From Bhopal to Deepwater Horizon, history shows that catastrophic accidents are rarely unforeseen—they are often the consequence of organisations failing to act on warning signs, sustain a strong safety culture and learn from near misses.
Whenever I study the investigation reports of major industrial disasters such as the Bhopal Gas Tragedy, Jaipur Terminal Fire, Tatipaka Natural Gas Pipeline Failure, Texas City Refinery Explosion, Buncefield Depot Explosion, Deepwater Horizon Blowout and the Styrene Gas Leak at Visakhapatnam, one common thread becomes impossible to ignore. These incidents were rarely the result of a single equipment failure or an isolated human mistake. Instead, they were the outcome of a gradual erosion of safety culture. The warning signs were almost always present, but they were ignored, normalised or accepted as part of routine operations until catastrophe became inevitable.
The organisational behaviours and cultural attributes that quietly determine whether safety barriers remain effective or fail before disaster strikes:
Equipment rarely fails without giving warning signals. We ignore the warning signals and invite unsafe situations. Recurring alarms, abnormal vibrations, repeated maintenance issues, inspection observations and small process deviations are often early indicators that something is wrong. Unfortunately, organisations sometimes become accustomed to these warning signals and tend to ignore or normalise them. This normalisation of deviation, in my view, represents one of the greatest threats to process safety.
The greatest challenge facing high-hazard industries today is not the absence of safety regulations or engineering codes / standards. The real challenge is ensuring that people consistently make the right decisions, especially when no one is watching. Safety culture fills this gap. It influences everyday behaviours, priorities and decisions far more than any written procedure.
Safety culture is the invisible protective barrier that exists above engineering safeguards, management systems and operating procedures. While hardware can fail and procedures may become outdated, a strong safety culture encourages people to identify weak signals, question unsafe practices and intervene before incidents escalate into disasters. Over the years, I have come to believe that organisations with mature safety cultures consistently display several defining characteristics.
Just Culture: Employees should be encouraged to report mistakes, procedural deviations and unsafe acts without fear of unfair punishment. This does not mean the absence of accountability. Rather, it means recognising the difference between genuine human error, risky behaviour and deliberate negligence.
Reporting Culture: It has been observed that people hesitate to communicate bad news because they fear criticism or believe that raising concerns may create unnecessary problems. Bad news is good news; it prevents and provides the organisation's earliest opportunity to prevent a major accident. A leaking valve, a bypassed safety interlock or an overdue inspection may appear insignificant individually, but collectively they may indicate that critical safety barriers are weakening.
Learning Culture: Every incident, whether it occurs within our own installations or in other industries, offers valuable lessons. Unfortunately, organisations sometimes conduct thorough investigations only to gradually forget the findings as employees retire, change roles or leave the company. Memory fades and accidents continue to happen. Therefore, it is paramount to institutionalise the learning process. Lessons learned must be systematically captured and embedded into organisational practices.
Flexible Culture: Technologies evolve, operating conditions change, and new risks continuously emerge. Safety management systems cannot remain static. Organisations must therefore modify procedures, strengthen controls, update the Standard Operating Procedures (SOP) and regulations based on the new technological developments in the field.
Trusting Culture: Finally, no safety culture can mature without trust. Employees, contractors, supervisors and senior management must feel comfortable discussing problems openly. Expressing dissenting views. Trust develops when leadership consistently demonstrates integrity, fairness and commitment and leaders walk the talk.
Organisations possessing the above qualities resemble what are often called High Reliability Organisations. Their success does not stem from believing that accidents are impossible. Instead, they operate with a constant awareness that failure is always possible and therefore remain continuously vigilant.
“It has been observed that people hesitate to communicate bad news because they fear criticism or believe that raising concerns may create unnecessary problems”
Leadership, however, remains the single most influential factor in shaping safety culture. Employees pay far greater attention to what leaders do than to what they say. If production issues receive most attention while safety concerns are postponed, the workforce understands the organisation's true priorities. Safety culture is therefore built through visible actions rather than speeches or posters. We must ask the question: production at what cost?
I believe every leader should periodically ask a few uncomfortable questions. Do I genuinely encourage people to challenge my decisions? Am I creating an environment where employees feel safe reporting concerns? Have we become complacent simply because we have not experienced a major accident in recent years? Yesterday’s safe performance does not guarantee a safe tomorrow.
One of the most dangerous assumptions any organisation can make is believing that the absence of incidents indicates the presence of safety. Many major accidents have occurred in installations with excellent occupational safety statistics. Low injury rates are certainly desirable, but they should never be mistaken for strong process safety performance.
This is why I believe leaders must devote greater attention to leading indicators rather than relying exclusively on lagging indicators such as Lost Time Injury Frequency Rate. The number of impaired safety-critical devices, overdue inspections, Management of Change backlogs, emergency drill performance and near-miss reporting trends often provide a far more realistic picture of process safety health than injury statistics alone.
Visible leadership commitment is equally important. Senior management should regularly visit the site, engage with frontline employees and review process safety concerns. Such interactions demonstrate that safety is genuinely valued throughout the organisation.
Adequate investment is another essential leadership responsibility. Preventive maintenance, inspections, competency development, hazard studies and emergency preparedness should never be viewed merely as operational expenses. Deferred maintenance and shrinking training budgets may appear financially attractive in the short term, but they often become precursors to much larger losses.
“Every near miss, every equipment abnormality and every operational deviation should be treated as an opportunity to strengthen the system before something more serious occurs”
As the energy sector progresses towards sustainability and net-zero objectives, we must believe that safety is not in competition with sustainability or decarbonisation or operational efficiency rather safety supplements the same. Safe operations and sustainable operations are mutually reinforcing. Process safety failures resulting in fires, explosions, hydrocarbon releases or methane emissions damage both human safety and environmental performance. One cannot be achieved at the expense of the other.
Perhaps the most important lesson I have drawn from studying major accidents is that organisations should never allow success to create complacency. Years of incident-free operation should increase vigilance rather than reduce it. Every near miss, every equipment abnormality and every operational deviation should be treated as an opportunity to strengthen the system before something more serious occurs.
Professor James Reason once observed that successful organisations are not those that never fail, but those that continually anticipate failure and prepare for it. I believe this philosophy captures the essence of process safety.
“Ultimately, process safety is far more than engineering excellence or regulatory compliance. It reflects an organisation’s values, leadership, culture and willingness to learn”
Before I conclude, let me state that in the Indian oil & gas industry, safety has improved a lot, accident rates are showing a downward trend and people are more aware of process safety management issues. Still, 85-90 percent of accidents take place due to three major reasons like violation of the work permit system, disregard to SOPs and poor site visit. All these incidents can be preventable provided we strengthen the safety culture.
Ultimately, process safety is far more than engineering excellence or regulatory compliance. It reflects an organisation's values, leadership, culture and willingness to learn. Engineering and Administrative controls provide the first line of defence, but it is safety culture that determines whether those defences remain effective throughout the life cycle of the installation.
In my opinion, the next major industrial accident will not be prevented solely by introducing another regulation or another checklist. It will be prevented when organizations consciously build a culture in which people remain vigilant 24X7, empowered to speak up and committed to quality. That invisible barrier called safety culture must remain our strongest defence against any major incidents & catastrophic failures.
The author is a former Executive Director, Oil Industry Safety Directorate (OISD), and Expert Advisor, Petroleum and Natural Gas Regulatory Board (PNGRB). Views are his own.