- "Never remove equipment or abandon procedures before it is discovered why they were introduced". This is so obvious and so often neglected that no further comment from me is necessary.
- "Include a note on the reason why for every instruction, code and standard..." Although he doesn't say so, I'm sure he expects that the note should be part of the standard, not separated off in the dreaded "guidance notes".
- For each process, there should be a folder of reports on past accidents, and that these should be compulsory reading for new recruits.
There is more, some of which is obvious, but the paper is worth reading in its own right. It can be found here: Proceedings of the Institution of Civil Engineers – Civil Engineering, 2006, 161, No. CE6.