If you look at a selection of some recent UK disasters after which there has been a public inquiry or a coroner’s court – the King’s Cross fire, the Clapham rail disaster (where British Rail was fined £250,000), the Marchioness disaster, the Hillsborough tragedy, the Cowden rail disaster – one key point stands out from the judges’ or coroners’ remarks in all cases: the information needed to avoid the disaster was known somewhere inside the organization but neither the system nor the emotional climate to move such learning to where it was needed existed. The emotional climate created by the
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