Please read this before using presentation 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: or visit 1

Can you move from who to what and why to how? Anagram approach to site incident investigations 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 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 4

5 Safety culture spectrum VulnerableRule followersRobustEnlightenedResilient In denial Messengers shot Whistleblowers dismissed or discredited Protection of the powerful Information hoarded Responsibility shirked Failure punished or covered up New ideas crushed Deal by the book Conform to rules Target = zero Reactive Repair not reform Information neglected Responsibility compartmentalised New ideas = problems Develop risk management capacity Enhance systems Improve suite of performance measures Develop action plans Monitor and review progress Clarify/refine objectives Active leadership Safety management plan widely known Competent people with experience Accountabilities understood Advanced performance measures Regular reviews Range of emergency responses catered for Strive for resilience of systems Reform rather than repair Responsibility shared Actively seek new ideas Messengers rewarded Proactive as well as reactive Failures prompt far- reaching inquiries Flexibility of operation Consistent mindset is wariness in disarray pathological organised reactive credible calculative trusting proactive disciplined generative SanctionDirectEncouragePartnerChampion Messengers shot Whistleblowers dismissed or discredited Repair not reform Reform rather than repair Proactive as well as reactive Failures prompt far-reaching inquiries

Resilient safety culture Safety is not the absence of accidents It is the presence of capacity and defencesHow does your site investigate incidents? What happens with that information? 6

What is the difference in how we see events? Old viewNew 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 These investigations must find inaccurate assessments and bad decisions To explain failure, do not try to find out where people went wrong Instead, find out HOW peoples actions and assessments made sense at the time, given the circumstances that surrounded them 7

Changing who and why WHO? WHY? AT 8

Reasons Swiss cheese model James Reasons Swiss cheese model

Workshop WHAT happened here and HOW? Focus on the safety systems that failed and HOW that could have happened (contributory factors) 10 Source:

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