Incident Causal Factors and the Reasons for Conducting Investigations: A Study of Five Ghanaian Large-Scale Mines (original) (raw)
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Safety Science, 2019
Incident investigation has been regarded as one of the means of improving safety performance. Limited published research exists that focuses on the context of practical investigation and the perspectives of investigators in the field. This research addresses this gap by evaluating how investigations are conducted in the Ghanaian Mining Industry. Forty-one investigators with diverse backgrounds were interviewed and the data collected was analysed through qualitative content analysis. Results of the study indicate that the blame culture is still evident, there is a lack of focus on controls and narrow dissemination of post-investigation findings. 49% of investigators had no knowledge of accident causation models and investigation methods. 37% of investigators had received no investigation training although they continue to investigate incidents. The frequently used data sources included interviewing victims/witnesses and evidence from the incident scene, while data from safety-related activities such as previous investigations and risk assessment were often under-utilised. An event tree showing opportunities to improve incident investigation and learning was developed to support the prioritisation of strategies for improving investigation practices. A framework has also been proposed to help incident investigators self-assess the maturity/effectiveness of their investigation practices.
Mining, Metallurgy & Exploration, 2019
Incident investigation is of utmost importance in most high-risk industries and is often used to improve organisational safety. This study was undertaken to examine the content of past incident investigation reports to determine the effectiveness of the incident investigations. The study uses a semi-quantitative method to assess the effectiveness of incident investigations in the Ghanaian mining industry by evaluating the quality of past investigation reports. The assessment tool consists of five elements with several indicators and rating scales for assessing the quality of an investigation report as a measure of the effectiveness of the investigation. The method was applied to 304 investigation reports of three Ghanaian large-scale gold mines, and the results correlated with incidence rates of the mines to determine if any relationship existed. The results showed that the mines differ significantly in the quality of their investigation reports, suggesting differences in the effectiveness of their investigations. In addition, the incidence rates of the mines negatively correlated with some elements of the assessment tool. In general, the method was found useful and revealed areas where improvement is needed.
Safety Science, 2020
The literature on learning from incidents indicates that there is more focus on the initial stage of incident analysis to identify causes and less focus on the latter stages associated with implementing improvements. To improve safety, it is important to develop and implement remedial measures that better address the causes and consequences of incidents. This study focused on the planning and implementation of remedial measures after incident analysis. Thirty-five safety professionals involved in developing and implementing remedial measures from incident investigations at four large-scale gold mines in Ghana were interviewed using the critical incident technique. The nature of past remedial measures was studied, as well as understanding the current process of planning and implementing remedial measures. Results showed that remedial measures most frequently targeted human behaviour, and the majority of recommendations were focused at the lowest levels of the organisation. Moreover, ...
Safety
Effective incident investigations have been recognised as a vital means of improving safety. Nevertheless, there has been little attempt to link incident investigations to actual safety performance. In this study, a framework for assessing the maturity of incident investigations and identifying areas for improvements is described. The framework was developed based on a literature review and interviews with 41 investigators across five large-scale Ghanaian gold mines. The framework consists of 20 elements across four dimensions and five maturity levels. The dimensions (investigator competencies, system of investigation, stages of investigation and post-investigation findings) consider the most relevant aspects of practical investigation and for each dimension, elements that are more specific were defined across five maturity levels. Mapping the interview data collected from five mines into a maturity framework highlighted that the mines occupied different positions on the framework. ...
University of Cape Town, 2019
This study establishes how systemic factors contribute to accidents at a copper mining company in Zambia. A set of 100 accident reports from the mine were analysed using an existing framework that is based on Mark III of the Swiss Cheese Model, Incident Cause Analysis, safety management principles and the Nertney Wheel. The study revealed that routine violation (with 38%) was the most prominent form of unsafe acts whereas the most prominent workplace factor identified was behavioural environment (25.8% of all accidents analysed). The most common systemic factors identified as contributing to accidents were leadership (22.6% of all accidents analysed) and hazard identification (21.7% of all accidents analysed). The study also recognized physical environment as the second highest workplace factor (23.4% of all accidents analysed). Further analysis to indicate which systemic factors were linked to workplace factors shows physical and environment problems, fitfor purpose equipment and competent people. When systemic factors were linked to physical environment, the problems recognized involved management of change, work schedule, maintenance management and housekeeping. When systemic factors were when linked to behavioural environment, the most common problems identified were leadership, hazard identification and contractor management. Management of change, work schedule, maintenance management and housekeeping were recognized to be prominent when systemic factors were linked to unsafe work practices, whereas when systemic factors when were linked to competent people, leadership, hazard identification, design and training and competence were identified as the major problems involved. Finally, when systemic factors were linked to fit-for purpose equipment the most identified factors causing accidents were risk management, hazard identification, provision of resources, maintenance management, leadership and design. The outcome of this study demonstrates how systemic factors, workplace factors and violations contribute to accidents.
Journal of the Southern African Institute of Mining and Metallurgy
This paper aims to demonstrate how a systemic approach can be applied to the analysis of the causes of accidents in South African mines. The accident analysis framework used was developed previously by the authors from the combination of the Mark III version of the Swiss Cheese model, Incident Cause Analysis Method (ICAM), the Nertney Wheel model, and safety management principles. Data on 91 accidents occurring from 2010 to 2012 at the site of a platinum mine in South Africa were used to populate the newly developed framework. The results obtained show that while routine violations (45% of all accidents analysed) were the most common form of human error, problems in the physical environment of workers were the most common workplace factor (39.6% of all accidents analysed). Furthermore, inadequate leadership was found to be the most common systemic factor responsible for accidents (51.6% of all accidents analysed). Some workplace factors were more commonly associated with particular unsafe acts than others, and some systemic factors were more associated with particular workplace factors than others. The outcome of this study demonstrates that systemic factors, rather than human errors and violations, are the chief causes of accidents in the mining sector. mine safety, systemic factors, accident causality, human error.
Analysis of Recommendations from Mining Incident Investigative Reports: A 50-Year Review
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A systematic analysis was conducted using ten occupational health and safety commissioned reports from Canada, New Zealand, United States, United Kingdom, and Australia spanning from 1967 to 2015. The objective was to identify commonalities and differences in the key recommendations across the identified reports. The text-mining software Leximancer was utilized to analyze the content of the recommendations through the semantic extraction of dominant themes, and the relational extraction and mapping of thematic relationships against each other. The identified themes were then analyzed within the concept map to fully understand the relationships. Based on the concept map, the thematic analysis provided a longitudinal perspective of the recommendations, identifying six key themes and 49 sets of overlapping recommendations. Key themes included: health and safety hazards (n = 10), legislation, regulations and organizational structure (n = 13), emergency management and mine rescue (n = 9)...
Ecoment Global Journal , 2023
Objective: This study seeks to dissect the occurrences of work-related accidents at PT Indo Muro Kencana (PT IMK) over a period spanning from 2018 to 2023. It aims to pinpoint the contributing factors to these mishaps, analyzing them to forge actionable recommendations and preventive strategies aimed at mitigating accident risks and enhancing workplace safety and health. Design/Methods/Approach: Employing a quantitative descriptive methodology, this research adopts an observational descriptive design to catalog and scrutinize work accident incidents. The Loss Causation Model serves as the analytical framework, facilitating a thorough evaluation of accident causatives. The study encompasses all PT IMK employees during the specified timeframe, utilizing a total sampling approach. Data compilation hinges on secondary sources, including company accident reports and relevant literature, with SPSS Statistics 25 software facilitating cross tabulation for data analysis. Findings: Analysis reveals a fluctuating pattern of work accidents over the years, with a significant portion resulting from direct physical interactions such as collisions and strikes. Predominantly occurring in excavation and roadway sectors, these incidents frequently involve heavy machinery and service vehicles. Notably, accidents disproportionately affect younger employees with limited tenure, though veterans are not exempt from risk. Primary accident triggers are identified as unsafe acts-including procedural breaches and poor decision-making-and unsafe conditions like slippery surfaces and subpar equipment. Underlying causes are attributed to human elements, notably inadequate judgment skills, and occupational hazards, including poor hazard awareness and deficient job safety analysis. Originality/Value: This research pioneers in its focused examination of work accident causatives within PT Indo Muro Kencana's gold mining operations, marking a novel contribution to occupational safety and health literature in the mining sector. Practical/Policy implication: The insights garnered herein are poised to inform the development of targeted safety programs, underlining the study's utility in propelling occupational safety and health consciousness, alongside facilitating accident risk reduction initiatives.
Practitioners’ perspectives on incident investigations
Safety Science, 2017
The ongoing existence of workplace accidents suggests that opportunities exist for organisations, regulators and other government bodies to improve their ability to learn from past events. The processes and outcomes of incident investigations are crucial to understanding the vulnerabilities and opportunities associated with work related incidents and accidents. Many scholarly articles exist that discuss the failure to learn from industrial incidents and incident investigation processes. However, very little research has been published on practitioner's views on incident investigations. In this article we begin to address this gap by presenting findings from a survey that gathered practitioners' perceptions of incident investigation processes. The article begins with a review of existing literature that was used to inform the survey distributed to practitioners. Results from the 222 respondents indicated that most incident investigation processes directed investigators to identify the cause of the incident, and to generate recommendations. Few required mitigation controls and the initiating event (i.e., the hazard) be identified. Even fewer organisations' incident investigation processes required a description of the incident or sequence of events, the identification of Human Factors issues, or the identification of prevention controls. Feedback from practitioners indicated that current incident investigation processes had certain strengths, and that opportunities existed for further improvement. Results suggest that further research is needed to determine the benefits of integrating risk control identification and analysis, as well as Human Factors, into incident investigation processes to optimise organisational learning.
Identifying Antecedent Conditions Responsible for the High Rate of Mining Injuries in Zambia
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The incident rates of mining-related accidents and injuries in developing countries exceed those of developed nations. Interventions by international organizations routinely fail to produce appreciable long-term improvement. One major reason is the inability to identify and analyze the underlying factors responsible for creating unsafe working conditions. Understanding these antecedent conditions is necessary to formulate effective intervention strategies and prioritize the use of limited resources. This study utilized a logic model approach to determine the root causes and broad categories of potential interventions for mining accidents and injuries in Zambia. Results showed that policy interventions have the greatest potential for substantive change. A process of educating officials from government and mining companies about the economic and social merits of health and safety programs and extensive changes in regulatory structure and enforcement are needed.