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Safety Wise Solutions_ICAM.pdf - MIRMgate

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Systemic Incident Investigation<br />

Annual Quarrying & Small Mines<br />

<strong>Safety</strong> & Health Seminar


A Few Questions<br />

• What worries you<br />

• Where will your next incident happen<br />

• What occupies most of your time<br />

• Had any new incidents lately<br />

• What’s wrong with what we have been doing for years<br />

Why change now


Today’s Operating Environment<br />

Maximum return to shareholder<br />

Keep operating licence<br />

What price<br />

safety<br />

Management<br />

strategies & decisions<br />

Keep DME<br />

sweet<br />

How safe is<br />

safe enough<br />

Accident<br />

Incident<br />

Near miss<br />

Equip.failure<br />

Production loss<br />

Prove due<br />

diligence<br />

Public expects &<br />

demands zero risk<br />

Stakeholder &<br />

society demands<br />

Good corporate<br />

citizen<br />

Repeat incidents are a symptom of poor investigations<br />

and management of corrective actions<br />

Zero Harm ethical organisation


What is Needed:<br />

• A risk-based foundation for management systems<br />

• More sophisticated risk and incident management processes<br />

• Integration of risk management process into the company’s decision<br />

making processes<br />

• Using every incident as an opportunity to reduce risk in our business<br />

processes and prevent repeat events


Tools for a safe system<br />

Management support understanding & commitment<br />

Behavioural<br />

safety<br />

Safe conditions<br />

& equipment<br />

Safe behaviours<br />

Safe operating<br />

procedures<br />

Compliance<br />

Risk<br />

management<br />

Safe System Design


What is the process<br />

What is an investigation What do we want from it<br />

Step Determine Process Tools<br />

1. “What Happened” Data collection PEEPO<br />

2. “Why it Happened” Collected data<br />

analysis<br />

3. “What are we going to<br />

do about it”<br />

4. “What did we learn that<br />

we can share”<br />

Develop<br />

recommendations<br />

Key learnings<br />

<strong>ICAM</strong><br />

Hierarchy of control<br />

Benefit assessment<br />

Incident Report<br />

Toolbox briefings<br />

Product – risk reduction, prevention of recurrence


Consequence based usage<br />

Frequency<br />

Consequence<br />

Management,<br />

workforce & HSE<br />

investigate<br />

10<br />

1<br />

Fatality<br />

Serious<br />

injury<br />

Workforce<br />

investigate<br />

30<br />

Minor injury<br />

600<br />

Hazards &<br />

near misses<br />

Depth of investigation and reporting requirements vary by consequence.<br />

The <strong>ICAM</strong> process is the same for all levels of consequence


Risk based usage<br />

Consequence<br />

Insignificant Minor Moderate Major Extreme<br />

Likelihood<br />

Almost Certain Significant Significant High High High<br />

Likely<br />

Moderate Significant Significant High High<br />

Moderate Low Moderate Significant High High<br />

Unlikely Low Low Moderate Significant High<br />

Rare Low Low Moderate Significant Significant


Did somebody screw up <br />

The role of the<br />

investigator is to<br />

find out why<br />

The role of<br />

management is to<br />

resource the<br />

investigation and<br />

support the<br />

findings


Shared Responsibility<br />

The Workforce<br />

• Participate in the events<br />

• Bend & break the rules of<br />

the events<br />

• Try to complete the events<br />

The Organisation<br />

• Prepares the venue<br />

• Sponsors the participants<br />

• Sets the rules of the events<br />

• Manages the events<br />

• Adjudicates the events<br />

• Sets the goals of the events


A Structured Framework<br />

Like sorting the deck into suits<br />

ORGANISATIONAL<br />

FACTORS<br />

TASK /<br />

ENVIRONMENTAL<br />

CONDITIONS<br />

INDIVIDUAL /<br />

TEAM ACTIONS<br />

ABSENT OR<br />

FAILED<br />

DEFENCES


Sound<br />

Organisational<br />

Factors<br />

Produces<br />

Safe<br />

Workplace<br />

Reduces<br />

Errors &<br />

Violations<br />

<strong>Safety</strong> net<br />

Redundancy<br />

Risk management<br />

Error traps<br />

Error mitigation<br />

Safe & efficient<br />

task completion<br />

Organisational<br />

Factors<br />

Task /<br />

Environmental<br />

Conditions<br />

Ind / Team<br />

Actions<br />

Absent / failed<br />

Defences<br />

Leadership<br />

<strong>Safety</strong> culture<br />

Safe systems<br />

Safe procedures<br />

Staff selection<br />

Training<br />

Ops vs safety goals<br />

Risk mgt.<br />

Contractor mgt<br />

Mgt of change<br />

Working conditions<br />

Time pressures<br />

Resources<br />

Tool availability<br />

Job access<br />

Task complexity<br />

Fitness for work<br />

Workload<br />

Task planning<br />

Errors<br />

and<br />

Violations<br />

Interlocks<br />

Isolation<br />

Guards<br />

Barriers<br />

SOP’s<br />

JSA’s<br />

Awareness<br />

Supervision<br />

Emerg.response<br />

PPE<br />

Accident<br />

Incident<br />

Near miss<br />

Equip.failure<br />

Production loss<br />

Corrective<br />

actions<br />

Local<br />

learning<br />

Behaviour<br />

management<br />

Corrective<br />

actions


<strong>ICAM</strong> and risk management<br />

<strong>ICAM</strong> Model<br />

Org.<br />

Factors<br />

Task<br />

Environ.<br />

Conditions<br />

Individual<br />

Team<br />

Actions<br />

Absent<br />

Failed<br />

Defences<br />

Adverse<br />

Outcome<br />

Sound<br />

Organisational<br />

Factors<br />

Produces<br />

Safe<br />

Workplace<br />

Reduces<br />

Errors &<br />

Violations<br />

<strong>Safety</strong> net<br />

Redundancy<br />

Risk management<br />

Error traps<br />

Error mitigation<br />

Safe & efficient<br />

task completion<br />

Mgt Stds<br />

Formal Risk<br />

Assessments<br />

Design Review<br />

Job <strong>Safety</strong><br />

Analysis<br />

Take 2<br />

Risk Based<br />

Decision Making<br />

Risk<br />

Controls<br />

Audits<br />

Desired<br />

Outcome<br />

Risk Management Model


<strong>Safety</strong> performance improvement strategies<br />

DEFENCES<br />

Error<br />

Prevention<br />

Error<br />

Trapping<br />

Error<br />

Mitigation<br />

Zero Fatalities<br />

Zero Harm<br />

ORG.<br />

FACTORS


Truck Into Swamp Case Study


Pre - Incident Summary<br />

• During night shift the driver of haultruck 336 reported a diesel leak<br />

• A mechanic was dispatched to the site and took the vehicle back<br />

to the workshop<br />

• During day shift, the vehicle underwent an F5 inspection and the<br />

fuel pump suction pipe was repaired by soldering<br />

• The vehicle was returned to service<br />

• During night shift pre-start a diesel leak was again reported,<br />

mechanics re-torqued the fuel pump suction pipe


Incident Summary<br />

• At 0715 hours, haultruck 336 was hauling to the crusher and the<br />

vehicle suffered a total loss of engine power<br />

• The driver reacted by trying to shift down a gear to maintain<br />

forward motion. As the gear selector reached neutral, the driver<br />

could not select another gear, lost steering control and reported<br />

poor braking.<br />

• He applied the emergency brake which started to retard the<br />

vehicle, but he had no steering control.<br />

• The vehicle drove off the left hand side of the haulroad tipping<br />

onto its left hand side into a swamp.


Consequence<br />

• The driver escaped without injury.<br />

• The truck suffered damage estimated at $45,000 and needed<br />

extensive repair to its electrical system and was out of service for<br />

3 months.<br />

• One load of ore was lost in the swamp without any environmental<br />

impact.<br />

• Because of the potential consequences of the incident an<br />

investigation was conducted at 3 different levels<br />

– Descriptive<br />

– Compliance<br />

– <strong>ICAM</strong>


Descriptive level outcome<br />

Cause<br />

1. Sloppy work by the mechanics<br />

2. The haultruck driver did not adequately react to the<br />

emergency situation<br />

Recommendations<br />

1. Tell the haultruck driver and mechanics to take more care<br />

2. Discuss at a meeting with drivers and mechanics<br />

3. Send out a safety notice<br />

Is there more to be learnt from this incident to prevent recurrence <br />

Let’s try a compliance level investigation.


Compliance level findings<br />

The Company has a risk control in place to manage the hazard :<br />

Driver and maintenance contractors are to ensure they follow all<br />

the site rules and work safely to a high standard<br />

That risk control or ‘defence’ failed because of poor performance<br />

by the driver and mechanics


Compliance level outcome<br />

Cause The contractors did not provide an adequate standard of<br />

work and therefore were not working safely<br />

Recommendation<br />

1. The driver and maintenance contractors should be sacked<br />

2. Interview the Contract Manager and threaten contact<br />

termination if they have any further incidents.<br />

Or is there more to be learnt fromthis incident<br />

to prevent recurrence using <strong>ICAM</strong>


Absent / failed defences<br />

Failed<br />

• Well maintained FFP vehicle<br />

Absent<br />

• Driver awareness that engine shut down with<br />

vehicle in motion<br />

• SWP for dealing with engine shut down when<br />

vehicle is in motion<br />

• No barrier (berm, tyres etc) to protect against<br />

high risk areas adjacent to haul road


Team / individual actions<br />

Maintenance<br />

• Poor quality solder repair carried out on<br />

suction pipe<br />

• No testing carried out after repair<br />

• Suction pipe over-torqued<br />

Driver of Haultruck 336<br />

• Did not react correctly to engine shut<br />

down while vehicle was in motion


Task / environmental conditions<br />

• Generally poor repair practices<br />

• Pressure to keep MDT fitted haultrucks on line<br />

• Poor maintenance standards oversight<br />

• Poor spare parts availability & supply chain<br />

• Driver panic – “OOH SHIT !”<br />

• Inexperience and training in this type of<br />

emergency<br />

• General level of complacency on the site<br />

• Suction pipe failed at an inopportune time (on a<br />

right hand bend with a swamp to the left)<br />

• Shifting into neutral led to loss of powered<br />

steering


Organisational factors<br />

• CM No maintenance documents for Terberg -<br />

Volvo engine available at site<br />

• MM Poor maintenance standards and practices<br />

in maintenance workshop<br />

• CM Poor management and oversight of<br />

contractor maintenance standards<br />

• PR Lack of procedures for dealing with engine<br />

shut down while vehicle is in motion<br />

• TR Lack of training for drivers in handling<br />

emergency situations<br />

• TR Lack of competency based training and<br />

assessment of mechanics


Recommended corrective actions<br />

1. The quality of maintenance standards & practices must be improved to meet<br />

Company requirements<br />

2. Improve the quality and frequency of Company auditing of contractor<br />

maintenance of vehicles involved in Company operations<br />

3. Standard operating procedures must be developed for all emergency situations<br />

that may arise during hauling operations such as:<br />

a) engine shut down (while truck is in motion)<br />

b) loss of air pressure<br />

c) loss of brakes,<br />

d) tyre failure.<br />

4. Introduce emergency procedure training as part of initial and ongoing driver<br />

training


Recommended corrective actions<br />

5. Contractor to introduce competency based training for all mechanics<br />

involved in the maintenance of Company dedicated vehicles<br />

6. Maintenance procedures and parts catalogues for all vehicle types<br />

maintained by Contractor must be available on site<br />

7. Adequate risk control measures must be in place at all high risk areas<br />

adjacent to the haulroad


Key Learnings<br />

Oversight of contractor practices<br />

• The Company cannot discharge its duty of care for safe practice to its contractor.<br />

The Company must continually monitor the safe performance of its contractors.<br />

Quality Audits<br />

• The quality and frequency of audits ensures continual improvement of safety<br />

performance and operational efficiency<br />

Quality of Maintenance<br />

• The quality of maintenance has a direct influence on the safety of vehicles and<br />

those operating them.


Errors are like mosquitoes<br />

You can swat them one<br />

by one, but they still<br />

keep coming<br />

(adapted from Reason, 1990)


It’s best to drain the swamps in which they breed<br />

inadequate<br />

training<br />

poor<br />

design<br />

conflicting<br />

goals<br />

inadequate<br />

procedures<br />

(adapted from Reason, 1990)


The bottom line of safety<br />

In a competitive market :<br />

– Without sustained profit, the organisation has no future<br />

– Profit can not be sustained without efficiency<br />

– Efficiency can not be sustained without safety<br />

– <strong>Safety</strong> is therefore a core management issue<br />

Inefficiencies, or other words such as damage, failures, losses, accidents, incidents<br />

and injuries are all used to describe events that have two common features:<br />

– they are unplanned, and<br />

– they disrupt the flow of revenues but allow the expenses to continue<br />

Preventing unplanned events through learning from our incidents<br />

liberates capital and operating resources<br />

(Prof. Jose Blanco U of T )


Thank You<br />

Any Questions <br />

Gerry.Gibb@safetywisesolutions.com<br />

www.safetywisesolutions.com

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