In the previous examples, we can find many learning and key moments
where there was not a good safety culture.
In Davis Besse, the CEO himself talks about "overconfidence",
working in isolation or without learning, reactive and defensive attitudes,
and above all, not having safety as a priority.
This same erroneous focus on the result, over and above safety,
made NASA engineers to live with the latent error
of the partial detachment of the insulator of the Columbia.
These lessons on where to focus are very important,
and so are those derived from the events at BP
where after the accident in Texas City with the Baker report,
the industry begins to talk about leadership for safety
and process safety
taking into account all the interactions as we have seen here.
After the DeepWater accident, the term "safety culture" appears
appears for the first time officially.
So as we have seen through all these events in the industry,
we have seen and reviewed the concepts outlined
in the introduction to this NOOC.