A pervasive lack of proactive measures

"Organizational accidents typically have multiple contributing causes, involve people at numerous levels within the organization, and are characterized by a pervasive lack of proactive measures to ensure adoption and compliance with a safety culture. They are generally catastrophic in nature and require complex organizational changes. All these aspects are present in this accident."

 -- September 3, 2011 San Bruno Pipeline Blast: NTSB lays out another system failure http://disaster-wise.blogspot.com/2011/09/san-bruno-pipeline-blast-ntsb-lays-out.html

A summary of facts and technical findings presented by Ravi Chattre, NTSB engineer and chief investigator. http://www.ntsb.gov/news/events/2011/san_bruno_ca/presentations/San_Bruno_IIC_Opening_Statement.pdf