Safety Wise Solutions_ICAM.pdf - MIRMgate

Systemic Incident Investigation
Annual Quarrying & Small Mines
Safety & Health Seminar

A Few Questions
• What worries you
• Where will your next incident happen
• What occupies most of your time
• Had any new incidents lately
• What’s wrong with what we have been doing for years
Why change now

Today’s Operating Environment
Maximum return to shareholder
Keep operating licence
What price
safety
Management
strategies & decisions
Keep DME
sweet
How safe is
safe enough
Accident
Incident
Near miss
Equip.failure
Production loss
Prove due
diligence
Public expects &
demands zero risk
Stakeholder &
society demands
Good corporate
citizen
Repeat incidents are a symptom of poor investigations
and management of corrective actions
Zero Harm ethical organisation

What is Needed:
• A risk-based foundation for management systems
• More sophisticated risk and incident management processes
• Integration of risk management process into the company’s decision
making processes
• Using every incident as an opportunity to reduce risk in our business
processes and prevent repeat events

Tools for a safe system
Management support understanding & commitment
Behavioural
safety
Safe conditions
& equipment
Safe behaviours
Safe operating
procedures
Compliance
Risk
management
Safe System Design

What is the process
What is an investigation What do we want from it
Step Determine Process Tools
1. “What Happened” Data collection PEEPO
2. “Why it Happened” Collected data
analysis
3. “What are we going to
do about it”
4. “What did we learn that
we can share”
Develop
recommendations
Key learnings
ICAM
Hierarchy of control
Benefit assessment
Incident Report
Toolbox briefings
Product – risk reduction, prevention of recurrence

Consequence based usage
Frequency
Consequence
Management,
workforce & HSE
investigate
10
1
Fatality
Serious
injury
Workforce
investigate
30
Minor injury
600
Hazards &
near misses
Depth of investigation and reporting requirements vary by consequence.
The ICAM process is the same for all levels of consequence

Risk based usage
Consequence
Insignificant Minor Moderate Major Extreme
Likelihood
Almost Certain Significant Significant High High High
Likely
Moderate Significant Significant High High
Moderate Low Moderate Significant High High
Unlikely Low Low Moderate Significant High
Rare Low Low Moderate Significant Significant

Did somebody screw up
The role of the
investigator is to
find out why
The role of
management is to
resource the
investigation and
support the
findings

Shared Responsibility
The Workforce
• Participate in the events
• Bend & break the rules of
the events
• Try to complete the events
The Organisation
• Prepares the venue
• Sponsors the participants
• Sets the rules of the events
• Manages the events
• Adjudicates the events
• Sets the goals of the events

A Structured Framework
Like sorting the deck into suits
ORGANISATIONAL
FACTORS
TASK /
ENVIRONMENTAL
CONDITIONS
INDIVIDUAL /
TEAM ACTIONS
ABSENT OR
FAILED
DEFENCES

Sound
Organisational
Factors
Produces
Safe
Workplace
Reduces
Errors &
Violations
Safety net
Redundancy
Risk management
Error traps
Error mitigation
Safe & efficient
task completion
Organisational
Factors
Task /
Environmental
Conditions
Ind / Team
Actions
Absent / failed
Defences
Leadership
Safety culture
Safe systems
Safe procedures
Staff selection
Training
Ops vs safety goals
Risk mgt.
Contractor mgt
Mgt of change
Working conditions
Time pressures
Resources
Tool availability
Job access
Task complexity
Fitness for work
Workload
Task planning
Errors
and
Violations
Interlocks
Isolation
Guards
Barriers
SOP’s
JSA’s
Awareness
Supervision
Emerg.response
PPE
Accident
Incident
Near miss
Equip.failure
Production loss
Corrective
actions
Local
learning
Behaviour
management
Corrective
actions

ICAM and risk management
ICAM Model
Org.
Factors
Task
Environ.
Conditions
Individual
Team
Actions
Absent
Failed
Defences
Adverse
Outcome
Sound
Organisational
Factors
Produces
Safe
Workplace
Reduces
Errors &
Violations
Safety net
Redundancy
Risk management
Error traps
Error mitigation
Safe & efficient
task completion
Mgt Stds
Formal Risk
Assessments
Design Review
Job Safety
Analysis
Take 2
Risk Based
Decision Making
Risk
Controls
Audits
Desired
Outcome
Risk Management Model

Safety performance improvement strategies
DEFENCES
Error
Prevention
Error
Trapping
Error
Mitigation
Zero Fatalities
Zero Harm
ORG.
FACTORS

Truck Into Swamp Case Study

Pre - Incident Summary
• During night shift the driver of haultruck 336 reported a diesel leak
• A mechanic was dispatched to the site and took the vehicle back
to the workshop
• During day shift, the vehicle underwent an F5 inspection and the
fuel pump suction pipe was repaired by soldering
• The vehicle was returned to service
• During night shift pre-start a diesel leak was again reported,
mechanics re-torqued the fuel pump suction pipe

Incident Summary
• At 0715 hours, haultruck 336 was hauling to the crusher and the
vehicle suffered a total loss of engine power
• The driver reacted by trying to shift down a gear to maintain
forward motion. As the gear selector reached neutral, the driver
could not select another gear, lost steering control and reported
poor braking.
• He applied the emergency brake which started to retard the
vehicle, but he had no steering control.
• The vehicle drove off the left hand side of the haulroad tipping
onto its left hand side into a swamp.

Consequence
• The driver escaped without injury.
• The truck suffered damage estimated at $45,000 and needed
extensive repair to its electrical system and was out of service for
3 months.
• One load of ore was lost in the swamp without any environmental
impact.
• Because of the potential consequences of the incident an
investigation was conducted at 3 different levels
– Descriptive
– Compliance
– ICAM

Descriptive level outcome
Cause
1. Sloppy work by the mechanics
2. The haultruck driver did not adequately react to the
emergency situation
Recommendations
1. Tell the haultruck driver and mechanics to take more care
2. Discuss at a meeting with drivers and mechanics
3. Send out a safety notice
Is there more to be learnt from this incident to prevent recurrence
Let’s try a compliance level investigation.

Compliance level findings
The Company has a risk control in place to manage the hazard :
Driver and maintenance contractors are to ensure they follow all
the site rules and work safely to a high standard
That risk control or ‘defence’ failed because of poor performance
by the driver and mechanics

Compliance level outcome
Cause The contractors did not provide an adequate standard of
work and therefore were not working safely
Recommendation
1. The driver and maintenance contractors should be sacked
2. Interview the Contract Manager and threaten contact
termination if they have any further incidents.
Or is there more to be learnt fromthis incident
to prevent recurrence using ICAM

Absent / failed defences
Failed
• Well maintained FFP vehicle
Absent
• Driver awareness that engine shut down with
vehicle in motion
• SWP for dealing with engine shut down when
vehicle is in motion
• No barrier (berm, tyres etc) to protect against
high risk areas adjacent to haul road

Team / individual actions
Maintenance
• Poor quality solder repair carried out on
suction pipe
• No testing carried out after repair
• Suction pipe over-torqued
Driver of Haultruck 336
• Did not react correctly to engine shut
down while vehicle was in motion

Task / environmental conditions
• Generally poor repair practices
• Pressure to keep MDT fitted haultrucks on line
• Poor maintenance standards oversight
• Poor spare parts availability & supply chain
• Driver panic – “OOH SHIT !”
• Inexperience and training in this type of
emergency
• General level of complacency on the site
• Suction pipe failed at an inopportune time (on a
right hand bend with a swamp to the left)
• Shifting into neutral led to loss of powered
steering

Organisational factors
• CM No maintenance documents for Terberg -
Volvo engine available at site
• MM Poor maintenance standards and practices
in maintenance workshop
• CM Poor management and oversight of
contractor maintenance standards
• PR Lack of procedures for dealing with engine
shut down while vehicle is in motion
• TR Lack of training for drivers in handling
emergency situations
• TR Lack of competency based training and
assessment of mechanics

Recommended corrective actions
1. The quality of maintenance standards & practices must be improved to meet
Company requirements
2. Improve the quality and frequency of Company auditing of contractor
maintenance of vehicles involved in Company operations
3. Standard operating procedures must be developed for all emergency situations
that may arise during hauling operations such as:
a) engine shut down (while truck is in motion)
b) loss of air pressure
c) loss of brakes,
d) tyre failure.
4. Introduce emergency procedure training as part of initial and ongoing driver
training

Recommended corrective actions
5. Contractor to introduce competency based training for all mechanics
involved in the maintenance of Company dedicated vehicles
6. Maintenance procedures and parts catalogues for all vehicle types
maintained by Contractor must be available on site
7. Adequate risk control measures must be in place at all high risk areas
adjacent to the haulroad

Key Learnings
Oversight of contractor practices
• The Company cannot discharge its duty of care for safe practice to its contractor.
The Company must continually monitor the safe performance of its contractors.
Quality Audits
• The quality and frequency of audits ensures continual improvement of safety
performance and operational efficiency
Quality of Maintenance
• The quality of maintenance has a direct influence on the safety of vehicles and
those operating them.

Errors are like mosquitoes
You can swat them one
by one, but they still
keep coming
(adapted from Reason, 1990)

It’s best to drain the swamps in which they breed
inadequate
training
poor
design
conflicting
goals
inadequate
procedures
(adapted from Reason, 1990)

The bottom line of safety
In a competitive market :
– Without sustained profit, the organisation has no future
– Profit can not be sustained without efficiency
– Efficiency can not be sustained without safety
– Safety is therefore a core management issue
Inefficiencies, or other words such as damage, failures, losses, accidents, incidents
and injuries are all used to describe events that have two common features:
– they are unplanned, and
– they disrupt the flow of revenues but allow the expenses to continue
Preventing unplanned events through learning from our incidents
liberates capital and operating resources
(Prof. Jose Blanco U of T )

Thank You
Any Questions
Gerry.Gibb@safetywisesolutions.com
www.safetywisesolutions.com