When systems fail.
This review provides a detailed account of managerial causes of failure and managerial failure prevention strategies. The authors discuss the organizational tension that exists in balancing efficiency with reliability and emphasize the building blocks in becoming a high-reliability organization (HRO). They provide four case examples to illustrate their points and contrast organizational successes with factors that lead to potentially catastrophic failures. They offer a series of recommendations to enhance reliability and minimize risk within organizational structures.