As usual the phone call comes in on Friday afternoon – ‘Can you help with an investigation in Mt Isa?’
‘They want you yesterday. Can you ring the contact now to organise the trip?’
So I ring the contact who is an inexperienced Safety Coordinator on a small site. The organisations Safety Manager is based in Brisbane but can’t come to the site to assist and has suggested he engage a Safety Consultant. He has done the ICAM Lead course but has only conducted a few minor investigations and has no other support on site. He describes the incident which is a near miss involving an excavator with what seems to be a very realistic fatality potential. The ground under the machine had slumped away into what was later revealed to be a void at the top of an old underground stope. One track of the excavator had fallen into the stope but fortunately the machine stopped in that position.
The first question I ask is regarding their initial response to the incident. The Safety Consultant told me that the operator of the excavator got himself out of the machine as others came to assist him. They all moved away from the area fearing further collapse and the area was barricaded by the Supervisor on what they were confident was solid ground. The operator was not injured and had been offered counselling which he had refused but was being cared for by family. The Manager has suspended all activity on site.
We discuss the logistics of getting me on site and we agree it will take at least 2 days. This concerns my contact because his boss apparently wants things moving quickly.
His boss is right, investigations need to be started quickly while physical evidence and memories are fresh and a day has already elapsed.
As our discussion progresses it becomes apparent that the preliminary investigation is progressing well. Photos have been taken and an accurate sketch of the area produced. Being a mining incident there are drawings and plans of the area available, and some interviews of those involved have already been conducted.
I ask my contact if they have discussed who will make up the investigation team. He said not formally, but that the person who manages the area wants to be involved and that the Mining Engineer who has planned this activity is available, plus himself. I have a concern that these people may be too close to the activity to be unbiased but decide to keep this thought to myself for now. Part of my role will be to manage any strong opinions in the investigation team. We agree that he will send me what he has and that I will start to organise my travel. We also set a time for a conference call early the next morning so that we can do a PEEPO. My contact is going to organise the other members of the team to be present and brief them on the PEEPO process before the call.
The PEEPO is that part of the ICAM investigation process where we plan the data gathering activity using a ‘brainstorming’ approach under the categories of People, Environment, Equipment, Procedures and Organisation. This process is fully explained and practiced several times during ICAM training conducted by experienced Safety Wise Solutions incident investigators.
I was right with my estimate of two days to get to Mt Isa from Sydney. It’s only about 4 hours of flying time but coordinating the flights is awkward, especially on a weekend and I end up having to organise an overnight in Brisbane.
The conference call on Saturday morning goes fairly well. My contact has briefed the other team members on the PEEPO process and they have started before the phone call. They have already listed all the People who were involved in the incident and in the activities leading up to it. I get them to think about operators who do similar work on other shifts and the technical experts who were involved in the work design as it seems they were involved in an unusual mining technique. The Manager starts to explain the mining technique to me and I have to emphasise that this exercise is about developing a list of issues to be explored and that he can explain it all when I get there. I am a bit concerned that I may have offended him, but he soon gets back into the process.
They quickly list the obvious Environmental issues and then I ask them if there were any factors such as time pressures or problems with the project that could have influenced people on the job. This question brings silence, so I ask them to have a think about it and we move on.
The Equipment list is assembled quickly, and they apparently have most of this information already. Being a mining organisation, they are driven by Procedures and plans, so they tell me what they have assembled, and it seems pretty comprehensive with risk assessments mentioned a few times. They struggle a bit with what is needed under Organisation, so I ask them to see what their Safety Management System says about the activity being undertaken, if they have ever had anything similar happen before or know if it has happened anywhere else. I also ask them to list any auditing they conduct.
I then ask, ‘Do we have a plan?’ to which the Manager replies that they will start to gather up the information ready for when I get there. He seems enthusiastic so my concern about insulting him is dissipated. I ask the Safety Coordinator to email me information where it is practical so that I can be reading while I travel. The Mining Engineer asks if it would be okay to start interviewing her colleagues about the reasons behind the particular mining technique that they chose. I encourage her to do that and briefly outline the detail she should include in her notes.
By the time I arrived on site on Sunday afternoon the team had a dedicated room set up with the PEEPO on a white board and piles of paperwork neatly arranged on a table. The PEEPO had been developed a bit more as the group had considered other issues. Under Environment was now written the words ‘budget pressure’ so I can see they are starting to consider the higher level issues that can influence decisions. A lot of the information has already been emailed to me by the Safety Coordinator, so my flying time has been productive.
The Mining Engineer has conducted a few interviews with her colleagues and is busy typing them up. The investigation is off to a good start and the team are positive and focused.
This incident occurred a good few years ago, but the technique is one I have employed on many occasions. Whether you are a consultant like myself, or an in-house safety professional these planning phone calls have many advantages over waiting until you can get to the remote site to start the investigation.
Time – starting an investigation quickly while the evidence is still fresh is so important.
Ownership – by engaging the on site personnel in the initial data gathering without your presence helps to establish that this is their incident, not yours. You are coming to assist them, so it is important that you don’t ‘take over’ when you do arrive. If a Team Leader has not been formally assigned you will usually find that someone has assumed that role, so you can ensure that they continue in that capacity with your support.
Confidence - establishing a plan quickly after an incident occurs helps to build confidence in the Investigation Team that they are addressing the investigation in the most efficient and productive manner. Senior management will notice this and be reassured that they have the right people on the investigation and will be supportive.
Investigation Experience – often site personnel have done the ICAM training but have not gained much experience. Practicing the process with minimal support is a good way to build confidence.
Your time – travel time is used more effectively and when you arrive you can get straight into understanding the incident, without having to wait for information to be assembled. In many cases you may not need to rush to site but be able to have your weekend with the confidence that good people are already working on the investigation.
During ICAM training people will sometimes comment that they hope they will not have to use the process. They are thinking that if they don’t have any serious incidents then they won’t have to do ICAM investigations. I take advantage of these comments to emphasise that they need to be prepared for the possibility that a serious incident may occur by practicing the process on minor incidents and near misses to develop the confidence to get the investigation started in a timely manner.
Interested in Knowing More?
Further information on Safety Wise’s Incident Cause Analysis (ICAM) Training is available from our website: http://www.safetywise.com/
Additional ICAM Related Services
Safety Wise also offers the following additional services for sites that adopt the ICAM investigation analysis method:
Quality review of incident investigations using ICAM
Trend analysis of organisational factors contributing to serious incidents
Participation in investigations as an external / independent party
ABOUT THE AUTHOR- Ken Horspool (Investigator/Trainer)
As one of the first consultants with Safety Wise, Ken’s experience has been very broad. He has conducted investigations into many serious incidents in mining, manufacturing and construction industries and trained supervisors and managers in the ICAM process.
Ken has extensive experience in South Africa and South East Asia including auditing investigation quality and Safety Management System performance in challenging cultural environments.
Ken’s career started with BHP Steel in Port Kembla (now Bluescope) as a metallurgist operating and managing Blast Furnaces for 25 years before an MBA focused on organisation development led him into Safety Management.
Incident Investigation fits neatly with Ken's passion for continuous improvement in both process and culture leading to safe, environmentally friendly and profitable businesses