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Suite 2, Level 1,

860 Doncaster Road,

Doncaster East, VIC 3109


January 7, 2019

The ripples of an accident
Spread further out day by day,
The impact never forgotten
The grief never far away.

Losses are measured in numbers 
But don’t forget each had a name,
They were people with a full life 
Each one unique and not the same.
The ripples of the accident
Started with the tragedy, 
It touched so many forever
The impact creating agony.
The operators hurt and killed
Never thought that shift was their last,
There was just no time to escape
It all unfolded way too fast.

The witnesses just froze in shock
Seeing tragedy so close by,
Nobody expects to come to work
To see colleagues get hurt or die.

Emergency sirens sounded
Rescuers raced out to the scene,
Rescue protocols were reviewed
For an accident never seen. 
Emergency response arrived
They tried hard to save each one,
The scene was just so horrific 
Nightmares plagued them once they were done.
Senior Management then got the call
They shakily asked “Are you sure?”,
They knew it would not be the same 
Things would never be the same as before.
Management activated the plan,
The plans told them what they should do,
In the event they had a death
Or a major accident too.

The local Police were called and came
They recorded the loss of lives, 
They shook their heads – they knew these men
Then went to notify the wives.
The town had heard the siren blare
Everyone woke in disbelief, 
Praying the Police wouldn’t visit
With official notices of grief.
Lives of wives and kids were broken
As they answered the door that night,
Seeing the Police standing so solemn
Expressing sorrow for their plight.

Word of mouth spread the news quickly
Colleagues and workmates heard the news,
The impact of loss haunted them
Whole towns would fill churches and pews.

Families and friends were heart-broken
They visited the accident site,
The work makes tried to console them
Many tears were shed that night.

The victims were finally recovered
They laid the stretchers side by side,
Media took photos and reported
Telling the story of those who died.

Support services were arranged
For the families and site crews,
Newspaper and TV reporters
Captured the grief for prime-time news.

Forensic clean-up crews arrived
They tried to sanitise the site,
Recovering biohazards 
They scrubbed and washed throughout the night.
Legal counsel had been engaged
They flew in the very next day, 
They briefed the site on what to do
And what they should and shouldn’t say.

The event was so significant
Regulators were notified, 
The sent a team of Inspectors
Due to the number who had died.
The Union sent Reps for their members
To provide advice and support,
They knew that this eventually 
Would be a case that would go to court.
The site started their Investigation
But the company board said “No”,
We need independent experts
We need people who really know.
The Police were there for the Coroner
Recording evidence for days, 
While operations and production
Were subject to lock-outs and stays.

The scene was then handed over
To the Regulators in wait, 
While the crews milled around and watched
Thinking when would all this abate.

Autopsies on victims were held
Families waited for their release, 
Funerals and wakes were planned for days
Knowing the pain would never cease.

Flags throughout the town were lowered
Every one of them flew at half mast,
The towns folk shocked at the horror
Wondering how long this would last.

The whole town stood still in honour 
Funeral processions went on for days,
So many people affected 
Existing in a shocked, sad daze.
Investigators toiled for weeks
Examining the evidence, 
Conducting interviews for days
Dealing with wary reticence.

The data was finally gathered
And the analysis complete, 
Recommendations were included
To hopefully avoid a repeat.

An Inquiry was established
All evidence was scrutinised, 
Accusations were raised by some
That evidence was sanitised.

Witnesses tried to remember 
Barristers and lawyers argued,
Deflection of guilt abounded
Nobody wanted to be sued.

The legal defence was considered
A ruling was finally made,
The penalty was a pittance
A cost the site readily paid.
Families asked for recognition
A memorial was then built, 
Some said to respect and honour
Some said to alleviate guilt.
Two years later it was announced
A Coroner’s Inquest would begin, 
The pain would be dredged up again
For all families and next-of-kin.

Findings were finally published
Recommendations were stated,
Five years after the tragedy 
The families and friends had waited.
Changes were made to Industry
Six years after the accident,
Some regulations enacted 
Some token change and sentiment.
For outsiders and the public
Memories ebbed and slowly wane, 
While families still cry and just hope
That their loss was never in vain.

The ripples of an accident
Spread further out day by day,
The impact never forgotten
The grief never far away.




Interested in Knowing More?

Further information on Safety Wise’s Incident Cause Analysis (ICAM) Training is available from our website:


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- Jo De Landre (Chief Operations Officer)

After 15 years with the Bureau of Air Safety Investigation (BASI),which became part of the multi-modal Australian Transport Safety Bureau (ATSB), Jo started co-facilitating ICAM training with Safety Wise in 2001 as the Principal Human Factors Consultant.


In 2005, Jo was promoted to the position of Executive General Manager of Safety Wise and beyond providing human factors specialist services and ICAM training and Investigations, she is now involved in strategic activities such as project management and developing safety management programs.


Jo has been the Safety Wise Lead Investigator for many high profile accidents, including multiple fatality investigations. She has a Bachelor’s Degree in Applied Psychology and a Graduate Diploma of Psychology, and has published papers in aviation, mining and police journals and publications.


Joanne has also been Secretary of the Australian Aviation Psychology Association (AAvPA) for close to a decade.







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