Find the Aligned Holes in a Baggage Miss
Identify layered defenses and latent weaknesses behind a baggage loading miss.
Baggage reliability Eighteen transfer bags miss an outbound flight after several small weaknesses line up across the ramp. The endpoint is visible, but the path crosses multiple defenses. Swiss Cheese Layered defenses with imperfect holes The model asks which layers should have blocked the failure and why their holes aligned this time. Shortcut Blame the last handler. The fix strengthens a layer instead of scolding the endpoint. When multiple weak layers align, the corrective action must target the layer, not just the person nearest the miss. 01 Layer 02 Hole 03 Fix Layer map Defense one
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