Operational Decision Making In High Hazard Organizations

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Operational Decision-making in High-hazard Organizations

Author : Jan Hayes
Publisher : CRC Press
ISBN 13 : 1317085353
Total Pages : 296 pages
Book Rating : 4.3/5 (17 download)

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Book Synopsis Operational Decision-making in High-hazard Organizations by : Jan Hayes

Download or read book Operational Decision-making in High-hazard Organizations written by Jan Hayes and published by CRC Press. This book was released on 2017-09-18 with total page 296 pages. Available in PDF, EPUB and Kindle. Book excerpt: This book takes a fresh look at safety decision-making by documenting and examining stories told by front-line managers in three different high-hazard industries: a chemical plant, a nuclear power station and an air-navigation service provider. From Piper Alpha to Deepwater Horizon, accident analysis has stressed the importance of excellent decision-making by those in charge out in the field. Organizations rely critically on the judgement and experience of such senior operations personnel and yet these qualities are undervalued in a business environment that emphasises documentation and measurement. Whilst operational managers are guided by rules, they also draw on their own long experience and can formulate a situation-specific ’line in the sand’ to apply the experience of the operating team to complex, real-world situations that rule writers may not have foreseen. This volume refocuses our attention on the people who make these important decisions and the organizational processes that support the best choices. Jan Hayes uses her multi-disciplinary experience to draw together an account of safety decision-making that is both technically robust and yet accessible to academics, practitioners and regulators alike. Readers will see that the stories retold in this book provide a way for operational managers to share their knowledge, experience and expertise - with each other and with us.

Operational Decision Making in High Hazard Organisations

Author : Jan Hayes
Publisher :
ISBN 13 :
Total Pages : 299 pages
Book Rating : 4.:/5 (845 download)

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Book Synopsis Operational Decision Making in High Hazard Organisations by : Jan Hayes

Download or read book Operational Decision Making in High Hazard Organisations written by Jan Hayes and published by . This book was released on 2009 with total page 299 pages. Available in PDF, EPUB and Kindle. Book excerpt:

Decision-Making in High Risk Organizations Under Stress Conditions

Author : Anthony J. Spurgin
Publisher : CRC Press
ISBN 13 : 1498721230
Total Pages : 191 pages
Book Rating : 4.4/5 (987 download)

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Book Synopsis Decision-Making in High Risk Organizations Under Stress Conditions by : Anthony J. Spurgin

Download or read book Decision-Making in High Risk Organizations Under Stress Conditions written by Anthony J. Spurgin and published by CRC Press. This book was released on 2016-08-19 with total page 191 pages. Available in PDF, EPUB and Kindle. Book excerpt: This book discusses management decision-making under accident conditions as a vehicle to confirm the importance of clear decision-making guided by a systems approach on how an organization functions related to the role of managers, operators, and the operation of the plant. The book shows how to effectively assess the reliability of an organization particularly those organizations responsible for critical infrastructure. The authors have used Stafford Beer’s cybernetic model as a basis to model the behavior and reliability of such organizations. A series of case studies are used to draw conclusions not only how training, experience, and education can improve the strategy and response of management to reduce the probability of an economic or social disaster, but also draw attention to the fact that managers need to be made aware of the consequences of their decisions. Poor management decisions made under stress conditions can lead to the collapse of an organization together with its underlying business, possibly linked to a social disaster with loss of life. Some technology-ignorant management decisions even under non-stress conditions can lead to dangerous situations, which can increase the economic burden placed on an organization. This book describes such situations in order to promote improvement in organizational preparedness by training, experience, and education to reduce safety and economic risks. This book offers: • Case studies of accidents that have affected different HROs (high-risk organizations) and others, due to poor decision-making by management • Training methods (advocated by Admiral Hyman Rickover, adopted by military bodies and others) to prepare staff to make critical decisions under difficult conditions and examine their applicability to training managers of high-risk facilities • Documentation on how making decisions in difficult situations have psychological constraints related to the degree of preparedness and the tools available to aid the decision maker(s) • Studies on the key actions taken before, during, and after accidents and how these management decisions can affect accident propagation, and how one could improve management decision-making by the use of training in decision-making and an understanding of Ross Ashby’s Law of Requisite Variety. • Simulation techniques to improve training of front-line operators and management • Consideration of cost and investment evaluations and how they can distort the selection of tactics and measures that ensure successful operations and avoidance of accidents

Team Leadership in High-Hazard Environments

Author : Randy E. Cadieux
Publisher : Routledge
ISBN 13 : 131704651X
Total Pages : 287 pages
Book Rating : 4.3/5 (17 download)

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Book Synopsis Team Leadership in High-Hazard Environments by : Randy E. Cadieux

Download or read book Team Leadership in High-Hazard Environments written by Randy E. Cadieux and published by Routledge. This book was released on 2016-04-01 with total page 287 pages. Available in PDF, EPUB and Kindle. Book excerpt: Safety performance is a complicated issue, particularly in high-hazard environments, where time and other constraints can be amplified, and result in numerous impacts. From an organizational and business perspective, safety and production/performance are often seen as competing goals. When production is increased, safety defenses and barriers frequently decrease, and when programs are developed in an effort to improve safety, employees may be unable to meet production goals within the safety constraints. Team Leadership in High-Hazard Environments recognizes these difficulties and constraints and proposes an approach to safety leadership in which safety and organizational performance are inextricably linked; one that addresses safety from both the systems and human factors perspectives. To that end, Randy Cadieux introduces the nine essential components to team leadership. By studying these areas and using the information in each chapter, organizational leaders, managers, and supervisors will gain an understanding of key factors that will help them design, develop, and implement team training programs that improve the way employees work together and the way they mitigate hazards. Additionally, the book describes how work systems and work environments may be designed or shaped so that teams are placed in a position to do their optimal work, maximizing the potential for human and team performance. This is an important book that draws on techniques and models developed from Crew Resource Management, human factors, risk management, as well as more traditional HR management disciplines.

Inside Hazardous Technological Systems

Author : Kenneth Pettersen Gould
Publisher : CRC Press
ISBN 13 : 1000407616
Total Pages : 220 pages
Book Rating : 4.0/5 (4 download)

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Book Synopsis Inside Hazardous Technological Systems by : Kenneth Pettersen Gould

Download or read book Inside Hazardous Technological Systems written by Kenneth Pettersen Gould and published by CRC Press. This book was released on 2021-07-19 with total page 220 pages. Available in PDF, EPUB and Kindle. Book excerpt: This book explores the challenges, opportunities, applications, and implications of applying qualitative research to critical questions of research and practice in the field of organizational risk and safety. The book brings together a diverse perspective to explore the practice of conducting qualitative research as well as to debate the quality of research and knowledge, drawing on a range of different perspectives and traditions. It offers novel and innovative developments in data collection and data analysis methods and tools that can be applied to safety, risk, and accident analysis in complex systems. It also will present practical issues associated with data access and empirical research in challenging and high-stakes environments. This book will provide academics, researchers, students, and professionals in the fields of safety, accident analysis, and risk with a broad-range and expert guide to the key issues and debates in the field, as well as a set of exemplary cases and reflective narratives from leading researchers in the field.

Decision-Making in High Risk Organizations Under Stress Conditions

Author : Anthony J. Spurgin
Publisher : CRC Press
ISBN 13 : 131535375X
Total Pages : 206 pages
Book Rating : 4.3/5 (153 download)

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Book Synopsis Decision-Making in High Risk Organizations Under Stress Conditions by : Anthony J. Spurgin

Download or read book Decision-Making in High Risk Organizations Under Stress Conditions written by Anthony J. Spurgin and published by CRC Press. This book was released on 2016-08-19 with total page 206 pages. Available in PDF, EPUB and Kindle. Book excerpt: This book discusses management decision-making under accident conditions as a vehicle to confirm the importance of clear decision-making guided by a systems approach on how an organization functions related to the role of managers, operators, and the operation of the plant. The book shows how to effectively assess the reliability of an organization particularly those organizations responsible for critical infrastructure. The authors have used Stafford Beer’s cybernetic model as a basis to model the behavior and reliability of such organizations. A series of case studies are used to draw conclusions not only how training, experience, and education can improve the strategy and response of management to reduce the probability of an economic or social disaster, but also draw attention to the fact that managers need to be made aware of the consequences of their decisions. Poor management decisions made under stress conditions can lead to the collapse of an organization together with its underlying business, possibly linked to a social disaster with loss of life. Some technology-ignorant management decisions even under non-stress conditions can lead to dangerous situations, which can increase the economic burden placed on an organization. This book describes such situations in order to promote improvement in organizational preparedness by training, experience, and education to reduce safety and economic risks. This book offers: • Case studies of accidents that have affected different HROs (high-risk organizations) and others, due to poor decision-making by management • Training methods (advocated by Admiral Hyman Rickover, adopted by military bodies and others) to prepare staff to make critical decisions under difficult conditions and examine their applicability to training managers of high-risk facilities • Documentation on how making decisions in difficult situations have psychological constraints related to the degree of preparedness and the tools available to aid the decision maker(s) • Studies on the key actions taken before, during, and after accidents and how these management decisions can affect accident propagation, and how one could improve management decision-making by the use of training in decision-making and an understanding of Ross Ashby’s Law of Requisite Variety. • Simulation techniques to improve training of front-line operators and management • Consideration of cost and investment evaluations and how they can distort the selection of tactics and measures that ensure successful operations and avoidance of accidents

Researching Patient Safety and Quality in Healthcare

Author : Karina Aase
Publisher : CRC Press
ISBN 13 : 1317065530
Total Pages : 265 pages
Book Rating : 4.3/5 (17 download)

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Book Synopsis Researching Patient Safety and Quality in Healthcare by : Karina Aase

Download or read book Researching Patient Safety and Quality in Healthcare written by Karina Aase and published by CRC Press. This book was released on 2016-10-03 with total page 265 pages. Available in PDF, EPUB and Kindle. Book excerpt: Researching Patient Safety and Quality in Health Care: A Nordic Perspective is an anthology based on contributions from leading researchers on quality and safety in healthcare in the Nordic countries together with four internationally renowned patient safety authors. Research on patient safety and quality has been dominated by countries such as the USA, England, Canada, and Australia. This book addresses the current debates in research on patient safety and quality in healthcare from a Nordic perspective. What are the flavours of Nordic research within these topics? What does it add to the international research literature? This book illustrates the unique nature of researching patient safety and quality with the Nordic perspective as well as showcasing representative work. The book presents an overview of the status and evidence of international and Nordic research on quality and safety in healthcare. Four different perspectives are used to present the trends within the research field: a patient perspective, a methodological perspective, a theoretical perspective, and a clinical perspective. The book then presents the status of Nordic research in the field and displays a set of illustrative work and current research topics within the Nordic context, concluding with a discussion of the characteristic features of Nordic research on patient safety and quality in healthcare. The anthology presents an inter-professional perspective and researchers from disciplines such as medical and nursing sciences, humanities, social sciences and engineering. It is written to contribute to the patient safety cause with translational knowledge that will be useful to researchers, policy makers and healthcare managers within Nordic countries and internationally.

Decision-Making Under Stress

Author : Rhona Flin
Publisher : Routledge
ISBN 13 : 1351945947
Total Pages : 328 pages
Book Rating : 4.3/5 (519 download)

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Book Synopsis Decision-Making Under Stress by : Rhona Flin

Download or read book Decision-Making Under Stress written by Rhona Flin and published by Routledge. This book was released on 2017-03-02 with total page 328 pages. Available in PDF, EPUB and Kindle. Book excerpt: In our high technology society, there is a growing demand for a better understanding of decision making in high risk situations in order to improve selection, training and operational performance. Decision Making Under Stress presents a state-of-the-art review of psychological theory, in research and practice, on decision making in high pressure and emergency situations. It focuses on the experienced decision makers who deal with such risks, principally on flight decks, at civil emergencies, in industrial settings and military environments. The 29 chapters cover a wide range of perspectives and applications from aviation, military, industry and the emergency services. The authors, all international invited experts in their field, are based in research centers and universities from Europe, North America and Australia. Their common interest is in the theories and methods of a new research domain called NDM (naturalistic decision making). This volume comprises the edited contributions to the Third International NDM conference, sponsored by the US Army Research Institute and the US Naval Air Warfare Center, which was held in Aberdeen, Scotland in September 1996. The NDM researchers are interested in decision making in situations characterised by high risk, time pressure, uncertain goals, ambiguous information and teamwork. The extent to which the NDM approach can explain and predict human performance in such settings is a central theme, discussed with many practical examples and applications. This book is essential reading for applied psychologists, pilots, emergency commanders, military officers, high hazard managers, safety and emergency response professionals.

Risk Governance of Offshore Oil and Gas Operations

Author : Preben Hempel Lindøe
Publisher : Cambridge University Press
ISBN 13 : 1107025540
Total Pages : 457 pages
Book Rating : 4.1/5 (7 download)

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Book Synopsis Risk Governance of Offshore Oil and Gas Operations by : Preben Hempel Lindøe

Download or read book Risk Governance of Offshore Oil and Gas Operations written by Preben Hempel Lindøe and published by Cambridge University Press. This book was released on 2014 with total page 457 pages. Available in PDF, EPUB and Kindle. Book excerpt: This book evaluates and compares risk regulation and safety management for offshore oil and gas operations in the United States, United Kingdom, Norway, and Australia. It provides an interdisciplinary approach with legal, technological, and sociological perspectives on their efforts to assess and prevent major accidents and improve safety performance offshore. Presented in three parts, the volume begins with a review of the technical, legal, behavioral, and sociological factors involved in designing, implementing, and enforcing a regulatory regime for industrial safety. It then evaluates the four regulatory regimes that encompass the cultural, legal, and other contextual factors that influence their design and implementation, along with their reliance on industrial expertise and standards and the use of performance indicators. The final section presents an assessment of the resilience of the Norwegian regime and its capacity to keep pace with new technologies and emerging risks, respond to near miss incidents, encourage safety culture, incorporate vested rights of labor, and perform inspection and self-audit functions. This book is highly relevant for those in government, business, academia, and elsewhere in civil society who are involved in offshore safety issues, including regulatory authorities and industrial safety professionals.

The Oxford Handbook of Organizational Decision Making

Author : Gerard P. Hodgkinson
Publisher : Oxford University Press, USA
ISBN 13 : 0199290466
Total Pages : 651 pages
Book Rating : 4.1/5 (992 download)

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Book Synopsis The Oxford Handbook of Organizational Decision Making by : Gerard P. Hodgkinson

Download or read book The Oxford Handbook of Organizational Decision Making written by Gerard P. Hodgkinson and published by Oxford University Press, USA. This book was released on 2008 with total page 651 pages. Available in PDF, EPUB and Kindle. Book excerpt: The Oxford Handbook of Decision-Making comprehensively surveys theory and research on organizational decision-making, broadly conceived. Emphasizing psychological perspectives, while encompassing the insights of economics, political science, and sociology, it provides coverage at theindividual, group, organizational, and inter-organizational levels of analysis. In-depth case studies illustrate the practical implications of the work surveyed.Each chapter is authored by one or more leading scholars, thus ensuring that this Handbook is an authoritative reference work for academics, researchers, advanced students, and reflective practitioners concerned with decision-making in the areas of Management, Psychology, and HRM.Contributors: Eric Abrahamson, Julia Balogun, Michael L Barnett, Philippe Baumard, Nicole Bourque, Laure Cabantous, Prithviraj Chattopadhyay, Kevin Daniels, Jerker Denrell, Vinit M Desai, Giovanni Dosi, Roger L M Dunbar, Stephen M Fiore, Mark A Fuller, Michael Shayne Gary, Elizabeth George,Jean-Pascal Gond, Paul Goodwin, Terri L Griffith, Mark P Healey, Gerard P Hodgkinson, Gerry Johnson, Michael E Johnson-Cramer, Alfred Kieser, Ann Langley, Eleanor T Lewis, Dan Lovallo, Rebecca Lyons, Peter M Madsen, A. John Maule, John M Mezias, Nigel Nicholson, Gregory B Northcraft, David Oliver,Annie Pye, Karlene H Roberts, Jacques Rojot, Michael A Rosen, Isabelle Royer, Eugene Sadler-Smith, Eduardo Salas, Kristyn A Scott, Zur Shapira, Carolyne Smart, Gerald F Smith, Emma Soane, Paul R Sparrow, William H Starbuck, Matt Statler, Kathleen M Sutcliffe, Michal Tamuz , Teri JaneUrsacki-Bryant, Ilan Vertinsky, Benedicte Vidaillet, Jane Webster, Karl E Weick, Benjamin Wellstein, George Wright, Kuo Frank Yu, and David Zweig.

Risk Management Handbook for Health Care Organizations, 3 Volume Set

Author :
Publisher : John Wiley & Sons
ISBN 13 : 0470649194
Total Pages : 2125 pages
Book Rating : 4.4/5 (76 download)

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Book Synopsis Risk Management Handbook for Health Care Organizations, 3 Volume Set by :

Download or read book Risk Management Handbook for Health Care Organizations, 3 Volume Set written by and published by John Wiley & Sons. This book was released on 2011-01-06 with total page 2125 pages. Available in PDF, EPUB and Kindle. Book excerpt: Continuing its superiority in the health care risk management field, this sixth edition of The Risk Management Handbook for Health Care Organizations is written by the key practitioners and consultant in the field. It contains more practical chapters and health care examples and additional material on methods and techniques of risk reduction and management. It also revises the structure of the previous edition, and focuses on operational and organizational structure rather than risk areas and functions. The three volumes are written using a practical and user-friendly approach.

Managing Business Risk

Author : Jonathan Reuvid
Publisher : Kogan Page Publishers
ISBN 13 : 0749466618
Total Pages : 304 pages
Book Rating : 4.7/5 (494 download)

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Book Synopsis Managing Business Risk by : Jonathan Reuvid

Download or read book Managing Business Risk written by Jonathan Reuvid and published by Kogan Page Publishers. This book was released on 2011-12-03 with total page 304 pages. Available in PDF, EPUB and Kindle. Book excerpt: Risk management is the identification, assessment and prioritization of risks, and effective risk management is a vital consideration when looking to safeguard your company's commercial future and deal with the latest regulatory requirements. Managing Business Risk will enable your company to maintain the clearest possible controls on risks that may threaten your business while at the same time delivering transparent reporting to your stakeholders.The book examines the key areas of risk you need to consider in today's competitive and complex business market. Drawing on expert advice from leading risk consultants, lawyers and regulatory authorities, it shows you how to protect your business against a rising tide of business risks.If you don't build risk controls into the structure of your company, from the boardroom down, then your business could be vulnerable to a number of threats - both internal and external. Identify and neutralise them now, and give your company a competitive advantage.

Principles of Risk-Based Decision Making

Author : In c. ABS Consulting
Publisher : Government Institutes
ISBN 13 : 0865879087
Total Pages : 225 pages
Book Rating : 4.8/5 (658 download)

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Book Synopsis Principles of Risk-Based Decision Making by : In c. ABS Consulting

Download or read book Principles of Risk-Based Decision Making written by In c. ABS Consulting and published by Government Institutes. This book was released on 2002-02 with total page 225 pages. Available in PDF, EPUB and Kindle. Book excerpt: Principles of Risk-Based Decision Making provides managers with the foundation for creating a proactive organizational culture that systematically incorporates risk into key decision-making processes. Based on methodology adopted by a number of organizations including the federal government, this book examines risk-based decision making as a process for organizing information about the possibility for unwanted outcomes in a simple, practical way that helps decision makers make timely, informed management choices that minimize harmful effects on safety and health, the environment, property loss, or mission success. Citing practical examples, charts, and checklists, the authors break the risk-based decision making process into five key components: establishing the decision structure, performing the risk assessment, managing sufficient risks, monitoring effectiveness of adopted risk controls through impact assessment, and facilitating risk communication. They examine each component in detail and outline available decision analysis and risk assessment tools that aid in each of these risk-based decision making functions. This book also walks readers through eight project management steps—from scoping a risk assessment to evaluating the recommendations—the components of each, and the importance of these steps to the success of a risk assessment. Special features include a table for applying the risk-based decision-making process, a hazard identification guidesheet, an example of human error, an acronym list, and a glossary.

Critical Steps

Author : Tony Muschara
Publisher : CRC Press
ISBN 13 : 1000476812
Total Pages : 195 pages
Book Rating : 4.0/5 (4 download)

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Book Synopsis Critical Steps by : Tony Muschara

Download or read book Critical Steps written by Tony Muschara and published by CRC Press. This book was released on 2021-11-22 with total page 195 pages. Available in PDF, EPUB and Kindle. Book excerpt: Critical Steps happen every day at work and at home, purposefully. Work does not happen otherwise. If an operation has the capacity to do work, then it has the capacity to do harm. Work is energy directed by human beings to create value. But people are imperfect—we make mistakes, and sometimes we lose control of the work. Therefore, work is the use of force under conditions of uncertainty. A Critical Step is a human action that will trigger immediate, irreversible, and intolerable harm to an asset, if that action or a preceding action is performed improperly. Whether the human action involves clicking on a link attached to an e-mail message, walking down a flight of stairs with a newborn baby in arms, engaging the clutch on a gasoline-driven chain saw, or administering a medication to a patient in a hospital, these all satisfy the definition of what constitutes critical risks in our daily lives, professionally or personally. The overarching goal of managing Critical Steps is to maximize the success (safety, reliability, productivity, quality, profitability, etc.) of people’s performance in the workplace, to create value for the organization without losing control of built-in hazards necessary to create that value.

Human and Organisational Factors

Author : Benoît Journé
Publisher : Springer Nature
ISBN 13 : 3030256391
Total Pages : 139 pages
Book Rating : 4.0/5 (32 download)

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Book Synopsis Human and Organisational Factors by : Benoît Journé

Download or read book Human and Organisational Factors written by Benoît Journé and published by Springer Nature. This book was released on 2020-01-02 with total page 139 pages. Available in PDF, EPUB and Kindle. Book excerpt: This open access book addresses several questions regarding the implementation of human and organisational factors (HOF) so that recent improvements in industrial safety can be built upon. It addresses sources of frustration in senior management with high expectations of operational recommendations and disquiet on the part of HOF specialists struggling to have an impact on high-level decision making. The brief explores these issues with an emphasis on examples and lessons learned based on the experience of its authors, who come from different academic disciplines and various industrial sectors such as oil and gas, energy and transportation. It then offers some ways forward for a better consideration of HOF in hazardous companies with a view of promoting safety and facing challenges in a rapidly changing world.

An Analysis of Organizational Decision-Making

Author : Andrea D. Begel
Publisher :
ISBN 13 : 9781423570615
Total Pages : 125 pages
Book Rating : 4.5/5 (76 download)

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Book Synopsis An Analysis of Organizational Decision-Making by : Andrea D. Begel

Download or read book An Analysis of Organizational Decision-Making written by Andrea D. Begel and published by . This book was released on 1997-12-01 with total page 125 pages. Available in PDF, EPUB and Kindle. Book excerpt: Every day organizations make decisions, triggering a chain of events, initiating certain activities, resulting in certain outcomes. Some organizations must manage incidents involving extreme levels of risk, under high levels of stress. Government agencies, law enforcement agencies, and military organizations are often presented with such scenarios. When outcomes are favorable, credit is given to the leadership, who presumably made the right decisions, and to those who carried out the decisions, presumably for their great skill in executing what needed to be done. When outcomes are not favorable, days, months, even years are spent analyzing what went wrong, and why. Often, failure is said to result from 'bad luck' or failure to execute one portion of a plan, which inevitably led to overall failure. By analyzing failed operations in high stress, high risk environments, one can argue that blaming the failure of large scale operations on one step in a chain of events is to neglect real underlying symptoms of poor organizational decision making, poor strategic planning, and poor contingency planning.

Organization at the Limit

Author : William Starbuck
Publisher : John Wiley & Sons
ISBN 13 : 140513108X
Total Pages : 421 pages
Book Rating : 4.4/5 (51 download)

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Book Synopsis Organization at the Limit by : William Starbuck

Download or read book Organization at the Limit written by William Starbuck and published by John Wiley & Sons. This book was released on 2005-09-12 with total page 421 pages. Available in PDF, EPUB and Kindle. Book excerpt: The book offers important insight relevant to Corporate, Government and Global organizations management in general. The internationally recognised authors tackle vital issues in decision making, how organizational risk is managed, how can technological and organizational complexities interact, what are the impediments for effective learning and how large, medium, and small organizations can, and in fact must, increase their resilience. Managers, organizational consultants, expert professionals, and training specialists; particularly those in high risk organizations, may find the issues covered in the book relevant to their daily work and a potential catalyst for thought and action. A timely analysis of the Columbia disaster and the organizational lessons that can be learned from it. Includes contributions from those involved in the Investigation Board report into the incident. Tackles vital issues such as the role of time pressures and goal conflict in decision making, and the impediments for effective learning. Examines how organizational risk is managed and how technological and organizational complexities interact. Assesses how large, medium, and small organizations can, and in fact must, increase their resilience. Questions our eagerness to embrace new technologies, yet reluctance to accept the risks of innovation. Offers a step by step understanding of the complex factors that led to disaster.