Lessons From The Wreck Of The Exxon Valdez

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Abstract
Investigations of large scale industrial accidents generally take one of two alternative approaches to identifying the cause or causes of those destructive events. The first is legal analysis, which focuses on the mechanical failure or human error that immediately preceded the accident. The second is socio-technical reasoning, which centers on the complexities of the interlocking technological and organizational systems that brought about the accident. Both are retrospective, and provide little insight into the means of avoiding industrial accidents in the future. This article looks at six levels of managerial responsibility within a firm, and suggests specific changes at all levels that should logically help in the prevention or mitigation of these high impactllow probability events. The most basicneed, however, is for imagination, empathy, and courage at the most senior level of the firm.

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