Safety Insights

The Safety Professional's Dilemma: Popularity or Prevention?
Rodney Rocha raised the alarm about Columbia's wing damage through every proper channel he had. It still wasn't enough. What his unsent email reveals about the real dilemma safety professionals face — and it isn't whether to speak up. Read more...
The Warning That Didn't Count
A month before Esso's Longford gas plant exploded, the exact precursor condition happened and nobody reported it — not because anyone hid it, but because the reporting system wasn't built to hear it. Why near-miss targets built around injury potential can make safety worse. Read more...
Abandoned industrial control room with glowing amber and red indicator panels and an empty operator's chair
Are We Blaming Human Error for Poor Engineering?
The Chernobyl disaster: when the people operating the equipment were blamed before the equipment itself was properly understood. What a reactor design flaw nobody told operators about reveals about investigating... Read more...
A refinery at dusk with an inspection checklist and pen resting on a railing in the foreground
The Problem With Safety Audits: Passing an Audit Doesn't Mean You're Safe
A 1975 safety audit at BP Grangemouth correctly identified the exact hazard that killed a contractor twelve years later. What the Grangemouth hydrocracker explosion reveals about the gap between an... Read more...
An empty operating theatre with a surgical checklist and pen resting on a steel trolley in the foreground
More Safety Procedures Don't Necessarily Mean a Safer Workplace
A Trust added more steps to its safety checklist than the national guidance required — and a patient still received a nerve block in the wrong leg. What a wrong-site... Read more...
A car ferry's open bow doors at a dark, stormy quayside at dusk
Why Your Safety Committee Might Be Wasting Everyone's Time
Safety meetings, hazard reports and action logs don't automatically make workplaces safer. What the Herald of Free Enterprise disaster teaches us about listening and acting on safety concerns. Read more...
A mine's advance-warning system for inspectors — what a safety record looks like when it's built for an audience
Safety Culture Is What Happens When the Manager Isn't Watching
At the Upper Big Branch Mine, security staff had an unofficial job: warning crews before a federal inspector arrived. Twenty-nine miners died on the one day nobody was due to... Read more...
Challenger's O-ring field joint — how repeated warnings became accepted practice before the 1986 disaster
"We've Always Done It This Way"
The Challenger engineers weren't wrong about the risk. They'd been right about it, in writing, for years. What changed wasn't the physics — it was that someone finally had to... Read more...
Transocean's perfect safety record alongside the Deepwater Horizon blowout one year later — measured, not managed
Have We Created an Industry That Measures Safety Instead of Managing It?
Transocean had its best-ever injury record and a regulator's top safety award the year before the Deepwater Horizon blowout. The number that got rewarded wasn't the one that would have... Read more...
Zero Harm engineering illustration: a petrochemical process unit with two gauges, one normal and one off-scale, showing why a good injury record is not proof the plant is safe
Is Zero Harm a Dangerous Target?
A falling injury rate and a catastrophic hazard can move in completely opposite directions, and most safety scoreboards aren't built to see it happen. In early 2005, BP's own safety... Read more...
Technical diagram of the RAF Nimrod MR2 fuel system and Cross-Feed/SCP duct, illustrating the risk assessment failures behind the XV230 disaster
The Illusion of Safety: When Every Box Is Ticked but Nothing Is Safe
Can an organisation look safe while its risk assessments are failing? A four-year, £400,000 Safety Case rated a fuel leak "Improbable" while the fleet was logging 40 a year. What... Read more...
Operator Error Was Never the Whole Finding
On 6 March 1987, the ferry Herald of Free Enterprise left Zeebrugge harbour with her bow doors wide open. Water poured onto the car deck as she picked up speed. Within about ninety seconds she had rolled onto her side in shallow water. The official finding records the loss of 188 lives. The assistant bosun responsible for closing the doors, Mark Stanley, had fallen asleep in his cabin. Above him, the chain of checks that should have caught his absence didn't hold either — the chief officer whose job it... Read more...
Isolated, According to the Tag
At around 1.05pm on 23 October 1989, maintenance workers at Phillips 66's Houston Chemical Complex in Pasadena, Texas, were clearing a settling leg on a polyethylene reactor — a routine job, done often. Within two minutes of the leg being opened, roughly 85,000 pounds (38.6 tonnes) of process gas had escaped and found an ignition source. The explosion threw debris six miles. A series of further explosions and fires followed, including a 20,000-gallon (75.7 m³) isobutane tank going up. Twenty-three people were killed. Over 130 more were injured. The site... Read more...
Everyone Signed Something
On 9 November 2016, at Carlsberg's brewery in Northampton, contractors were removing a compressor from a refrigeration system when ammonia escaped in a large, uncontrolled release. One contractor, 45, was killed. Another, 57, was seriously injured. Twenty other people needed hospital checks. It took several days to bring the gas down to a safe level. The isolation on that compressor was a single valve, not proved shut. HSE's own guidance calls that the lowest standard available. What the job needed was positive isolation — the highest standard, the kind that... Read more...
The Plant Was Never Designed For This Moment
On 13 March 2001, at a BP Amoco Polymers plant in Augusta, Georgia, workers tried to open the cover on a vessel called a polymer catch tank. It blew off, expelling hot plastic and killing three of them. A vapour cloud formed and ignited soon after. The catch tank's job was to receive partially reacted waste plastic diverted away from the main reactor whenever something downstream went wrong. Twelve hours before the explosion, the unit had attempted a startup. It didn't go cleanly: mechanical problems downstream sent an unusually large... Read more...
The Relief Valve Was Four Times Too Small
A reactor's relief system was sized for the wrong event. Why a Basis of Safety is the document that's supposed to catch that — and why so many sites don't really have one. Read more...
The Paperwork Said It Was Safe
Why a Safety Case and a Basis of Safety aren't the same thing — and why having one guarantees nothing without the other. Read more...
Luck Is Not A Strategy
Six minutes before the end of a night shift, someone asks whether the gas test really needs redoing. It was clear an hour ago. The permit's already signed off. Everyone wants to go home. Nobody says the words out loud, but the room has already decided: it'll be fine. It is fine. It's fine the time after that, and the eleven times after that — until, on some ordinary shift with nothing unusual about it at all, it isn't. That gap — between the ten times you got away with... Read more...
Safety Is A Journey, Not A Destination — And That Cuts Both Ways
A site puts up a banner in the canteen: 500 days without a lost-time incident. Someone takes a photo of it for the newsletter. Six weeks later a fitter loses two fingers on a machine whose guard interlock had been bridged for the better part of a year, because by that point nobody on shift thought there was anything left to check. "Safety is a journey, not a destination" has been on posters and lanyards for so long it's started to work against itself. It gets said in the same... Read more...
Familiarity Is Not Control
A site puts up a banner in the canteen: 500 days without a lost-time incident. Someone takes a photo of it for the newsletter. Six weeks later a fitter loses two fingers on a machine whose guard interlock had been bridged for the better part of a year, because by that point nobody on shift thought there was anything left to check. "Safety is a journey, not a destination" has been on posters and lanyards for so long it's started to work against itself. It gets said in the same... Read more...
The COSHH assessment is not the control
For every construction worker killed in an accident on a British site in 2012-13, roughly a hundred died of a cancer they picked up at work. That ratio is the HSE's, not ours. It has never really made the journey from the statistics annexe to the Monday morning safety meeting, where we still talk about the fall, the guard that went missing, the near miss on the loading bay — all real, all worth talking about, and all far less likely to be what eventually kills the people in the... Read more...
Running is not capturing
HSE's own guidance page for employers on local exhaust ventilation opens with a sentence worth sitting with for a moment: "Many employers buy LEV to protect workers' health but find that it doesn't work." That is the regulator conceding, at the top of its own advice page, that a control measure British industry has spent a great deal of money on frequently fails to do the one thing it was bought for. Not occasionally. Many. It's worth asking why a piece of engineering that is designed, installed, commissioned, examined annually... Read more...
Resilience Training Is PPE
You already know this site. Output is up eleven per cent on last year. Headcount is flat, because the business case for two more operators didn't survive the budget round. Three experienced shift supervisors have retired inside eighteen months and their replacements are capable people who have been in post for four months. The permit backlog is growing. The maintenance planner has started ringing people on their days off. Nobody has been hurt, the SHE stats look respectable, and the last audit closed out cleanly. Then absence starts to move.... Read more...
Nobody Fell Asleep at Texas City
On 23 March 2005, a distillation tower at BP's Texas City refinery was filled far beyond its normal level. Hydrocarbon erupted from a vent stack, found an ignition source and exploded. Fifteen people died and 180 were injured. Nobody at the controls was asleep. But by that morning, operators had been working 12-hour shifts for 29 or more consecutive days. What fatigue actually looks like Ask most people to picture a fatigued worker and they picture someone nodding off. Head drops, eyes close, the forklift drifts into the racking. That... Read more...
The Gauge Had Stuck 14 Times
At 06.01 on Sunday 11 December 2005, a vapour cloud ignited at the Buncefield oil storage depot in Hertfordshire. The tank at the centre of it, Tank 912, had been filling with unleaded petrol through the night. At 03.05 its level gauge stopped moving. The reading flatlined while the petrol kept coming, and for more than two and a half hours nobody knew. By the time of the explosion, over 250,000 litres had escaped. Over 40 people were injured. It was early on a Sunday, which is a large part... Read more...
The Same Meeting, Three Times a Week
Picture a Tuesday operations meeting. Forty minutes in, someone brings up the late supplier delivery. Fair enough, it's a problem. But it was a problem at Monday's production meeting too, and it'll get another airing at Thursday's weekly review. Mostly the same people will be in the room each time, nodding. Nobody set out to build that. Each of those meetings was started by a sensible person who had a real problem to solve. What went wrong is duller. Nobody has ever sat down and looked at all of the... Read more...
The Trees Were Real. The Advert Was Still Banned.
In October 2021 HSBC put two posters up on bus stops in London and Bristol. One of them said the bank was helping to plant 2 million trees in the UK, enough to lock in 1.25 million tonnes of carbon over the trees' lifetime. That was true. There was a £4 million partnership with the National Trust behind it, and 90,000 trees were already in the ground. The Advertising Standards Authority banned both posters anyway, on 19 October 2022. Its objection was to what wasn't on the poster. HSBC's own... Read more...
Drawn in Chalk
On 27 March 1974, Reactor 5 at the Nypro works at Flixborough started leaking cyclohexane. When the plant was shut down and the lagging came off, there was a crack in the shell two metres long. A meeting was called. The plant was back on stream on 1 April. Four days. The fix was a temporary pipe to carry the process straight from Reactor 4 into Reactor 6. There was no 28-inch pipe on site, so it was made from 20-inch pipe with a dog-leg in it to meet the... Read more...
7 Things Your Permit Training Left Out
On 7 September 1987, a contract rigger was killed on Piper Alpha. The investigation found the two things Lord Cullen would find a year later: the permit-to-work system was not working, and neither was shift handover. Occidental pleaded guilty. The system was not substantially changed. Ten months later, on the evening of 6 July 1988, the permit for condensate pump A's relief valve was carried back to the control room marked "SUSP". The supervisors were talking. The permit was put on the desk. Nobody mentioned it and nobody read it.... Read more...