"Considerable attention has been paid to safety culture since the 1986 Chernobyl nuclear power station accident. Researchers have studied it and companies and regulators have applied it to enhance safety. However, few research studies have been conducted that establish a link between safety culture and operational or process safety and methods used to assess safety culture, primarily questionnaires, have been criticized on methodological grounds. One way to enhance system safety is through applying the lessons of investigations of accidents of process safety to remediate organizational shortcomings identified in the investigation. Rather than attempting to assess safety culture directly, examining company actions and decisions directly after an accident can allow investigators to make inferences about safety culture at the time of the accident. This study suggests a method to directly examine the role of organizations in accidents by identifying the nature of organizational errors and describing the logic that can link these errors to accident causation. The application of this method in several accident investigations is described."

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