The procedures were not the problem. The sign on the wall was.

A defaced sign is not a housekeeping issue. It is a measurement of everything upstream of it.

A first of a kind programme of work in plant infrastructure that had not been accessed since the 1960s. The leadership were concerned that the emergency arrangements to support the programme weren’t adequate. The instinct was sound. The cause sat further upstream, spread across supervision, behaviours and what the workforce had come to expect and it was visible on a wall within ten minutes of us arriving.

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