Discussion and conclusions
This final chapter reviews some fundamental themes, before summarising and reviewing the research upon which the book is based. The summary includes observations and conclusions regarding the field investigations, interviews and documentary evidence, and provides an overview of the theoretical framework developed. The bulk of the chapter discusses a proposed systems-based organisational model that, if adopted, could be a basis for a national system to reduce socio-technical failures. The model consists of a hierarchy of subsystems, some of which would feed back information on socio-technical failures through several paths to industry, designers, legislators and educational establishments, to aid organisational learning.
KeywordsActive Learning Public Inquiry Organisational Learning Safety Culture Major Accident
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