Systemic Factors in Organisational Failures: A Review of some recent high-profile cases

Main Article Content

David H. Slater Ben Ale


This paper explores the various options for organisational structures by examining some high-profile incidents in the light of a number of theories that have been put forward to explain behaviours.

On first inspection, it might be concluded that a common theme emerging from studying the results of such organisational behaviours might be the slavish conformance to “acceptable” or expected “institutionalised” structures which stipulate impenetrable layers of middle management between the “sharp end” teams and the responsible executives and their governing Boards. This so called “clay layer” has been highlighted as a major factor in high profile incidents such as Challenger, Columbia, Chernobyl, Longford, Macondo blow out and many others .

However, on closer examination, there are other examples of corporate failures, (such as the Post Office computerisation scandal) which suggest that the “clay layer” in fact serves another purpose; to allow credible “deniability” for the controlling minds in difficult areas. The Health and Safety at Work Act 1974  maintains that the” person who was the 'controlling mind' of the organisation is personally responsible for the offence. This paper sets out to scrutinise whether these are borne out in practice. and urges that the design and application of organisational structures should be tailored to effective and ethical operation.

Article Details

How to Cite
SLATER, David H.; ALE, Ben. Systemic Factors in Organisational Failures: A Review of some recent high-profile cases. Medical Research Archives, [S.l.], v. 10, n. 12, dec. 2022. ISSN 2375-1924. Available at: <>. Date accessed: 19 june 2024. doi:
Review Articles


. Slater DH, Ale BJM. Organisations: Drifting or Dysfunctional? In Leva M, Patelli E, Podofillini P, Wilson S. Eds. Proceedings of the 32nd European Safety and Reliability Conference (ESREL 2022): Singapore: Research Publishing; 2022. ISBN: 978-981-18-5183-4. doi: 10.3850/978-981-18-5183-4_S32-02-197-cd.
. (as per 19/11/2022).
. Deming WE. Quality, productivity and competitive position. Cambridge: Massachusetts Institute of Technology; 1982. ISBN 0911379002.
. Wallis N. The Great Post Office Scandal: the fight to expose a multimillion pound IT disaster which put innocent people in jail. Bath: Bath Publishing; 2021.
. (as per 03/12/2022)
Slater D, Hollnagel E, MacKinnon R, Sujan M, Carson-Stevens A, Ross, A, Bowie P. A systems analysis of the COVID-19 pandemic response in the United Kingdom, Part 1, The overall context. Safety Science: 2022; 146: 105535.
Slater D. A Systems Analysis of the UK COVID 19 Pandemic Response: Part 2, Work as imagined vs Work as done. Safety Science: 2021; 146(8):105526. DOI: 10.1016/j.ssci.2021.105526
. Swuste P, Van Gulijk C, Zwaard W. Safety metaphors and theories, a review of the occupational safety literature of the US, UK and The Netherlands, till the first part of the 20th century. Safety Science: 2010;48: 1000–1018.
. LeCoze JC. Crisis Development: Normal Accidents and Beyond. Oxford Research Encyclopedias: 2022: (as per 18/11/2022).
. Perrow C. Normal Accidents: Living with High-Risk Technologies. New York: Basic Books; 1984.
. Hopkins A. The Limits of Normal Accident Theory. Safety Science: 1999; 2: 93 – 102.
. Bonneuil C, Fressoz JB. The Shock of the Anthropocene: The Earth, History and Us. London: Verso; 2013.
. Turner B.. The Organizational and Interorganizational Development of Disasters. Administrative Science Quarterly: 1976;21(3):378–397. CiteSeerX doi:10.2307/2391850. JSTOR 2391850.
. Perrow Charles. Normal Accidents: Living with High-Risk Technologies. New York: Basic Books; 1984.
. La Porte TR, Consolini PM. Working in Practice But Not in Theory. Journal of Public Administration Research and Theory: 1991; J-PART; 1: 19-48.
. Sagan S. The Limits of Safety. Princeton: Princeton University Press; 1993.
. Vaughan D. The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. University Of Chicago Press: 1996. ISBN 978 0226851761.
. Hopkins A. Lessons from Longford. London: Blackwells; 2002. ISBN 9781864686883.
. Le Coze JC. Post Normal Accident. Revisiting Perrow’s classic. Boca Raton: FL CRC Press, Taylor & Francis; 2020.
. Downer J. 737-Cabriolet: The Limits of Knowledge and the Sociology of Inevitable Failure. American Journal of Sociology. 2011;117(3):725-762.
. Pritchard S. An Environmental Disaster: Nature, Technology and Politics at Fukushima. Environmental History: 2012;17:219 – 243.
. Starbuck WH, Farjoun M. Organization at the limit: Lessons from the Columbia Disaster. Oxford: Blackwell Publishing; 2005.
. Ale BJM, Slater DH, Hartford DND. The ethical dilemmas of risky decisions. Risk Analysis: 2022;1–15.
. Moore-Bick M. Grenfell Tower Inquiry Phase 1 Report. REPORT of the PUBLIC INQUIRY into the FIRE at GRENFELL TOWER on 14 JUNE 2017. Crown Copyright; 2019. ISBN 978-1-5286-1602-7.
. infected blood inquiry (as per 03/12/2022).
. Peter LJ, Hull R. The Peter Principle. New York: William Morrow & Co Inc; 1969. ISBN: 0062092065
. Peter LJ. The Peter Pyramid: Or, Will We Ever Get the Point? New York: William Morrow and Company; 1986. ISBN 978-0688053802.
. Syed M. Clapped out: Is the NHS broken? Channel 4 Documentary, (as per 03/12/2022)
. Rezvani Z. Breaking the clay layer: The role of middle managers in safety management. PhD Thesis. Delft: TU Delft; 2018. ISBN 9789461868855,
. Heinrich H, Cranniss E. Industrial Accident Prevention, a Scientific Approach. New York: Graw Hill Book Company; 1959.
. Mason R, Mitroff I. Complexity: The nature of real world problems. In Bob de Wit B. Ron Meyer R. Eds. Strategy Synthesis. Stamford: Thomson Publishing; 2003: 26-36.
. Rittel HWJ; Webber MM. Dilemmas in a General Theory of Planning. Policy Sciences: 1973; 4 (2) 155–169. doi:10.1007/bf01405730. S2CID 18634229. Archived from the original on 30 September 2007.Reprinted in Cross, N., ed. Developments in Design Methodology. Chichester, England: John Wiley & Sons; 1984: 135–144.