Inquiries into major disasters

Inquiries into major disasters invariably identify the proximate or obvious ‘engineering’ type failures but the underlying causes often remain hidden from public scrutiny.  Using the Piper Alpha disaster or a case study of your choice, provide an example of the above statement, clearly identifying the root causes of the disaster in your answer.
Summarise your findings in the form of an article to be published in a health and safety culture management journal.