In every organization, things go wrong. For the most part, these errors are minor and often go unnoticed. However, when disaster occurs, external pressure often forces the exposure of many of the failures that occur within an organization. Thus, a disaster can offer an opportunity for in-depth analysis of the internal workings of an organization. The Moura mine explosion is one such disaster. In this book, Hopkins argues that the explosion was the result of a series of system, cultural, hierarchical, and managerial errors. Furthermore, he argues that the organization was “systematically inattentive to the potential for errors”. In order to correct this organizational shortcoming, steps must be taken to address the aforementioned series of errors. This book begins with a brief preview of literature on disasters that highlights organizational factors pertinent to the Moura mine disaster. Next, the roles of communication failure and organizational culture are discussed. Subsequent chapters cover management shortcomings, specifically targeting the issue of safety through safety audits, measures of safety, an emphasis on productivity over safety, and management risk assessment. Additionally, the issue of safety is discussed on a broader level, and the common argument “safety pays” is discussed. The book concludes with a discussion of regulatory systems that are most appropriate for the coal mining system, and Hopkins summarizes the organizational failings and lessons revealed by the Moura mine explosion.