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Simply put it looks at human-based systems as a block of Swiss cheese made up of slices where each slice represents an act of a human as part of the system. The point is…every person will make a mistake (a hole in the slice of cheese) from time to time in any system. The trick is to keep from the holes in the individual slices from lining up and making itself all the way through the block of cheese. Because when that happens a catastrophic event occurs.

In this model every attempt is made to ensure enough qualified and competent people in a high-quality system to keep those “holes” to one or two slices.

“Layered Security” example: To protect a forward operating base you have multiple layers of security that consists of outside perimeter patrols, an outer perimeter made up of mines, an inner perimeter of razor wire, barricades on the entry road to slow traffic, armed guards, guard towers, blast walls, etc. Each layer is meant to keep the bad guys outside of the wire and the people inside safe.

So how exactly does this work? Well, I want to touch on one other principle first; it will really help. There is a set of “best practices” out there called a High Reliability Operation (HRO). The principles are used to run high-risk operations where there could be catastrophic outcomes. US Navy uses it for its nuclear program, as well as its aircraft carrier flight deck operations, Special Operations uses a variant of it, and the list goes on. There are five basic concepts to HRO:

1. Preoccupation with failure
2. Reluctance to simplify
3. Sensitivity to operations
4. Commitment to resilience
5. Deference to expertise

I won’t go into detail because it would be a whole book by itself, but #2 is the important one in this case. It means that when looking at the causal factors of failure you don’t simplify. In other words, the reason(s) something fails is usually far more complex than simple.

When you combine the Swiss Cheese model with #2 above you avoid faulty reasoning such as “the last decision” caused the failure. Yes, the last decision might have been a bad one, but it may not the worst one, it is just one of many bad decisions that started long before the outcome occurred. That means there has been a history of poor/bad decision making in the “organization” and in the “process” that led up to the last bad decision.

Looking at the visual of the Swiss Cheese model, the bad decisions are the holes and they all lined up to have a bad outcome, usually a catastrophic outcome. No person in the organization or process prevented the bad decision from proceeding; there was however, no slice of cheese blocking the way of the event occurring.

And to bring this SA concept to the point of more easily being understood I am going to use the death of Freddie Grey in Baltimore in 2015.

So, let me ask the question, “Did the police kill Freddie Grey?” Yes, I consider death a catastrophic event in my way of thinking. So, again, “Did the police kill Freddie Grey?”

I have heard two lines of thought given; 1) he was a criminal, resisted arrest, and died by his own hand in the police van, or, 2) murdered by police officers.

Which is right?

Let’s review what we knew early on as fact from the incident:

• The cops’ own words for what Grey did, “He made eye contact and then ran.”
• He was never charged with a crime, the cops never said a crime occurred.

• He did run, cops chased him.
• Witnesses and video said the cops were very rough with him, he appeared to be injured at the time he was placed in the police transport van.
• The van stopped multiple times.
• Grey was eventually placed in leg restraints.
• Grey was never properly secured in a seat in the transport van.
• Grey was alive before he went into police custody.
• He died while he in police custody.
• He died of a crushed larynx and a severed spine.

So how did he die? Is that even the right question? Maybe it should be, “Who killed him?” or, “Why did someone kill him?”

Why the different questions? Why not accept one of the two original explanations of…“Did the police kill Freddie Grey?”

Wait, why does any of this even matter?

In emergencies, disasters and especially during a “grid-down” situation there is always always bad and incomplete information.

Sometimes the information is “bad” because it is intentionally so. Yes, the government has lied to us before during events and will continue to do so. No matter the reasons behind it, we just know they do. Actually, we know they intentionally lie to us every day, all day, day in and day out…IMHO.

We must be able to see through the lies and dis-information and understand what is actually happening. Because without a hard understanding, a true understanding of what is happening, how in the world would you ever be able to make the right decision for you and your family? You must be able to be Situationally Aware and not suffer from Normalcy Bias; anything less will result in poor decision making.

Back to the example – Let’s start by asking a couple of truly basic but insightful questions:

• Why would a person crush his own larynx?
• Why would a person sever their own spine?

Yes, there are a lot of people who commit suicide each year; many in weird and unusual ways. So let’s apply Occam’s Razor problem-solving principle to this specific question. To do so let’s look at a two common police practices; 1) choke hold, 2) suspect restraint while handcuffing. Both practices being widely taught and used by police officers in the last couple of decades to restrain suspects before and after handcuffing.

So which is the most likely event to have occurred causing Grey’s larynx to be crushed and his spine to be severed?

To me, reality (based on Occam’s Razor) the cops are far more likely to have caused the injury vs. self-inflicted. But that alone is not enough to convince me so let’s continue.

There were six police officers involved in the incident, five of which eventually gave statements after conferring with union representatives and lawyers. The sixth officer pleaded the “5th Amendment” and didn’t provide a statement. To refresh you on the 5th Amendment, a suspect “…nor shall be compelled in any criminal case to be a witness against himself…” In other words…a person can refuse to make a statement that would be an admission of guilt.

That pretty much says one of the cops knows he committed a serious crime and refused to make a statement because he would either admit he committed that crime or would have to make a false statement which is a felony. Reality once again speaks rather clearly based on this reasoning, a cop caused the death of Freddie Grey.

Then the medical examiner ruled Grey’s death a “homicide” not a “suicide.” Which means that Grey died at the hands of another person not at his own hands. Tie that back into the fact that the multiple injuries occurred while in police custody and no one but police had access to him during the time frame in which he injuries occurred.

In the previously mentioned statements of the five police officers they all failed to mention a stop that the transport van made. Officers knew of the stop but intentionally failed to mention it. If one or two had failed to mention it you could view it as a mere oversight, a lapse in memory. But when all the officers failed to mention the same stop it is called collusion.

Now let’s throw in another piece of the puzzle, Baltimore Sun News had done an extensive and thorough investigation into allegation of extreme abuse and violence against citizens by the Baltimore Police Department (BPD). It was proven through valid and reliable statistics that BPD has a very long, decades long, history of brutality and abuse against its own citizens. To substantiate the statistics…millions upon millions of dollars were paid out in abuse cases making it clear that the BPD had a systemic culture of violence by police against citizens.

Then later in the week the AP broke a story that was verified to be true, Lt. Brian Rice, the initial cop that went after

Grey had extensive mental problems. His mental state had become so mentally unstable in 2012 that he had his guns confiscated and had been admitted to a mental hospital. The record showed there were deep “…concerns about self-control and judgment…” and these significant mental problems were still evident in 2013. But less than two years later we see a cop with significant mental problems, who was determined by a court to be so dangerous to himself and others that his guns were legally confiscated, is now back on the street with weapons and supervising other cops. Really? Tell me how, in anyone’s mind that this is possible. Once again this shows a significant breakdown in the BPD.

But what was the BPD doing while all this information was coming to light? They “leaked” information that Gray had a criminal record. The police union went on a dis-information program. Another report was “leaked” by BPD that said a bolt in the van matched the injury on Gray’s head proving that Gray killed himself. A statement was “leaked” that the other prisoner in the van “heard” Gray trying to hurt himself while in the van.

But no one was asking, “How does the ‘bolt’ injury explain the severed spine and crushed larynx?”

And little coverage was given to the CNN interview where the other prisoner in the van stated on TV that he never made that statement, or any statement, concerning Gray to police. And that he now feared for his life because of police threats against him.

So you start to line up the slices of Swiss cheese and what do you get? A very clear picture that Freddie Gray died at the hands of police.

So what is the most likely story of who killed Freddie Gray? Remember a key principle of SA says you only need about 40 – 70% of information to make a valid decision. You don’t have to have to wait for 100% of the information to make quality decisions. So in this case of Freddie Gray, cops killed him plain and simple.

Note: This was just revealed on Friday 5/1/2020 that all six officers have been charged with various crimes including second degree murder in the death of Freddie Gray. It was also revealed that Freddie Gray was a confidential informant for the BPD and had done extensive work for them in helping to solve some serious crimes in Baltimore.

Now why again is this important?

Here are my answers and guiding principles:

• In a “grid-down” or other disaster situation you must keep your SA intact and at a high operational level.
• You must not be blind to the obvious, and you must be able to filter out the “dis-information” that is doled out.
• Use common sense.
• Use Occam’s Razor problem-solving principle.
• Use the HRO principle of reluctance to simplify.
• And remember the two primary motivations of those in authority; money & power.

Before I close this section of the article I want to create a visual of the Swiss Cheese model of the BPD’s murder of Freddie Gray. Hopefully through this visual you will be able to see how this model can be used to research, solve and represent catastrophic events. Then you can use it within the realm of your “prepping” activities to make you and your family less prone to catastrophic events during emergencies and disasters.

At any point had a decision been made differently, had a different choice been made, had inappropriate behavior and culture been corrected, then Freddie Gray would be alive and the city of Baltimore would not have experienced the riots to the extent that they occurred. A CVS store would still be providing goods and services to the residents of a neighborhood that needed them badly. There wouldn’t be a bunch of burned out buildings. The Ruling Class wouldn’t be more entrenched and more powerful. And the nation wouldn’t be one step closer to a National Police Force.

I painted how the “microcosm” looks in this situation but there is a bigger, far bigger, picture that needs to be painted. And that is the focus of this next section.

Those Baltimore Police Department officers didn’t just wake up that morning and decide to put such a beat-down on Freddie Gray that they would kill him. I actually doubt, to some degree, that they actually intended to kill him at all. But what is very clear is that there was a “culture” within the BPD that taught and tolerated this kind of conduct on the part of officers; probably even encouraged it. The BPD had a very long history of this kind of officer conduct. The BPD leadership didn’t stop it, the city leadership didn’t stop it and the citizens didn’t (or maybe couldn’t) stop it. Hence, the cultural-based conduct became the accepted “norm.”

But this didn’t develop in a vacuum either. The Baltimore officers didn’t just somehow dream this up all on their own. This kind of brutal and violent behavior can’t simply develop and exist in such a close-knit community such as law enforcement, other officers from other agencies knew about it. And since they didn’t do anything to stop it, it can only be logically assumed that they too participated in and advocated such brutality…or at least tolerated it.

So there were plenty of slices of cheese with holes in it. And in this case the holes lined up and a catastrophic event occurred. A person died, six police officers careers and lives were ruined, a police department continued it bad reputation, and tens of millions of dollars of destruction took place. Had a single piece of cheese prevented the holes from lining up…it could have all been avoided.