Surely pure luck can't be expected to be one of the criteria assessed. We've had a few incidents which were very close calls and not major accidents due only to pure luck. Maybe they considered those in their ranking process?! The organizational culture of 'safety first' would in these cases dictate major and drastic steps put in place to prevent reoccurring as if they were major accidents, or the regulating authority would force them to. That simply is not what has happened after such events here. Anyone with half a brain would consider the organization's culture in such assessments. We're still up to our waists in old & worthless call-outs and procedures from 20+ years ago. Maybe they considered that. No doubt things are getting better but very slowly.