As long as humans are involved in running our organizations, there will be holes (vulnerabilities) in our cheese. This is why I state that we will never have American cheese (no holes) representing our safety systems, because this would imply they would be failsafe and not impenetrable.
The Swiss cheese metaphor is more appropriate because we as human beings are NOT infallible. We are not perfect and we must acknowledge that in order to progress.
The holes in the Swiss cheese represent vulnerabilities that our safety systems are subject to. Many of these vulnerabilities are identified through our risk assessments such as Failure Modes and Effects Analysis (FMEA). This is where we seek to quantify risk by assessing our potential failure modes in a system via the following simple calculation…
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