Www.dmp.wa.gov.au/ResourcesSafety Please read this before using presentation This presentation is based on content presented at the Mines Safety Roadshow.

www.dmp.wa.gov.au/ResourcesSafety

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:

[email protected]

or visit

www.dmp.wa.gov.au/ResourcesSafety

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Can you move from “who” to “what” and “why” to “how”?

Anagram approach to site incident investigations

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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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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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www.dmp.wa.gov.au/ResourcesSafety 5

Safety culture spectrum

Vulnerable Rule followers Robust Enlightened Resilient

In denialMessengers ‘shot’Whistleblowers dismissed or discreditedProtection of the powerfulInformation hoardedResponsibility shirkedFailure punished or covered upNew ideas crushed

Deal ‘by the book’Conform to rulesTarget = ‘zero’ReactiveRepair not reformInformation neglectedResponsibility compartmentalisedNew ideas = ‘problems’

Develop risk management capacityEnhance systemsImprove suite of performance measuresDevelop action plansMonitor and review progressClarify/refine objectives

Active leadershipSafety management plan widely knownCompetent people with experienceAccountabilities understoodAdvanced performance measuresRegular reviewsRange of emergency responses catered for

Strive for resilience of systemsReform rather than repairResponsibility sharedActively seek new ideasMessengers rewardedProactive as well as reactiveFailures prompt far-reaching inquiriesFlexibility of operationConsistent mindset is ‘wariness’

‘in disarray’pathological

‘organised’reactive

‘credible’calculative

‘trusting’proactive

‘disciplined’generative

Sanction Direct Encourage Partner Champion

Messengers “shot”

Whistleblowers dismissed or discredited

Repair not reform

Reform rather than repair

Proactive as well as reactive

Failures prompt far-reaching

inquiries

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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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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

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 people’s actions and assessments made sense at the time, given the circumstances that surrounded them

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Changing who and why

W H O ?

W H Y ?

AT

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Reason’s Swiss cheese modelJames 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)

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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