20 Total 100 Lessons from Incidents : How to Manage Risk and Improve Safety : The Hub Oil Incident is another tragedy in our case study reviews . Now is our opportunity to learn from this incident in support of averting other similar tragedies . In the seminar , the major loss incident at Hub Oil was profiled in detail . We learned to appreciate a family - owned business wherein care for people is demonstrated yet the plant process risks are neither well - understood nor well managed . In this assignment , let us assume that another company called Miracle Oil exists that has the same basic facility design and management approach . After hearing about the Hub Oil Incident , the management has asked you , an independent consultant in incident investigation and root cause analysis , to investigate the Hub Oil Incident and to make recommendations for improvement to their facilities and management system . There are three key focus points on this assignment : 1 ) To formulate the links between basic causes and latent causes ( weaknesses in the management system and its elements ) . 2 ) To formulate recommendations for actions to