"Visualize any system's defenses against failure-a biological immune system, or a healthcare delivery system, or an aircraft control system-as a series of slices of delicious, creamy Emmentaler cheese. Each layer has a couple of holes (vulnerabilities) in it, of varying size, here and there, but as long as the holes are not aligned with each other, no threat to the system can pass all the way through all the layers,"
"So the Swiss Cheese Effect is when layers of a system happen to line up so that, for however brief an interval, the holes in the cheese slices align and a threat approaching from just the right angle can pass through all of the holes, causing the system to fail-without any particular one or two of the cheese slices having operated(?) other than how they were designed to."
Layered defenses can be modeled as slices of Swiss cheese, each slice containing holes that represent vulnerabilities. As long as holes do not line up across layers, threats cannot pass through every layer. The Swiss Cheese Effect occurs when holes happen to align temporally and spatially, permitting a threat to traverse all defenses and cause failure. Chance, human actions, design configurations, and environmental factors can create or prevent alignment. A converse example shows how random actions and small design changes can let a threat pass harmlessly, illustrating the role of coincidence and configuration in systemic risk.
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