9. In conclusion

Our analysis of these six major disasters shows that they all originated in a degraded mode, and that several causes of varied origins (organizational, technological, procedural, human, environmental) were necessarily required to allow the accidental sequence to develop.

Accidents can happen, because there is no such thing as zero risk. This is why it is pointless to try and implement organizations that guarantee faultlessness. Since we cannot cancel out the probability of a dreaded event occurring, we are left with only one possible option: to implement organizations capable of detecting any drift, any incidental or even accidental sequence as early as possible, and then, taking into account the technological, organizational and human systems in place, to reduce the consequences of any malfunctions that do occur to socially acceptable levels. It is in this spirit...