David and I studied risk management at the same time. He was studying risk as part of his aviation degree, me from a mining risk management approach. The principles were the same, accidents boil down to the failure of not one, but several layers of protection.
The Aviation Industry call it "the Swiss Cheese Model" which is far more tasty than the boring mining equivalent. Imagine slices of Swiss cheese lined up against each other - each slice represents a safety measure put in place to prevent accidents. No one measure is perfect though, that's why it's the Swiss cheese principle - the holes represent the imperfections. You can layer slice upon slice of safety measures but occasionally all the holes line up and an accident can slip through.
A real life example happened here on Friday night and it's reminded me of the principle we'd discussed.
The four holes of the swiss cheese principle (and coincidentally the ingredients for hand chips):
I bought potatoes that were slightly too big for our hand-operated potato chipper: hole in slice 1.
At dinner time both the girls wanted to help me make the chips, they fought over who should stand on the stool. My mind wasn't fully on the task at hand: hole in slice 2.
When I discovered that the guard wouldn't fit on the chipper because the potato was too big, my judgement was clouded by a heavy head cold and I didn't accurately assess the risks: hole in slice 3.
I decided to push the potato a little of the way in with my hand so the guard would fit: hole in slice 4 + hole in my left palm.
That, my friends, is a recipe for hand chips and an explanation of the swiss cheese principle all in one quick anecdote.
The moral of the story is the folks at Caloundra Hospital will kindly stitch you back together while ribbing you for foolishness, but unless you're hosting Hannibal Lecter chips made from potatoes will be more popular with your guests.
ever heard of the Swiss cheese Principle?