Zokaei M, Asady H, Najafi Mojre M, Biabani A,
Faghihnia Torshizi Y. Model of the selection KPI for assessing the
performance of the urban HSE management system. Iran Occup
Health 2019;16:60‑71.
2. Haas EJ, Yorio P. Exploring the state of health and safety
management system performance measurement in mining
organizations. Safety science. 2016:1;83:48‑58.
3. Fernández‑Muñiz B, Montes‑Peón JM, Vázquez‑Ordás CJ. Safety
leadership, risk management and safety performance in Spanish
firms. Safety science. 2014 Dec 1;70:295‑307.
4. Dunning D, Heath C, Suls JM. Flawed self‑assessment:
Implications for health, education, and the workplace. Psychol
Sci Public Interest 2004;5:69‑106.
5. Health and Safety Executive. AGuide to Measuring Health & Safety
Performance. United Kingdom (UK): Health and Safety Executive;
2001. Available from:
.pdf. [Last accessed on 2001 Dec 07].
6. Bergh LI, Hinna S, Leka S, Jain A. Developing a performance
indicator for psychosocial risk in the oil and gas industry. Saf Sci
7. Martin A, Walker K, editors. Oil and Gas Industry
Leading Health Performance Indicators. SPE International
Conference on Health, Safety, and Environment. Ja arta,Indonesia: Society of Petroleum Engineers; 2014. Available fr
‑paper/SPE‑168359‑MS. [Last accessed on 2014 Mar 18].
8. Hallowell MR, Hinze JW, Baud KC, Wehle A. Proactive
construction safety control: Measuring, monitoring, and
responding to safety leading indicators. J Constr Eng Manag
9. Sinelnikov S, Inouye J, Kerper S. Using leading indicators to
measure occupational health and safety performance. Saf Sci
10. Lebni JY, Azar FE, Sharma M, Zangeneh A, Kianipour N,
Azizi SA, et al. Factors affecting occupational hazards among
operating room personnel at hospitals affiliated in Western Iran:
A cross‑sectional study. J Public Health 2020;24:1‑8.
11. Redinger CF, Levine SP. Development and evaluation of the
Michigan Occupational Health and Safety Management System
Assessment Instrument: A universal OHSMS performance
measurement tool. Am Ind Hyg Assoc J 1998;59:572‑81.
12. Redinger CF, Levine SP, Blotzer MJ, Majewski MP. Evaluation
of an occupational health and safety management system
performance measurement tool‑II: Scoring methods and field
study sites. AIHA J (Fairfax, Va) 2002;63:34‑40.
13. Redinger CF, Levine SP, Blotzer MJ, Majewski MP. Evaluation
of an occupational health and safety management system
performance measurement tool‑III: Measurement of initiation
elements. AIHA J (Fairfax, Va) 2002;63:41‑6.
14. Cambon J, Guarnieri F, Groeneweg J. Towards a new tool for
measuring Safety Management Systems performance. Learning
from Diversity: Model‑Based Evaluation of Opportunities for
Process (Re)‑Design and Increasing Company Resilience; 2006.
p. 53.
15. Cambon J, Guarnieri F, Groeneweg J, Scholten E, Hinrichs J,
Lancioni G, editors. Bringing Tripod Delta to France for the
analysis of organizational factors. European Safety and Reliability
Conference (ESREL 2006): Taylor & Francis; 2006.
16. Khammar A, Poursadeghiyan M, Marioryad H, Nabi Amjad R,
Alimohammadi M, Khandan M. Patient safety climate and
its affecting factors among rehabilitation health care staff of
hospitals and rehabilitation centers in Iran‑Tehran. Iran Rehabil
J 2019;17:39‑48.
17. Khammar A, Hosseinighosheh S, Abdolshahi A ,
Hosseini Ahagh M, Poursadeqiyan M. Forecast of the future
trend of accidents in an electricity distribution company of Iran:
A time series analysis. Iran J Public Health 2019;48:2315‑7.
18. Saaty TL. A scaling method for priorities in hierarchical structures.
J Math Psychol 1977;15:234‑81.
19. Vaidya OS, Kumar S. Analytic hierarchy process: An overview
of applications. Eur J Oper Res 2006;169:1‑29.
20. Falahati M, Karimi A, Mohammadfam I, Mazloumi A,
Khanteymoori AR, Yaseri M. Development of safety and health
leading performance indicators in the phase of construction of a
gas refinery plant using Bayesian network and AHP. Int J Adv
Biotechnol Res 2017;8:1440‑53.
21. Falahati M, Karimi A. Development and ranking of
safety performance indicators using Bayesian network
and analysis hierarchical process: Case of work at height of
the oil and gas refinery construction phase. Iran Occup Health
22. Falahati M, Dehghani F, Malakoutikhah M, Karimi A, Zare A,
Yazdani Rad S. Using fuzzy logic approach to predict work‑related
musculoskeletal disorders among automotive assembly workers.
Med J Islam Repub Iran 2019;33:136.
23. Falahati M, Karimi A, Zokaie M, Biabani A, Faghihnia Torshizi Y.
Development and validation of active performance indicators of
electrical safety using bow‑tie and bayesian network techniques
case study: Oil and gas industries construction projects. Iran
Occup Health 2019;16:22‑33.
24. Zokaee M, Falahati M, Asady H, Rafee M, Najafi M, Biabani A.
Development and validation of a practical model for quantitative
assessment of HSE performance of municipalities using the impact
of urban management system components. J Health Saf Work
25. International Petroleum Industry Environmental Conservation
Association Tgoagiafeasi, International Association of Oil &
Gas Producers (IOGP). Health Leading Performance Indicators
Report; 2016.
26. Reason J. The contribution of latent human failures to the
breakdown of complex systems. Philos Trans R Soc Lond B Biol
Sci 1990;327:475‑84.
27. Bonsu J, Van Dyk W, Franzidis JP, Petersen F, Isafiade A.
A systems approach to mining safety: An application of the Swiss
cheese model. J South Afr Inst Min Metall 2016;116:776‑84.
28. Perneger TV. The Swiss cheese model of safety incidents: Are
there holes in the metaphor? BMC Health Serv Res 2005;5:71.
29. Underwood P, Waterson P. Systems thinking, the Swiss Cheese
Model and accident analysis: A comparative systemic analysis
of the Grayrigg train derailment using the ATSB, AcciMap and
STAMP models. Accid Anal Prev 2014;68:75‑94.
30. Collins SJ, Newhouse R, Porter J, Talsma A. Effectiveness of the
surgical safety checklist in correcting errors: A literature review
applying Reason’s Swiss cheese model. AORN J 2014;100:65‑79.
31. Reason J. Human error: Models and management. BMJ
32. Reason J, Hollnagel E, Paries J. Revisiting the Swiss cheese model
of accidents. J Clin Eng 2006;27:110‑5.
33. Podgórski D. Measuring operational performance of
OSH management system A demonstration of AHP‑based
selection of leading key performance indicators. Saf Sci
34. Leka S, Jain A, Iavicoli S, Vartia M, Ertel M. The role of policy
for the management of psychosocial risks at the workplace in the
European Union. Saf Sci 2011;49:558‑64.
35. Leka S, Jain A, World Health Organization. Health Impact of
Psychosocial Hazards at work: An Overview. World Health
Organization; 2010.
36. Chen WQ, Yu IT, Wong TW. Impact of occupational stress
and other psychosocial factors on musculoskeletal pain among
Chinese offshore oil installation workers. Occup Environ Med
37. Arassi M, Mohammadi H, Motamedzade M, Kamalinia M,
Mardani D, Mohammadi Beiragani M, et al. The association
between psychosocial factors and occupational accidents among
Iranian drilling workers. Ergonomics 2014;2:36‑45.
38. Poursadeqiyan MA, Khaleghi S, Moghadam AS, Mazloumi E,
Raei M, Hami M, et al. Investigation of the relationship between
the safety climate and occupational fatigue among the nurses of
educational hospitals in Zabol. J Educ Health Promot 2020;9:238.
39. Poursadeqiyan MF. Health, safety, and environmental status
of Iranian school: A systematic review. J Educ Health Promot
40. Milczarek M, Brun E, Houtman I, Goudswaard A,
Evers M, Bovenkamp M, et al. Expert Forecast on Emerging
Psychosocial Risks Related to Occupational Safety and Health.
European Agency for Safety and Health at Work: Brussels,
Belgium: 2007.
41. Kim HC, Min JY, Min KB, Park SG. Job strain and the risk for
occupational injury in small-to medium-sized manufacturing
enterprises: A prospective study of 1,209 Korean employees. Am
J Ind Med 2009;52:322‑30.
42. Ariëns GA, van Mechelen W, Bongers PM, Bouter LM,
van der Wal G. Psychosocial risk factors for neck pain:
A systematic review. Am J Ind Med 2001;39:180‑93.
43. van der Wal RA, Bucx MJ, Hendriks JC, Scheffer GJ, Prins JB.
Psychological distress, burnout and personality traits in Dutch anaesthesiologists: A survey. Eur J Anaesthesiol 2016;33:179‑86.
44. Zhao J, Chen L. Individualism, collectivism, selected personality
traits, and psychological contract in employment. Manage Res
News 2008;3:289‑304.
45. Eyayo F. Evaluation of occupational health hazards among oil
industry workers: A case study of refinery workers. IOSR J
Environ Sci Toxicol Food Technol 2014;8:22‑53.
46. Gardner R. Overview and characteristics of some occupational
exposures and health risks on offshore oil and gas installations.
Ann Occup Hyg 2003;47:201‑10.
47. Golara M, Shokat Sadry S. Employees occupational diseases:
Reference to oil and gas companies. JLS 2015;5:4317‑22.
48. Heras M. From Performance Measurement to Performance
Management. Full Time MBA Electives; 1995. p. 76.