(152c) Investigating beyond the Human Machinery - a Closer Look at True Accident Causation in High Hazard Industries

Human error is not a cause of an accident - it's a symptom of underlying problems. Attempting to modify operator behavior to prevent human error will not rectify those underlying problems nor will it prevent major

catastrophic accidents. This paper will provide evidence to support why an organization's safety focus should not be solely on behavior-based safety. It will demonstrate how an equal emphasis and focus needs to be placed on the safety systems of the organization, as these aspects of

safety provide a more accurate assessment of a company's true safety state. By taking another look at the U.S. Chemical Safety Board's completed investigations, this paper will demonstrate how one must go beyond the actions and decisions of frontline operators to truly understand the causes of any given incident and to safeguard against

major accident hazards.