While incomplete, in the sense that the above case histories are still "works in progress," we can draw some important lessons from the experiences: 1. Organizational change does not equate to cultural change ― Merely moving people around does not alter that way they think and act. Further, organizational changes made without evaluating the safety implications (i.e., loss of job expertise in critical positions) can and will compromise overall safety management. 2. Cultural change must address fundamental business problems ― Cultural change must have a driver. In all of the case histories discussed above, there had been accidents, resulting in concerns by either top management, nearby communities, or outside investors. 3. Change requires action, not just words ― By taking action, as in Case Histories 2 and 3, management made it apparent to the workforce that they were serious about implementing change. Too many "programs du jour" have come and gone without fostering substantive change. Cultural change must be visibly supported. 4. There must be a plan, and a rollout ― Cultural change can't just be announced, or declared. It involves commitment and buy-in from all. Patience is required as well. It will take time for anti-PSM habits and behaviors to completely disappear. 5. Cultural change requires a committed top management ― This has long been seen as synonymous with successful PSM. In many cases, new managers have assumed important positions without understanding the role that PSM plays in their business. Ongoing management education is essential. 6. Organizations have inertia ― Organizations are like great ships. Their course cannot be quickly changed, and management should not wait until the iceberg is just off the bow to begin the course correction. Cultural change cannot be implemented rapidly, and management must be diligent in monitoring the health of the process safety management culture to ensure that corrections are implemented before problems arise. One final lesson implied in each of the case histories is that cultural change must be evergreen... that is, it is an evolutionary process. It must have the seeds for its perpetuation embedded into the process. Effective PSM systems are in constant need of justifying resources for preventing accidents that never happened. For ineffective systems, the justification is self-evident.
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