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In The Decision Book: 50 Models for Strategic Thinking, refer to The Swiss Cheese Model. In The Swiss Cheese Model, the authors refer to 3

In The Decision Book: 50 Models for Strategic Thinking, refer to "The Swiss Cheese Model." In "The Swiss Cheese Model," the authors refer to 3 different types of mistakes. If a sewage treatment plant supervisor forgets the long-standing process where a sequence of treatments are applied to sewage and instead just releases the raw sewage into a river, what type of mistake does that illustrate

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