本論文依照系統動力學的假設，重新整理危機管理理論中相關的定義，認為危機中除了天然或人為疏失之外，也有所謂決策者自行造成的危機：危機來自於當時正確的決策，經由複雜的系統互動之後，卻有可能導致錯誤的結果。如果能找出這類型的危機，例如避免錯誤的決策，或是改善錯誤的結構。及早預防，那麼危機管理的資源就可以多放一點在處理不可預測的意外部分，減輕管理資源分配的分擔。
總結來說，本研究之結論為：
1.將危機重新分類成逐漸形成的危機與突發型危機兩類，並發現可以逐漸形成的危機是可以使用系統觀點予以處理的。此一發現解決了學者對危機認知的分歧，並大幅減低決策者對危機的認知的複雜程度。
2.使用系統思考分析危機管理個案之歷史，發現當決策時如果不考慮其副作用與後遺症，可能會引發系統內的主導環路，引發危機。而決策時考量的因素可能受決策者個人的定靜程度或是心智模式所影響。
3.學習型組織中的五項修練，都有可能使組織變的更加健康，不容易產 生在本研究個案中所產生的困境，避免決策者或組織受到錯誤的心智模式所綑綁，而做出未來會產生危機的決策行為。

This study is according to the assumption of Systems dynamics approach to discuss the definitions of crisis management theory, and believes that there is not only crisis that happened naturally or simply created by human error, but also self-formed crisis by decision maker: Crisis comes from a decision which was right at that time. After complex interaction in the organization structure, this decision could turn into a serious crisis. If we can find out which decision would created crisis like that, or change the wrong structure, manager could put more effort on those crisis that could not be predict, and release the resource burden of management.
The conclusions of this study are presented as follows:
1. This study divides crisis into two categories: Crisis that formed gradually and accident. The former could be solved by systematic view.
2. Form the history of studied case, we found that if decision maker didn’t think about what side effect might have in the future, it could trigger some of reinforce loops and cause the crisis. And the reason of why they make the wrong decision is caused by the mental models of what could be right.
3. Each of the Fifth disciplines of learning organization could make the organizations more healthy, it could have chance to avoid all the troubles in this case study, and keep the decision makers and members of organization from making wrong decision according to their mental models.

目錄
謝 詞

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