The Weekly Reflektion 35/2025
One of the key factors in learning from Major Accidents is a thorough investigation to find out what happened, how and why. From this investigation, measures can be identified to prevent other Major Accidents. Changes can be implemented that improve the reliability, robustness and resilience of technical, operational and organisational barriers. Learning can occur if the investigation provides a solid foundation for this learning. People that know how to investigate properly are worth their weight in gold.
Will you still learn from Major Accidents without the CSB?
The Trump administration has proposed to shut down the US Chemical Safety and Hazard Investigation Board (CSB), an independent federal agency charged with investigating industrial accidents and developing recommendations to prevent their recurrence. The government wants the agency’s $14 million (£10 million) budget to be withdrawn by 30 September 2025, before the start of the next fiscal year.
The CSB has carried out many important Major Accident investigations, including the explosion at the BP Texas City refinery that took 15 lives and injured 180 on March 23, 2005. Reflekt has used this investigation report and several others in Reflektions and seminars.
The news didn’t dominate headlines, but within industries that rely on safe handling of hazardous materials, refineries, chemical plants, manufacturing sites, etc. it had a major impact. For decades, the CSB has served as an impartial voice in the aftermath of disaster. The CSB doesn’t assign blame, that is for the Law Enforcement Agencies, Regulatory Agencies and/or the Civil Courts. The CSB focus is on how to prevent recurrence and what can be learned. Discontinuing the CSB is not just a bureaucratic change, it risks eroding the cultural memory of risk in one of the most safety-critical sectors in modern industry. Three points that we at Reflekt are concerned about:
· Independent insight matters. The CSB stood outside regulatory, commercial, or political influence. Its sole mandate: to learn, share, and prevent. Without it, who investigates with neutrality when explosions, leaks, or near-misses occur?
· Accidents fade fast. Lessons fade faster. From the BP Texas City disaster to the West Fertilizer explosion, the CSB’s visual reports, animations, and plain-language findings reached boardrooms, classrooms, and shop floors. They didn’t just report—they taught.
· An invisible layer of resilience is being stripped away. Not all safety systems are pipes, alarms, and locks. Some are institutional: teams dedicated to learning from failure at a systemic level. That layer just got thinner.
The decision reflects a deeper and more concerning trend, when safety is viewed as a cost, not an investment, the returns come in the form of future disasters. As safety advisor Trevor Kletz once said, ‘There’s an old saying that if you think safety is expensive, try an accident’.
So, what needs to happen now, in the absence of the CSB?
· Organizations must double down on their own investigations. Not just asking “what went wrong”, but “what could have gone wrong?” Learning must be embedded, not outsourced.
· Leaders must signal clearly: safety is strategic. The removal of the CSB cannot be used as a justification for cutting internal safety budgets or slowing reporting processes.
· The industry must collaborate more—not less. Share learnings across company lines, sectors, and geographies. In the CSB’s absence, collective memory must not be eroded.
· Revisit the stories. Bring CSB case studies back into the fold, for example in inductions, toolbox talks, board risk sessions.
The legacy of the CSB must not be lost. Remember the CSB was not just about prevention, it was to ensure the fatalities and injuries from any Major Accident were not in vain.