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This presentation is based on content presented at the Mines Safety
Roadshow held in October 2013
It is made available for non-commercial use (e.g. toolbox meetings,
OHS discussions) subject to the condition that the PowerPoint file is not
altered without permission from Resources Safety
Supporting resources, such as brochures and posters, are available
from Resources Safety
For resources, information or clarification, please contact:
RSDComms@dmp.wa.gov.au
or visit
www.dmp.wa.gov.au/ResourcesSafety
www.dmp.wa.gov.au/ResourcesSafety
1
Anagram approach to site incident investigations
Can you move from “who” to “what” and “why” to “how”?
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2
What should an investigation achieve?
Gather information needed to identify trends and problem
areas, permit comparisons and satisfy legal requirements
Identify basic causes (direct and indirect) that
contributed to incident
Identify deficiencies in management system that
permitted incident to occur
Suggest specific corrective action alternatives for
management system
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3
What is the objective of the Act?
Mines Safety and Inspection Act 1994 aims to:
• Promote and secure the safety and health of persons
• Assist employers and employees to identify and
reduce hazards
• Protect employees against risks associated with
mining operations
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4
Safety culture spectrum
Vulnerable
In denial
Rule followers
Deal ‘by the book’
Messengers
“shot”
Messengers ‘shot’
Conform to rules
Whistleblowers
dismissed or
discredited
Target = ‘zero’
Reactive
Whistleblowers
Repair not reform
dismissed
or
Protection
of the
Information neglected
powerful
discredited
Responsibility
Information hoarded
Responsibility shirked
compartmentalised
New ideas = ‘problems’
Repair not reform
Failure punished or
covered up
Robust
Develop risk
management capacity
Enlightened
Active leadership
Enhance systems
Safety management
plan widely known
Improve suite of
performance measures
Competent people with
experience
Develop action plans
Accountabilities
understood
Monitor and review
progress
Clarify/refine objectives
Advanced performance
measures
Regular reviews
Range of emergency
responses catered for
New ideas crushed
Resilient
Strive for resilience of
systems rather
Reform
Reform rather than
than
repair
repair
Responsibility shared
Actively seek new
ideas
Proactive
as
Messengers rewarded
well asas
Proactive
well as
reactive
reactive
Failures prompt farreaching inquiries
Failures
prompt
Flexibility
of operation
Consistent mindset is
far-reaching
‘wariness’
inquiries
‘in disarray’
pathological
‘organised’
reactive
Sanction
Direct
‘credible’
calculative
‘trusting’
proactive
Encourage
Partner
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‘disciplined’
generative
Champion
5
Resilient safety culture
Safety is not the absence of accidents
It is the presence of capacity and defences
How does your site investigate incidents?
What happens with that information?
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6
What is the difference in how we see events?
Old view
New view (reform)
Human error is a cause of
accidents
Human error is a symptom of
trouble deeper inside a system
To explain failure, investigations
must seek failures of parts of
systems
To explain failure, do not try to
find out where people went
wrong
These investigations must find
inaccurate assessments and
bad decisions
Instead, find out HOW people’s
actions and assessments made
sense at the time, given the
circumstances that surrounded
them
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7
Changing who and why
W H O?
AT
WHY ?
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8
James Reason’s ‘Swiss cheese model’
Reason’s Swiss cheese model
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Workshop
WHAT happened here and HOW?
Focus on the safety systems that failed
and HOW that could have happened
(contributory factors)
Source: http://www.youtube.com/watch?v=hfh2yObrOHw
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Take-away messages
• Look beyond formal investigations and adopt this
approach in the workplace setting when planning jobs
• Ask WHO is doing what task and WHY before
starting the job
• Near-miss events are opportunities to maximise the
benefits from asking WHAT and HOW during an
investigation
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