I spent some time this weekend reading one of Sandra Brown’s suspense novels that involved a scene where an airplane pilot is describing the near-miss he had earlier in his career. He termed it “The Swiss Cheese Model.”
“In order for a catastrophic event, such as a plane crash, to occur, a sequence of events precedes it, Think of these separate factors as slices of Swiss cheese lined up one behind the other. If any one of the holes in them doesn’t align with the others, the series of events is changed or curtailed, and a catastrophe is prevented. But if all the holes line up –”
The character went on to describe the scenario from his past: the first officer spilling his coffee, the mechanic who failed to notice the coffee had shorted out a wire, the false alarm the short triggered, the pilot being short on sleep, the lightning storm, etc. It was not one factor that nearly caused a crash, rather the (mis)alignment of many events in a row.
Think of how you can install warning signals in your organization that could alert you when a few pieces of “cheese” are beginning to assemble. Are there trigger events that should signal a management review or certain actions that should require more than one person to be involved in the decision making? Many organizations monitor key performance indicators, but do you pay attention to sequencing, not just the data itself? And when something does go wrong, do you review the “pieces of cheese” that led up to the problem rather than just examining the ultimate outcome?
Every strategy has holes in it. Your job as a leader is to ensure that the holes don’t line up in a way to create a disaster.
Source: Low Pressure by Sandra Brown, 2012, pp. 269-270.