1. An operator made a mistake and opened the wrong valve during a routine operation. 15000 liters of hydrochloric acid flooded the factory. As the flood started from the side with the emergency exits, it trapped the workers, 20 people died horribly.
2. At a chemical factory, the automated system that handles tank transfers was out of order. A worker was operating a manual override and attempted to open the wrong valve. A safety interlock prevented this. Violating procedure, the worker opened the safety interlock, causing 15000 liters of hydrochloric acid to flood the facility. As the main exit was blocked, workers scrambled towards an additional emergency exit hatch that had been installed, but couldn't open the door because a pallet of cement had been improperly stored next to it, blocking it. 20 people died horribly.
If you look at them in isolation, the first looks like just one mistake was made, while the second looks like one grossly negligent fuckup after another, making the second report look much worse. What you don't notice at first glance is that the first facility didn't have an automated system that reduced risk for most operations in the first place, didn't have the safety interlock on the valve, and didn't have the extra exit.
So, when you read an incident report, pay attention to this: If it doesn't look like multiple controls failed, often in embarrassing/bad/negligent/criminal ways, that's potentially worse, because the controls that should have existed didn't. "Human error took down production" is worse than "A human making a wrong decision overrode a safety system because they thought they knew better, and the presubmit that was supposed to catch the mistake had a typo". The latter is holes in the several layers of Swiss Cheese lining up, the former is only having one layer in the first place.
My point was that in any competent organization, incidents should be rare, but if they still happen, they almost by necessity will read like an almost endless series of incompetence/malfeasance/failures, simply because the organization had a lot of controls in place that all had to fail for a report-worthy bad outcome.
Overall incident rates are probably a good way to distinguish between "well-run organization had a really unlucky day" and "so much incompetence that having enough layers couldn't save them" by looking at overall incident rates... and in this case, judging by the reports about how many accidents/incidents this company had, it looks like the latter.
But if you judge solely on a single incident report, you will tend to see companies that don't even bother with safety better than those that generally do but still got hit, and you should be aware of this effect and pay attention to distinguish between "didn't even bother", "had some safety layers but too much incompetence" and "generally does the right thing but things slipped through the cracks this one time".
Why?
Someone decided to walk across the road, was wearing dark clothing, had an eyepatch on so he couldn't see one side of the road well, and was struck by a forklift while the operator was on the phone.
What combination of coincidences is striking? People are careless all the time.
It would only really be a striking coincidence if each of these elements is a rare occurence - although if the site has a poor safety culture and this sort of stuff is happening all the time, it becomes less of a coincidence and more of an inevitability.
In the UK for example sites generally mandate hi-vis vests, establish pedestrian walk routes, ensure visitors can't walk straight into the warehouse without supervision or training, and ban using mobile phones when using any form of MHE - so if sites had good safety standards and enforced all this, then the chance of it happening would be much smaller than a site that didn't enforce all this (Just saying this is how it is in the UK as my experience all this is less common in the USA - although no doubt many sites operate the same).
If a site lets people wear what they want and does not stop MHE operators from using phones and lets a visitor freely walk around the warehouse... I don't know if a person getting hit at that stage is a coincidence IMO (regardless of the eye patch).
Knowing about the swiss cheese model is great, but you also need to have some heuristic about when those holes might line up and bite you. Typically it's when people are rushed, stressed and tired and you have to be able to spot that even when you're rushed, stressed and tired.
That said, forgetting to put on your hi-vis might be a careless error, but walking outside of marked pedestrian zones and operating a forklift while using a phone absolutely aren't! The forklift driver fleeing the scene makes me think safety culture had to be abysmal.