Qualche post fa ho accennato al modello del formaggio svizzero, anche detto modello di Reason, dal nome del suo inventore. Nel link l’articolo originale.
In an ideal world each defensive layer would be intact. In reality, however, they are more like slices of Swiss cheese, having many holes—though unlike in the cheese, these holes are continually opening, shutting, and shifting their location. The presence of holes in any one “slice” does not normally cause a bad outcome. Usually, this can happen only when the holes in many layers momentarily line up to permit a trajectory of accident opportunity—bringing hazards into damaging contact with victims (figure).
The holes in the defences arise for two reasons: active failures and latent conditions. Nearly all adverse events involve a combination of these two sets of factors.Leggi l’articolo originale Human error: models and management da PubMed Central, l’archivio delle pubblicazioni dei U.S. National Institutes of Health’s National Library of Medicine (NIH/NLM)
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