Swiss Cheese Governance

Who saw the Space Shuttle disintegrate during launch in 1986 taking 7 lives? It wasn’t only a faulty o-ring - it was a sequence of events that started well before launch.

When things go badly wrong, it’s always a combination of events that on their own seem innocuous. The Swiss Cheese model helps illustrate risk management - when cheese slices are stacked together at some point the holes line up.


· Known faulty o-rings

· Near a fuel tank

· Unusually cold weather

· Managers disregarded persistent warnings (culture)

· No escape hatch for the crew

Most of the shuttle crew likely died not from the explosion but when their cabin hit the ocean at terminal velocity.

Victoria had zero cases of coronavirus transmission back in May. What could possibly go wrong from there?

It was combined factors that enabled a stealthy killer to find a crack in our government’s COVID defences:

- First, poor training in infection control for hotel security employees

+ Low paid, insecure workforce

+ Inadequate messages to ethnically diverse communities

The result: many preventable deaths, economic impacts of Stage 4 and unnecessary racial tension.

The signs were right there, but no-one joined the dots at the time.