What types of issues are mine investigations finding and fixing?
This study – I think the first I’ve covered from Ghana – investigated the recommendations from 500 investigation reports.
Findings are similar to investigations elsewhere (Aus, US etc) and similar to my audit findings research.
PS. Check out my YouTube: https://www.youtube.com/@safe_as_pod
Findings:
- “individual and the work environment (79%) were mostly the focused during the search for causes, with limited focus on organisational factors (21%”
- “Forty eight percentage of the recommendations were administrative, focussing on fixing the problem in the immediate affected area or department of the victim(s)”
- Examples included review of SOPs or providing info and comms to workers
- “Most recommendations (70.4%) were support activities that only enhance the effectiveness of control but do not prevent/mitigate the failure directly”
- “Across all the mines, there was no focus on evaluating the performance of remedial measures after their implementation”
- 44% of remedial measures focused on fixing org problems, whereas 18% focused on human acts
- “few recommendations (12.5%) are targeted at addressing mine system deficiencies/external influence,“
- “Across all the mines, the remedial actions were not linked to causes to indicate the particular causal factor a recommendation seeks to address”
- “Most of the recommendations across all Mines were supporting activities (70.4%), which only enhanced the effectiveness of existing controls, with few being preventative (5.6%)”
- There were few “review of similar cases (past events and their proposed recommendation) during investigations”
- “Planning of recommendations is mostly influenced by the extent to which the Mines search for causes and what they accept as a cause of an accident and “Identifying sharp end causes leads to proposing weak recommendations which fail to address latent organisational conditions”
- “Across all mines, the cases are closed after the remedial measures are implemented. There are no systems to check whether the implemented corrective action addresses the problem identified during the investigation process”
- “All the Mines fail to assess the risk introduced into the system by the remedial measures, which is a significant factor to consider in accident prevention”
- “across all the Mines, there was no causes-remedial measure mapping; as a result, the remedial measures implemented do not address the significant causal factors”
- “Majority of the recommendations were non-controls which are to ensure the effectiveness of risk controls that are absent or not effective in preventing failure within the system”
- “Although supporting activities are essential and needed, the focus should be on mitigating or preventing the undesired event. It was observed that, across the participating mines, there was limited focus on analysing the performance of risk controls, and this was identified as a significant setback”
- “At the planning stage, the team should explicitly indicate, which recommendations are preventative, mitigative, and supporting activities”
- “The proposed corrective actions must also respond to failed and absent crucial risk controls. The proposed remedial measures must be measurable”
SafetyInsights.org 