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Failure domains
- specific acts
- preconditions
- supervision
- organizational influences
- span
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Holes and slices
- The holes in the slices represent weaknesses in individual parts of the system and are continually varying in size and position across the slices
- An organisation's defenses against failure are modeled as a series of barriers, represented as slices of cheese
- The system produces failures when a hole in each slice momentarily aligns, permitting "a trajectory of accident opportunity", so that a hazard passes through holes in all of the slices, leading to a failure
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Active and latent failures
- Latent failures include contributory factors that may lie dormant for days, weeks, or months until they contribute to the accident.
- Active failures encompass the unsafe acts that can be directly linked to an accident, such as (in the case of aircraft accidents) a navigation error
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Correct Version
- Active failure => Immediate causes
- Precondition
- Latent Failure => underlying causes
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Applications
- A useful theoretical model to explain the multifaceted (human, organizational and technological) aspects of healthcare data breaches
- Crew Resource Management
- The same framework can be applicable in some areas of healthcare.
- Can be used in big projects like Telecommunications which need Environmental, Health and Safety is a crucial aspect of projects delivery.