Cheese is by far one of the greatest foods. It is my only ambrosia, wrapping around my taste buds and sending fireworks of pleasure around my brain. In particular, I love the nutty flavor of Switzerland's holiest of cheeses: Emmental. When you meet me, I will happily bore you into a coma when I start talking about cheese.
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Today it isn't Emmental or any other real cheese that has stimulated my quality receptors; it's a management theory that you may be familiar with: the Swiss cheese model (aka "Reason's dynamics of accident causation model").
If you've ever taken part in a failure investigation, you may have seen a diagram, or even produced the diagram yourself, that illustrates all the failure points in the system that produced the undesirable outcome. A perfect storm of a problem, the failure points were precisely aligned in layer upon layer of Swiss cheese slices, creating an aperture through which a bullet could pass without resistance, hitting the failure target.
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Comments
Gorgonzola Vs. Emmental
Hi, Paul: I plaudit your latest column; and I would plaudit you more, had you quoted the celebrated Gorgonzola cheese: even John Steinbeck made a myth of it. Though I read your piece all too quickly - I apologize for that, but, at 5 o'clock a.m. local time ... I guess you understand - I share your point of view: all too often I turn up my nose at problem solving records claiming that the failure's root cause was human error. By definition any error is systemic, non systematic: were it systematic it would be a common, not special cause of variation. Thank you.
PS: Swiss cheese-makers ignore the role of Wine in aprreciating cheese; the French and Italians don't.
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