Safety Wise Solutions_ICAM.pdf - MIRMgate

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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
Page 1 and 2: Systemic Incident Investigation Ann
Page 3 and 4: Today’s Operating Environment Max
Page 5 and 6: Tools for a safe system Management
Page 7 and 8: Consequence based usage Frequency C
Page 9 and 10: Did somebody screw up The role of
Page 11 and 12: A Structured Framework Like sorting
Page 13 and 14: ICAM and risk management ICAM Model
Page 15: Truck Into Swamp Case Study
Page 18 and 19: Incident Summary • At 0715 hours,
Page 20 and 21: Descriptive level outcome Cause 1.
Page 22 and 23: Compliance level outcome Cause The
Page 26 and 27: Organisational factors • CM No ma
Page 28 and 29: Recommended corrective actions 5. C
Page 30 and 31: Errors are like mosquitoes You can
Page 32 and 33: The bottom line of safety In a comp

Safety Wise Solutions_ICAM.pdf - MIRMgate

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