Conclusion
Risks in complex systems

Organizational analysis and the organizational paradigm that underpins it nowadays appear to be a fundamental complementary response to the problems, on the one hand, of safety, and, on the other, of the productive and economic performance of complex socio-technical systems at risk. Research into and analysis of human error on the part of personnel at the direct interface with technical systems, while necessary, are far from sufficient.

Decisions are taken, often at high levels of management and expertise, which then trickle down, to use Diane Vaughan's metaphor and analysis