Body & HealthMental model

An accident needs holes that happen to line up.

James Reason described safety systems around 1990 as a stack of cheese slices: each layer is a barrier, each hole a weakness. Only when the holes in every layer happen to align does the hazard pass through. He separates active failures from latent ones that lie dormant for a long time.

Useful: Look-alike drug packages stored side by side are a latent hole – long before anything goes wrong.

Source: en.wikipedia.org

Denkwerkzeug Sicherheit

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