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Beirut Port Explosion: A Tragedy Foreseen Through the Swiss Cheese Model

  • Writer: cjd608
    cjd608
  • Jul 31
  • 4 min read

When Every Layer Fails, Disaster Finds a Way Through


🔥 A Catastrophe Captured by the World

On the evening of August 4, 2020, Beirut was shaken—literally and figuratively—by one of the most powerful non-nuclear explosions in recorded history. Captured in videos and shared across social media within minutes, the blast killed over 200 people, injured 6,500, and left 300,000 homeless. But this was not a freak accident. It was a predictable and preventable disaster—one that unfolded in slow motion over six years of systemic failure.

At the heart of this analysis lies the Swiss Cheese Model: a simple yet powerful way to understand how disasters occur when multiple safety barriers fail simultaneously.


🧠 What is the Swiss Cheese Model?

The Swiss Cheese Model, developed by psychologist James Reason, is widely used in safety-critical industries such as aviation, healthcare, emergency services, and chemical processing.


🧀 Here’s how it works:

  • Each slice of cheese represents a layer of defence: regulations, policies, infrastructure, inspections, etc.

  • Every slice has holes—gaps caused by human error, complacency, poor communication, or systemic flaws.

  • When these holes momentarily align, they allow a pathway for failure—resulting in harm or catastrophe.


Rather than focusing on individual blame, this model helps us look at the system—how multiple missed opportunities can combine to allow disaster to unfold.


📉 How the Swiss Cheese Model Explains the Beirut Explosion

Below, we apply this model to the chronology of failures that led to the Beirut Port tragedy.


🧀 Layer 1: Dangerous Cargo Seized and Forgotten (2013)

The cargo ship MV Rhosus, impounded at Beirut Port, was carrying 2,750 tonnes of ammonium nitrate (AN)—a highly explosive material.


🔴 Hole: No plan for safe disposal or removal despite repeated legal advice and the known volatility of Ammonium Nitrate.


🧀 Layer 2: Hazardous Storage Conditions (2014–2020)

Lebanese authorities offloaded the Ammonium Nitrate and stored it in Hangar 12, where it remained for nearly six years.Ammonium Nitrate was stored alongside fireworks and other flammable materials, with no climate control, segregation, or protective infrastructure.


🔴 Hole: Gross violation of basic fire safety and chemical storage standards. Lebanese building codes (e.g., LIBNOR NL 147:2016) were not enforced.


🧀 Layer 3: Ignored Warnings from Officials (2014–2019)

The Director of Customs repeatedly warned about the risks—emailing the Urgent Matters Judge and submitting formal reports. Nothing changed.


🔴 Hole: Bureaucratic inertia and fragmented communication channels meant these alarms were ignored.


🧀 Layer 4: Port Authority Warning Ignored (2019)

The Port Authority wrote to the Lebanese Government to warn of the dangers posed by the dangerous chemical and the risk posed by storing it in it's current location and condition.


🔴 Hole: Warnings were ignored allowing the situation to decay.


🧀 Layer 5: Unsafe Welding Sparks Ignition (2020)

In early August 2020, welders were assigned to repair a hole in the hangar’s wall. Sparks ignited nearby fireworks—setting off the chain reaction.


🔴 Hole: No risk assessment, no fire watch, no temporary relocation of hazardous materials, and no hot work permits.


💥 The Explosions: What Happened That Day?


🔹 Initial Fire and First Blast

  • Grey smoke, flashes, and fireworks were visible from the port.

  • Bystanders began recording and posting to social media.


🔹 Secondary Explosion

  • Approximately 30 seconds later, a massive fireball erupted.

  • A mushroom cloud and blast wave tore through the city.

  • Windows shattered up to 15 miles away; the sound was heard 240 km away in Cyprus.


🧍‍♂️ Human Impact

The consequences were catastrophic:

  • 178+ killed, including port workers, residents, and passersby

  • 6,500 injured

  • 300,000 left homeless

  • 55 hospitals and clinics damaged or destroyed

  • Entire neighbourhoods—Gemmayzeh, Karantina, Bourj Abi Haidar—were devastated, Hospitals were overwhelmed, with the World Health Organization (WHO) reporting that many were forced to turn away patients due to structural damage.


🧪 The Science Behind the Blast

The explosion’s force was calculated using the TNT equivalency method. With AN’s explosive potential, the blast generated overpressures high enough to:

  • Destroy structures in a multi-kilometre radius

  • Cause fatalities from debris and pressure wave effects

  • Shatter glass and rupture buildings far from the epicentre

 

Academic studies (Babrauskas, 2016; Pittman et al., 2014) confirm that ammonium nitrate disasters are recurrent, preventable, and often follow the same pattern of neglect.


🧠 Why the Swiss Cheese Model Matters

This model is more than a metaphor—it’s a practical framework for risk analysis:

Feature

Benefit

Systems-based

Shifts focus from blaming individuals to understanding system flaws

Visual and intuitive

Easy for teams and decision-makers to grasp and apply

Predictive

Helps identify where holes might align in future incidents

Cross-sector

Used in aviation, healthcare, emergency response, and industry

In the case of Beirut, each layer—customs enforcement, storage safety, regulatory oversight, communications, and safe maintenance—had holes. The tragedy wasn’t caused by a single spark; it was the result of compounding system failures over time.


🚨 Final Thought: A Preventable Tragedy

The Beirut explosion is not just a case study in disaster—it’s a lesson in what happens when we ignore the layers of defence meant to protect us. The Swiss Cheese Model teaches us that risk isn’t eliminated with one policy or inspection—it’s managed through layers of protection, constant vigilance, and a culture of accountability.

When all else fails—and the holes align—the consequences are devastating.


 

Watch the visual breakdown of how the Beirut explosion unfolded through the Swiss Cheese Model.



📚 References

  • Babrauskas, V. (2016). Explosions of ammonium nitrate fertilizer in storage or transportation are preventable accidents. J. Hazard Mater.

  • Pittman, W. et al. (2014). Lessons from 100 years of ammonium nitrate disasters.

  • WHO (2020). Beirut blast response report.

  • Dyer, O. (2020). Beirut: hospitals overwhelmed after deadly blast.

  • The Guardian (2020). Initial reporting and timeline.

  • BBC News (2020). Mapped damage zone and blast radius.

  • Lebanese Standards Institution (LIBNOR), NL 147:2016 & NL EN 54

  • Reason, J. (1990). Human Error and the Swiss Cheese Model.

 

 
 
 

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