Chapter 13The System
I hate the goddamn system, but until someone comes along with some changes that make sense, I’ll stick with it.
English psychologist James Reason developed his “Swiss cheese model” of error after analyzing scores of terrible mistakes in industries ranging from nuclear power to commercial aviation. Reason’s model holds that all complex organizations harbor many “latent errors,” unsafe conditions that are, in essence, mistakes waiting to happen. They’re like a forest carpeted with dry underbrush, just waiting for a match or a lightning strike.
Still, there are legions of errors every day in complex organizations that don’t lead to major accidents. Why? Reason found that these ...
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