Sidebar #2: The Swiss Cheese Model - Jacob Kaplan-Moss
This is the forth part of my series on thinking about risk, and second “sidebar” to part 1, my basic introduction to risk. It’ll make the most sense if you’ve read that piece and understand the terms risk, likelihood, and impact that I discussed there.
One of the riskiest near misses1 I’ve experienced was when, on a late fall trip to the Boundary Waters, a member of our trip experienced mild hypothermia2. Hypothermia is nearly always a result of poor risk management: hypothermia of this type develops over time from extended exposure to cold without proper management. Hypothermia is easy to prevent (stop and warm up before you get there!) but increasingly hard to treat the worse it gets. In the end everything turned out okay: we were able to rewarm them with sleeping bags and warm sugary drinks. Still, it was quite spooky, so we cut our trip short and exited the next morning.
I tell this story because it follows an extremely common pattern. True fluke accidents are incredibly rare; most of the time, accidents happen not because of a single isolated incident, but because of a series of small missteps that add up to serious consequences.
