Why Major Incidents Still Happen in “World-Class” Operations

September 24, 20252 min read

High-hazard organisations often have strong compliance records and impressive audit scores. Yet catastrophic events still occur. The gap is rarely a missing rule. It is usually a leadership and systems gap in how work is planned, resourced, and actually carried out under pressure. This is where process safety leadership makes the difference.

See us at IChemE Hazards 35
Peter Neal will be speaking at IChemE’s Hazards 35, taking place 4–6 November 2025 in Birmingham. One of the conference themes is the role of executive leadership in managing major hazards, closely aligned to this article. If you’ll be there, let’s connect to compare approaches and lessons learned.

Complex systems create surprising interactions

In complex sociotechnical systems, performance depends on the interaction between people, plant, and context. Small changes in one area can amplify risk elsewhere. Tight coupling, time pressure, and multiple stakeholders increase the chance of unexpected outcomes.

Leadership implication: move beyond “find the broken procedure” to “understand how the system adapts in real conditions.”

Warning signs are often social, not technical

Before a major accident, there are usually weak signals. These often show up in conversations, handovers, near-miss patterns, or workarounds that staff consider normal. Dashboards may stay green while culture and behaviour drift.

Leadership implication: listen for changes in language and routines. Treat workarounds as data, not disobedience.

From compliance to capability

Compliance creates a baseline. Capability creates resilience.

Capability shows up as:

  • Frontline confidence to speak up and stop work

  • Cross-functional alignment on credible worst cases

  • Leaders visible in the field and curious about “work as done”

  • Mechanisms to test assumptions under uncertainty

Leading indicators that matter

Move the monthly review beyond lagging metrics. Add a focused set of leading indicators, for example:

  • Frequency and quality of leadership safety conversations in the field

  • Proportion of actions from learning reviews closed on time and verified

  • Velocity of control restoration after an impaired barrier

  • Near-miss capture rate, with narrative richness rather than just counts

  • Percentage of critical tasks with pre-job risk discussions observed

Anatomy of a robust learning review

When a near miss or deviation occurs, ask:

  1. What made success possible today despite the conditions

  2. Where the system is too reliant on heroics

  3. Which signals we missed and how to surface them earlier

  4. What we will change in design, supervision, or information flow

What boards should ask this quarter

  • Where could a single point of failure still surprise us

  • Which barriers are most often impaired, and why

  • How confident are we that contractors experience our safety culture as intended

  • What have we stopped doing because it did not add value to risk control

How Premier Safety Associates Can Help PSA

Our Process Safety Leadership Assessment and bespoke education programmes focus on leadership behaviours, governance, and organisational learning in complex systems. Book Your Complimentary Consultation - or meet Peter at Hazards 35 to discuss your priorities.

Peter is a Chartered Engineer with a BSc in Mechanical Engineering and Business Economics. He was an offshore installation manager in the North Sea and an offshore inspector with the Health and Safety Executive. Peter has global experience in high-hazard industries and combines his technical expertise with a human-centred approach to safety leadership education and investigating major incidents worldwide. Outside work, he enjoys traveling, hiking, cycling, and family life.

Peter Neal

Peter is a Chartered Engineer with a BSc in Mechanical Engineering and Business Economics. He was an offshore installation manager in the North Sea and an offshore inspector with the Health and Safety Executive. Peter has global experience in high-hazard industries and combines his technical expertise with a human-centred approach to safety leadership education and investigating major incidents worldwide. Outside work, he enjoys traveling, hiking, cycling, and family life.

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