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The lack of safety culture and the resultant safety errors were evident in the following manners:

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The problems encountered during the C824 project cannot be described as rare, localized or minor. Serious problems were encountered from August 2003 to April 2004 in Launch Shaft 2, Type K, Type M2 and Type M3 itself.

There is no issue that the consideration and decision to stop should be a joint collective effort by the relevant engineers and managers in any project, who should be reposed of the ability to make sound engineering judgments and recommendation in appropriate circumstances to the persons, whom the power to issue stop work is vested.

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The serious problems are well documented and include the following:

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Safety and the safety culture in the Circle Line project for C824 fell short. There were many safety mistakes and errors. These led to under-design of the temporary retaining wall system, poor quality during construction, ineffective engineering control and judgment, and critically, an unresponsive safety management.

The accident on the 20 April 2003 was rooted in history. It was a history of safety errors and organizational failures. Organizational failures are the manifestation of a lack of safety culture.