Must accidents happen? Lessons from high-reliability organizations
基于高可靠性组织的研究，向管理者提出三条建议：主动探寻未知、设计激励系统以体现失败成本与可靠性收益、向全员传达全局信息，以降低事故发生的概率和严重性。
Executive Overview In the more than 15 years since the initial publication of Charles Perrow's Normal Accidents, practitioners and academics have contemplated how plane crashes, earthendam collapses, ship collisions, nuclear disasters, and chemical-plant explosions can be prevented, mitigated, or avoided. While no one has yet learned how to make the inevitable avoidable, a literature on high-reliability organizations (HROs) has developed that gives some hope that disasters can be minimized in frequency and severity. The value of this research to practicing executives is to take the lessons learned through the research on HROs and apply them to their own organizations. This article is about how to beat the odds of having an incident or accident that one is unprepared for, regardless of the organization's purpose. Neither the sausage maker nor the chemical-plant manager is immune from errors that can have far-reaching consequences. The three major recommendations we offer are that managers should aggressively seek to know what they don't know, design reward and incentive systems to recognize the cost of failure and the benefits of reliability, and communicate the big picture to everyone.