Process Safety and Bottom of the Pyramid!

I am borrowing a phrase from the late Dr Prahalad, Management Guru, when he was mentioning the fortune to be mined at the bottom of the pyramid.As far as process safety goes., misfortune lies at the bottom of the pyramid!
A news article mentions today that 9 IOC officials, including the GM of the oil depot have been arrested by the police for the Jaipur oil depot fire. The report quotes the incident investigation report by an independent panel which mentions that "human error, lack of safety procedures and design flaws were found to be the major reasons responsible for the fire.The basic or root cause is an absence of site-specific written operating procedures, absence of leak stopping devices from a remote location and insufficient understanding of hazards, risks and consequences,M.B. Lal, who chaired the independent inquiry committee, said. In a 2003 audit, the Oil Industries Safety Directorate found that the remote leak stopping device was not working at the Jaipur terminal. The inquiry found that despite the recommendation in 2003, the device was never operational in the last six years, he added".
Does it not speak of an organizational safety culture issue??
Read the article in this link.