Failure To Learn by David Hopkins
A forensic analysis of a catastrophic refinery explosion that exposes how organizations can systematically fail to learn from near-misses and prior warnings. It shows how an emphasis on personal injury metrics, cost-cutting, and production targets eclipsed process safety, while siloed communication, weak oversight, and normalization of deviance allowed hazards to accumulate. Drawing on investigation evidence, it maps the cultural and structural drivers behind the disaster, from aging equipment and inadequate alarms to flawed contractor management and decision-making under pressure. The book distills practical lessons for leaders, regulators, and practitioners on building stronger process safety systems, using leading indicators, and creating a culture that surfaces and acts on warning signs.
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