Process Safety Culture, Incident Investigation - Tool - Building Process Safety Culture Tool Kit

As the complex technical and managerial  discipline of process safety has matured, our ability to analyze and assert control over adverse outcomes has reached to deeper and deeper levels.  At first, we sought to assess blame on the parties causing accidents: the operator who didn’t follow procedure, the engineer who chose the wrong material of construction, or the supervisor who botched the work safety permit.  Later, we learned to question management systems; were the procedures in fact possible to follow, was the engineer given enough time and resources to  choose the correct material, or did the supervisor received adequate training?  Over the years, we have also seen numerous examples of failures on an even deeper level, at the level of organizational culture.  This did not come into clear view until the final months of 2003.