ABSTRACT

Often when a disaster is described in the media, words like freak, unforeseen, human error, Act of God, technical failure, etc are used to explain the reasons for the incident occurring. One corollary which can drawn from the hypothesis with regard to the similar features of accidents is that any failure which occurs in one system will have a propensity to recur in another "like" system for similar reasons. while the "organizational specific" and "iconic" levels of analysis and learning are important it is the "isomorphic'" lessons drawn from the analysis of a disaster that are the most valuable, for it is at that level of analysis where complex large-scale socio-technical disasters can be seen more clearly. Organizational isomorphism should be looked for wherever it might exist for it is a useful abstraction which can greatly assist the learning process. At every large-scale accident inquiry the hope is expressed that the investigation will ensure that "this shall not happen again".