• The required Task Risk Assessment/Job Safety Analysis was not carried out.

• The mandatory job start meeting was not completed.

• There was a failure to adequately manage change i.e., failure to "stop the task" when changes occurred to re-assess the risks.

• There was a lack of field operators that caused a Manager/Supervisor to undertake the work.

• Fellow employees failed to challenge/question a senior colleague as to their work practices and "stop the task."

• There was a lack of appropriate equipment to safely complete the task.

• Shortcuts were taken to get the task done.

Chris also provided these questions for people to think about:

• Do you actively encourage people to raise safety issues with you, including issues relating to your own behavior?

• How do you (and will you) verify that people are complying? How do you know if people are complying with company policy/procedures or not complying?

His closing thoughts were:

• We must ask questions when unsure about the task, about how the crew will control hazards, and about how we will comply with all policies and procedures

• We need to be mindful and aware at all times of potential hazards. We must never get complacent and think, "... it can't happen to me."