The Mouse in the Salad
The Freakonomics Podcast, The Mouse in the Salad, Stephen Dubner explores crisis management, centering the discussion around an incident at the Pain Quotidien, on the Upper West Side of New York, in which a patron found a dead mouse in her salad. In this case, Dubner who took the photo above, muses whether the mouse incident is just one of those things, a view rejected by Dubner’s friend, James Altucher, who was eating with him at the time:
“Too many things went wrong. So, each one thing has a low probability. So a mouse gets into an open salad bag that happens to be lying around. That’s inappropriate. The mouse dies there. So, I don’t know, was it there overnight? The guy takes his hand in and puts it in a bowl and didn’t see the mouse. The waitress or waiter brings the mouse over and didn’t notice it. So, four or five things went wrong. Maybe the salad was delivered with the mouse in it to the store to begin with? So, we don’t know where it went wrong.”
While in this case we don’t know with certainty what went wrong, two things are clear:
- The mouse did not end up in the salad because of a rogue waiter; and
- The mouse did end up in the salad as a result of a myriad of organizational causes – like, failures of quality assurance to food preparation processes.
The Swiss Cheese Safety Model
Under the Rogue Worker Theory, disasters are the result of the actions of a few or one. The trouble with this explanation is that it ignores the way that organizations manage risk (well, good ones anyway).
All organizations face risks to the achievement of their objectives. The army trained us to organize defence in depth, so there was not a single point of failure. Organizations do the same thing, implementing a series of controls to manage risks. As depicted in the graphic below – the Swiss Cheese Safety Model – each of these controls comprises a single slice of Swiss cheese. Disasters occur when the holes in the slices ‘line up’.
Under the Swiss Cheese Safety Model, losses result from failures or gaps in organizational controls, such as internal processes, supervision, executive tone, and policy. Staff providing a service – whether a commodities trader or waiter in a Pain Quotidien – are just the last slice of cheese.
“There are no bad soldiers, only bad officers.”
The Rogue Worker Theory is seductive because the problem can be excised: staff can resign or be fired. Acknowledging the need to address the root causes of failure is a challenging proposition because it means the failure is about ‘us’ not some rogue ‘them’, and that organizational change, at all levels, must come.
With the above quote, Napoleon captures the inconvenient reality that organizational causes offer more powerful explanations for organizational failures and scandals than the Rogue Worker Theory. Disasters occur because of multiple organizational failure, not just because of the actions of a few (or one). Remember that the next time you find something unfortunate in your salad.