Chapter 1: Accidents, Tragedies And Disasters The Rule Of Accidental The Explanation Of Human Error The Explanation Of A Breakdown Of A Material Or Technical Component And Its Corollary, 'Risky Technology' Risky Or Unruly Technology? The Explanation Of Organizational Inertia Or Bureaucratic Drift Accidents Will Happen The Word Accident The Belief In Monocausality Multi-Causality And Multiple Responsibility Fault Finding And The Scapegoat Warnings And Ethics Freedom And Ethics Notes Chapter 2: Ethics As Involved In The Goals Of An Organization Ethics And The Conduct Of Business Enterprise Ethics And The Infrastructure Of A Business Organization Ethics And Informal Channels Of Communication Ethics And Formal Reporting Channels Chapter 3: The Buck Stops Here The Will To Communicate The Manager s Task Notes Chapter 4: Conceptual Preparedness The Explicit Prioritization Of A Safety Ethos Notes Chapter 5: The Vasa Disaster The Stability Test The Question Of Ballast The Wind Pressure On The Sails Conclusions Notes Chapter 6: The Collision Causes Of The Disaster Speed Of The Ship Weather Causes Of Deaths Relevant Design Features Rivets The Inadequacy Of The Human Error Hypothesis Lifeboats Third-Class Passengers Nearby Rescue Possibilities The Rescue By The S.S. 'Carpathia' Findings Of The Court Look-Out Speed Recommendations Notes Chapter 7: A Brief Synopsis Key Words The Word Accident Cause And Contributing Cause The Atmosphere Of The Decision Making Process A Fixed Deadline Must Be Met That A Wrong Decision Will Have Grave Consequences The Presence Of Irregularities (A.) The Lack Of Any Clear Uniform Guidelines As To Moral Criteria The Lack Of A Spelled Out Decision Making Mechanism Management Structure The Language Of Communication Responsibility: Bottom Up Top Down Responsibility Dormant Stage The Will To Communicate Chapter 8: Safety Priority Decision Making Safety First? Is There A Greater Sense Of Resp0nsibility Now? Were Middle Managers Simply Following Policy? Were The Middle Managers Moral? Normalized Decisions? Links Between Temperature And Erosion Faith In The Secondary Seal? The Question Of 'Hard Data' Ethical Decision Making Conclusion Notes Chapter 9: The Orders A Dysfunctional Management Technical Component The Closing Of The Doors The Will To Communicate Chapter 10: The King s Cross Underground Fire Epistemological Frameworks Compared The Use Of Words The Cause Of The Fire Responsibility For The Fire: Top Down Responsibility: Bottom Up The Importance Of A Safety Ethos Fennell s Recommendations: The Primacy Of Safety Chapter 11: The Disaster On Mt. Erebus A Short History Of The Disaster The Evidence From The Flight-Deck Tapes Vette s Text Macfarlane s Notes On Vette s Text Taking A Phenomenological View The Whiteout Phenomenon Phenomenological Approach: Tapes The Coherence Theory Of Truth Mismanagement The Cause Of The Disaster Defects In Administrative Structure Defects In Administrative Communications System Summary Of Management Defects The Lack Of Any Safety Ethos