The report is silent on the culture at site level. Indications are that the worker was diligent, he was seen on video surveillance recordings doing his tasks up to 10 minutes before the explosion. However, the corporate management culture, including lpoor attention to design standards and systems, lack of specialised training for onsite staff, poor communications with onsite staff, not sharing technical information with onsite staff, lack of auditing process and poor attitude to Preventative Maintenance KPI's was identified by the CSB as deficient
