One thing that becomes apparent when considering the previous chapters' case studies is that teamwork is an elusive thing. Through the analysis of the USS Greeneville disaster, for instance, we learned that the wider organizational system can sometimes demand skills from leaders to serve external purposes that then undermine the high-risk team's operational performance. The Hillsborough football stadium disaster showed us the dangers of a centralized leadership hierarchy when an inexperienced commander is working with an experienced team facing an unpredictable challenge. In the case of American Airlines Flight 587, we saw how a lack of organizational collaboration between designers and operators of complex systems can align with individual and team failures to end in disaster. And finally, through the example of the Bristol Royal Infirmary, we learned about the high price of organizational overreach and its detrimental impact on team performance in high-risk situations.

Just as Charles Perrow predicted, these unconventional failures challenged Greeneville sailors, Hillsborough police, American Airlines pilots, and Bristol medical professionals in unanticipated ways as one unexpected failure stressed different parts of the system in unusual ways, causing increasingly unanticipated results. Trained to respond ‘by the book’, it was difficult for each of these teams to think through their crises, managing anxieties and evolving their mental model of the unfolding disaster as new data emerged.