Conducting proper investigations into accidents so that the true cause can be identified
This is Part 4 (and last) of our four-part series on “How to prevent mining and other workplace accidents”. You can access Part 1 (the “Pearl Harbour Syndrome”) here, Part 2 (Getting Back to Basics – The Six Key Principles) here, and Part 3 (Management of Change) here.
All workplace incidents and accidents are preventable. To prevent similar incidents and accidents from recurring, it is essential to identify the true direct and underlying causes of an incident or accident. It is only when the true causes are identified that appropriate remedial measures can be implemented to prevent the recurrence of a similar incident or accident.
There are various methodologies available to investigate incidents and accidents, including ICAM, ICAT, RCAT, “5 Whys” or the “Why Tree Analysis.
Regardless of which methodology is used, there are certain principles that must be applied to ensure that the true causes are identified.
These principles include:
- The facilitator must be competent by virtue of his/her experience, qualifications, and training (it is logical that if the facilitator is not competent, particularly in relation to the methodology being used, the outcomes may not be correct);
- The investigation team must be multi-disciplinary. Far too often, the team conducting the investigation is not representative of the workplace where the incident or accident has occurred or the multiple stakeholders that are all typically involved. For example, if an incident or accident involves a mobile machine, then it is logical that the operators, technicians / artisans who carry out maintenance, the engineers, and the relevant supervisors, are involved in the investigation. The Original Equipment Manufacturer is another key role – player;
- All persons that may be involved should be interviewed, and only then should it be decided which witnesses and persons are relevant (often, as a result of preliminary information available, key witnesses are not interviewed);
- A document controller should be appointed to manage the flow of information / documentation which includes ensuring that the correct versions of documents are made available to the regulators and other stakeholders, and that there is a proper record of which documents are provided, and to whom they are provided;
- Because documents are often changed after an incident or accident as part of the remedial measures, it is essential to ensure that the version of the document that was applicable prior to the incident or accident, is kept;
- Proper photographic evidence must be kept, and where practically possible, proper survey plans must be prepared
- Where statements are taken, they must be signed (unfortunately statements are often changed throughout the process if they are not signed).
Unfortunately, a new trend is developing where the scene of the accident is tampered with or disturbed, and persons involved create narratives that are aligned with demonstrating compliance with their training and the workplace rules, rather than what actually happened during the incident or accident. This of course leads to the debate surrounding whether persons involved in an incident or accident should face disciplinary action or not as a result of their involvement in the incident or accident. This question is always challenging, and most employers have implemented disciplinary codes and procedures which require disciplinary action to be taken for breach of workplace health and safety rules. There is a fine balance to be achieved and this is not made any easier as a result of the need to use polygraph examinations in many instances, to test the truthfulness of a version of events.
To prevent incidents or accidents it is vital to get to the true causes and underlying causes, because it is only in this way that future incidents and accidents can be prevented.
For more information, please contact Warren Beech at warren@bv-inc.co.za