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We'll get to the Swiss cheese in a minute, but let me start with a proposition that I hope we all can agree on. No matter how important our mission to feed those in need might be,  our first and foremost priority must be to keep our clients - and ourselves - safe.  If you do not agree with that, then perhaps juggling chainsaws might be a better fit for you than working at the Pantry.  But back to why you came here: how I messed up.


Towards the beginning of June, we were wrapping up a regular Tuesday distribution. Most of the volunteers had dispersed to the mysteries of their lives outside of the Pantry, so it was just me and a couple of others who were still there when James and the Green Monster showed up with about six billion boxes of personal care items. The delivery wasn't unexpected, but its size certainly was. To be clear, that wasn't James's fault - he was just wearing his delivery driver hat here - but it was the trigger in the model described below.

Anyway, I was tired and I was concerned the other volunteers might be tired too. So when we quickly ran out of space in the designated areas for personal care storage, I told everyone to just stick the remainder anywhere they could find a space - including above food items. Now, this is a big no-no in the food safety world for the obvious reason a leak could contaminate food below it. I rationalized it by thinking that I'd be at the next distribution as usual and could make sure nothing had indeed leaked. But I knew I was crossing some sort of  line and said to myself, "gee, I hope Tom Himmelright doesn't see this."  I may have even said it aloud. I was actually thinking more about the higgledy-piggledy stacking than the leak risk (Tom was very particular about keeping our shelves neat and orderly), but that was certainly a red flag. 

Well, wouldn't you know it, Tom showed up in the Pantry before the next distribution and DID see it. Quite rightly, he reported it to the Board and the best I can say about the sorry affair is that I took my lumps with good grace and out-of-character humility. 

Clearly a learning moment for me, and I resolved to make a little lemonade out of lemons in this Newsletter with a request for everyone to read Connecticut Food Bank's Food Safety Handbook, and perhaps even take the accompanying test. The problem was, I HAD read the Handbook, several times. For once, ignorance wasn't my problem, it was something else. So to squeeze maximum lemonade out of this, let's take a look at ALL the ways we can try and avoid food safety-related incidents at the Pantry.

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The Swiss Cheese Model of accident prevention proposes that reducing risk is best achieved by layered security. The idea is that, if you have lots of layers, it doesn't matter if there is a failure (a hole in the cheese) in one - the next layer will stop a trigger becoming an accident.  There are lots of variations of the model,  but the idea is intuitively grasped. 


Insofar as  Daily Bread is concerned and the personal care items story in particular,  we have a big hole in our facilities layer - the Pantry is extremely small and that inevitably introduces risks. In the short and medium-term,  there is not much we can do about that. So that means we need to work on the other layers.  Some things - policies, training and culture, for example, are mainly the responsibility of the Board. But other things are the responsibility of everyone. In particular:

  • Please do read the Food Safety Handbook if you have not already (if you want to take the related test, let me know - it requires you to input some information about the Pantry) 

  • Speak up if you see anything you think is wrong or risky, or are asked to do something you think is risky - I hope the Pantry is operated in a non-hierarchical way but when it comes to safety it is most definitely a totally level platform.

    • If another volunteer tells you that what you are doing is not safe, don't get defensive. Even if you don't agree, take a step back, say thank you for pointing that out, and seek a second opinion from a Pantry leader.​

    • Unless willful, repeated and dangerous, no-one at the Pantry will get into trouble for mistakes.

  • Don't get hung up on the details of the graphic (I've somewhat arbitrarily grouped layers together for example), but do think about how the general concepts in each layer apply to the Pantry.

  • Be aware of the "human factors" I've listed that can act as a catalyst to the trigger:

    • By "routinization", I mean don't let the fact that a risky practice or behavior has not resulted in an incident before justify continuing it. You may be relying on the very last layer of all - luck.​

    • By "missionitis", I mean sacrificing safety to accomplish the Pantry's goal of helping others - or getting any particular task done that seems important at the time.

    • In addition to what I've listed, try to be aware of your own personality traits that might introduce risks. For example, I am extremely susceptible to missionitis and, more subtly, inclined to sympathize excessively with people who have caused spectacular disasters. If you feel most bad for Captain Smith when you think about the Titanic, you share that trait.  Armchair psychology, but I think I'm mentally giving myself a bit of a free pass for my own inevitable next screw-up.

  • Watch Titanic and think about the Swiss Cheese Model. Not really all Captain Smith's fault, was it?​

Food Safety is just one aspect of safety at the Pantry. I'm sure I will return to the wider subject in future Newsletters. In the meantime, stay safe, everyone.

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