See the holes before they line up

The move: review the defense stack, not only the last mistake. The Swiss cheese model is a simple way to talk about layered defenses. In a complex operation, no defense is perfect. Procedures, equipment, supervision, training, signage, staffing, and fatigue controls all have holes. A serious event happens when those holes align long enough for the hazard to pass through. This model is especially useful in cruise line management because shipboard work repeats under pressure. A provision trolley, a tender platform, a pool deck, a galley slicer, or a gangway queue can look routine until a small drift crosses several…

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