As Kevin Fuerst, general manager of Adomach Processing, scanned the preliminary event report, he suddenly felt lucky. Nobody had been seriously injured when the catalytic oxidizer had exploded several months earlier. But he was also in shock. Adomach had an excellent safety record. Employees received regular training, and quarterly bonuses were based – at least in part – on safety metrics. So he had always assumed that accident investigators would find fault in the equipment itself.

But now, scanning the detailed report, Kevin saw that responsibility for the explosion hit closer to him; it had been caused by one breakdown after another in the plant’s own safety protocols and processes.

Maintenance techs had failed to follow standard procedure in replacing a valve on one of the reactors served by the catalytic oxidizer. There was logic in the shortcut they had taken – which had even been approved by the lead operator. But their assumptions had been wrong, and when the reactor was re-started, it fed a large amount of potentially explosive gas into the oxidizer. This set off an unceasing string of alarms, flooding the four control-room operators with data as they scrambled to figure out what was happening.

One alarm signaled a sudden drop in pressure, which had been particularly confusing in the control room. The reason for the counter-intuitive (and short-lived) drop in pressure was explained in the report that Kevin was now reading. But it would have been a mystery to the operators; the information that might have helped came from a separate system that wasn’t part of the primary platform that dominated control-room activity.

By the time pressure started to rise again, the operators had only enough time to clear the plant floor. That action alone probably prevented serious injuries or even fatalities. But the blast broke the control room windows – hurling thousands of glass shards at the operators, who had to be treated at the hospital for multiple cuts.

Kevin knew it could have been much worse. And he now knew that safety at Adomach was nowhere near as robust as he had once believed. In time, there would be a full accounting for the accident. Meanwhile, Kevin was determined to make sure Adomach’s safety strategy was reviewed and seriously upgraded.

How can Kevin lead a safety overhaul at Adomach to assure that operations are safe, effective and truly capable of handling abnormal states?