A complex global chemical manufacturing plant with commodity products and high volumes of extremely dangerous ingredients experienced an undetected, uncommanded release of inert gas over a 24-hour period. Flash back a year earlier and that same facility experienced another uncommanded release, but that release was an organic solvent.

In these situations, a routine investigation is conducted, focusing on the specifics of the incident and typically result in a procedure modification and/or disciplinary action. Realizing what appear to be unrelated incidents often emerge from the same deep cultural factors, this organization reacted differently to the results.

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