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Understanding the true root causes of accidents: from accepting limitations to taking effective action. On the path toward safety, we have made tremendous efforts, yet accidents still occur. Behind this are a series of complex and often overlooked reasons. Acknowledging these realities and learning to focus efforts on areas that can truly bring about change may be the key to improving safety performance. I. Realities that cannot be completely avoided: Equipment has a lifespan, while people tend to rely on luck. Every piece of equipment has a certain period of useful life. Ideally, it should be retired before a failure occurs. However, a common mindset is: “It kept running for a long time after the last problem, so maybe it can hold on this time too.” ”We collect a large amount of data in asset integrity management, yet fail to make full use of this information to predict and respond. The unpredictability of accidents requires us to use data more proactively, rather than passively waiting for failures to occur. The limitations of human nature: In high-risk industries such as the chemical industry, no matter how advanced the level of automation is, human involvement remains essential. As long as there are people, there will be inherent limitations such as physical discomfort, mood swings, and difficulty concentrating. Attempting to completely change human nature is, like “trying to stop the sunrise,” doomed to be futile. We should accept the fact that people make mistakes and design fault-tolerant systems based on this, rather than having unrealistic expectations that people will never make mistakes. Core belief: Devices wear out, and humans make mistakes. These are two objective laws that cannot be fundamentally changed. Spending too much time and energy on creating a “perfect” error containment mechanism in an attempt to control the uncontrollable is nothing short of a waste of life. II. Areas where we can and should focus on making improvements Since there are some things that cannot be changed, we should allocate our limited resources to areas where real results can be achieved. It is not shameful to admit \"ignorance\" and to use systems to make up for it; it is the starting point of learning. The key is to minimize ignorance through effective training, clear guidance, and explicit written procedures. This is fundamentally different from “lacking the ability or willingness to learn*”. Many penalties stem from employees making mistakes, but the root cause is often insufficient effectiveness in training or guidance, which prevents employees from truly mastering the necessary procedures. Filling the gap of \"lack of experience\": Many accidents occur simply because people have never been in a similar situation before. This gap can be significantly filled through systematic training, mentorship, and the transfer of experiential knowledge. For example, when it comes to using equipment such as electric hoists, the experience of senior employees is an invaluable asset for new employees. Match skills with job requirements to avoid the mistake of incompetence. Incompetence does not mean that an employee is worthless; rather, it refers to a mismatch between their skills and the requirements of the job. We must ensure that the right people are placed in the right positions through strict qualification management and skills assessment. It is unwise to naively assume that “everyone can do everything well”. We need to identify employees’ strengths and place them in positions where they can add value. Beware of \"unintentional\" malice; it must be clearly understood that there are always individuals who, for various reasons such as pranks or dissatisfaction, intend to cause harm. For example, the incident where a golf ball was found at the inlet of a factory pump serves as a reminder that vandalism is also a threat that must be taken into consideration. We need to prevent such risks through access control, surveillance, and cultural development. Make good use of resources to avoid “wasted experience”. Research shows that in the vast majority of accidents, there is plenty of public information or internal data available as a warning prior to their occurrence; however, we often lack the willingness to proactively utilize such information. For example, 25 years after a major accident occurred, we found that clues for 90% of the incidents could be found in publicly available information. We must proactively seek out, learn from, and apply the experiences and lessons of others, rather than reinventing the wheel. Manage \"unreasonable pressure\" and defend sound planning – Pressures such as \"we can’t afford it\" or \"we have made promises to customers\" often lead to unplanned and high-risk production activities. However, the losses caused by unplanned shutdowns are far greater than those resulting from planned, orderly shutdowns. We must have the courage to reject unrealistic promises and defend reasonable production schedules and maintenance windows. Overcome \"inability to learn,\" embrace effective tools. Sometimes, we resist those tools and methods that could be beneficial to us. For example, some people refuse to use safety checklists because they \"don’t have time,\" or some maintenance engineers consider the use of torque wrenches to be an insult to their skills. Checklists are powerful tools that use collective wisdom to guide individual actions (such as the lists pilots use for each flight). We must change our resistant mindset and realize that using tools is intended to achieve higher standards of safety (such as zero leaks), rather than out of distrust. III. Our guide to action: Since mistakes are the norm (every failure involves mistakes, and even every success may hide errors), our strategy should be: Reflection and application: Have you truly applied the security knowledge learned over the past 20 years? After attending 20 safety training sessions, please take some time to reflect: why did you come? The goal is to strive to reduce the risks of “ignorance,” “lack of experience,” “mismatched capabilities,” and “malicious harm.” Match between employees and roles: If it is found that an employee has been assigned to a role that does not match their capabilities, efforts should be made to reassign them to a position where they can perform effectively. Acknowledge limitations: Accept openly that we cannot find answers to all questions. System inspection: Regularly review our security systems and design to proactively eliminate potential hazards. Ultimately, wisdom lies in distinguishing what we can change from what we must accept. Putting our passion and wisdom into the former, while maintaining a clear understanding and readiness for the latter, is what truly constitutes effectiveness and maturity in safety management.