A qualitative narrative analysis of 62 systemic failures in high-hazard industries
DOI:
https://doi.org/10.15282/jceib.v12i2.13384Keywords:
Qualitative analysis, Case study, Industrial accidents, Root cause analysis, Systemic failure, Safety culture, Organizational factorsAbstract
Quantitative research in safety science has successfully identified contributing factors to industrial accidents. However, how these factors interact in a real-world setting remains an elusive gap in understanding. This study fills that gap through a systematic qualitative analysis of root-cause narratives from 62 catastrophic industrial accidents investigated by the U.S. Chemical Safety and Hazard Investigation Board (CSB) and the UK’s Health and Safety Executive (HSE). But what is new in this paper is that it does not stop at counting the frequency but proceeds to analyse the causal chains and failure pathways detailed in the official reports. The analysis identified three dominant qualitative themes, including the domino effect of latent organisational failures. Deficiencies in safety management systems (SMS) and management commitment are predictably cascading into active frontline errors. The study also identifies the contextual drivers of procedural non-compliance, which is shown to be a symptom of deeper system pressures such as production goals and resource-strapped environments rather than a root cause. The data also points to the ongoing failure to learn culture, as demonstrated by the persistence of similar failure patterns, such as hot work permit failures and tank overfills, across decades and industries. This paper concludes that qualitative narrative analysis is needed to understand the why of systemic failures and offers the actionable context required to design resilient safety systems.
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