This review discusses the principles of incident analysis and management, and explores how best to put these to productive use on a mine. Topics covered include IT incident management, health and safety, and industry practices. Links to incident management software and consultants are also given.
To save money and save lives on your mine, practice incident analysis and management. I learnt the principles in the context of health and safety. Now I see the computer industry makes extensive use of the principles simply to provide better service.
On a well-run mine, the incident analysis and management function is under the health and safety department. And so it should be if the objective is to save limbs and lives. But maybe the mine's Information Technology (IT) department should have their own program to save money and time.
Hence in this review we take a look at the principles of incident analysis and management, and explore how best to put these to productive use on a mine where money and lives are both important.
INCIDENT MANAGEMENT DEFINED
Incident management means different things to different people. In my mind it is just one concrete example of the "no graffiti-fix the broken windows" theory. That is the idea that you can control crime by painting out the graffiti, fixing the broken windows, and stopping them peeing in the streets. Best explained thus
"Consider a building with a few broken windows. If the windows are not repaired, the tendency is for vandals to break a few more windows. Eventually, they may even break into the building, and if it's unoccupied, perhaps become squatters or light fires inside.
Or consider a sidewalk. Some litter accumulates. Soon, more litter accumulates. Eventually, people even start leaving bags of trash from take-out restaurants there or breaking into cars."
In short: on a mine, deal with the small, easy things, and somehow the big, bad things are precluded from happening. Control the incidents and accidents do not happen.
Thus we can consider an incident to be any event, however small and trivial, that is not the way things should be or is intended to be. No great harm involved in the incident; no blame really accruing to any person in particular; but a deviation from the planned, expected, or desired.
Too often, the natural human tendency is to ignore the incident: nobody was hurt, no expense incurred, altogether too trivial to act. But in ignoring the incident we may be loosing a valuable lesson, failing to notice a more serious problem lurking beneath the surface, ignoring a systematic tendency that one day will create a major malfunction.
Thus we should manage the incidents, and in so doing manage and improve the system so that big, bad events are precluded.
OSHA defines and summarizes how to deal with mining-related incidents thus:
Accident/incident investigation is another tool for uncovering hazards that were missed earlier or that slipped by the planned controls. But it's only useful when the process is positive and focuses on finding the root cause, not someone to blame! All accidents and incidents should be investigated. "Near-misses" are considered an incident, because, given a slight change in time or position, injury or damage could have occurred. Six key questions should be answered in the accident investigation and report: who, what, when, where, why, and how. Thorough interviews with everyone involved are necessary. The primary purpose of the accident/incident investigation is to prevent future occurrences. Therefore, the results of the investigation should be used to initiate corrective action.
This is the story of my first encounter with incident management in practice. I was excavating a test pit into the cover of an old landfill. The landfill rose some 300 feet above a busy freeway leading east from Los Angeles. The slopes were steep: one and a half horizontal to one vertical. We dug a neat pit and put the excavated soil in a pile on the slope besides the pit. Sometime into the excavation process, a clod tumbled off the waste pile, rolled and bounced down the slope, jumped the perimeter fence, and hence onto the freeway to splatter on the side of a passing car. The driver must have got a shock, but drove on in the busy stream of traffic with a big, brown splotch on his right-hand side door.
I mentioned this incident in passing at the technical review meeting that evening. The project manager, well trained in incident control, immediately tagged this event as an incident worthy of investigation. No blame to me, no retribution to anybody, but an event to be considered. He assembled a neutral team that included the health and safety officer and the community relations specialist. They went through the sequence of events carefully, evaluated root causes and potential really serious consequences, and considered methods to avoid a repeat or worse.
The upshot included these recommendations that were implemented throughout the remainder of the project:
- Place test pit spoil on a flat bench if possible.
- Place test pit soil upgradient of the test pit so clods rolling down enter the test pit.
- Install a plywood barrier along and above the perimeter fence to preclude any object falling or rolling down the slope from entering the freeway. This cost upward of a million dollars to install.
- Train all site staff in incident control and teach them to recognize incident to be reported and controlled.
By the end of the project, two years later, the plywood was sun-bleached and tatty. But it had stopped a few mishandled objects leaving the site, and no driver ever again got a shock from a passing clod. I was trained in incident control and made a believer in the process. So let me continue.
The Pennsylvania Bureau of Mine Safety
lists these reportable incidents-somewhat more serious than the "run-of-the-mill" incidents we deal with in the remainder of this review-but a valuable reminder, nonetheless, of what may constitute a serious incident:
- A death of an individual at a mine.
- An injury to an individual at a mine that has a reasonable potential to cause death and/or serious injuries resulting in the injured being admitted to a hospital excluding sprains and strains.
- An entrapment of an individual for more than 30 minutes.
- An unplanned inundation by a liquid or gas.
- An unplanned ignition or explosion of gas or dust.
- An unplanned mine fire requiring more than 5 minutes to extinguish.
- An unplanned ignition or explosion of a blasting agent or an explosive.
- An unplanned roof fall at or above the anchorage zone in active workings where roof bolts are in use; or an unplanned roof or rib fall in active workings that impairs ventilation or impedes passage.
- A coal or rock outburst that causes withdrawal of miners or which disrupts regular mining activity for more than one hour.
- An unstable condition at an impoundment, refuse pile, or culm bank which requires emergency action in order to prevent failure, or which causes individuals to evacuate an area; or failure of an impoundment, refuse pile, or culm bank.
- Accident to hoisting equipment in a shaft or slope that endangers an individual or which interferes with use of the equipment for more than 30 minutes.
- An event at a mine which causes death or bodily injury to an individual not at the mine at the time the event occurs.
- Ventilation interruptions requiring withdrawal of personnel from the entire mine.
- Unplanned connections into abandoned workings or boreholes.
IT INCIDENT MANAGEMENT
A long book on the subject is Critical Incident Management
by Alan B. Sterneckert. Here you will find a wealth of information on incident management theory, practice, and implementation. The book is written with the IT industry in mind, but the principles it sets out are equally applicable in the mining industry to asset management and health and safety.
Microsoft provides extensive documentation of incident management in the IT field. This is their definition of incident management:
Incident management is a critical process that provides organizations with the ability to first detect incidents and then to target the correct support resources in order to resolve the incidents as quickly as possible. The process provides management with accurate information on the incidents impacting the organization, so that they can identify the required support resources and plan for their provision.
They are talking of incident management as it applies to power-outages, vicious hackers, and other happenings that could make the computer system crash. Regardless, the benefits of incident management in mining applies to computers, cash flow, community relations, environmental impact, and health and safety in mining.
Be careful, however, in pouring over this document and many others that come up via Google under keywords, incident managements. Some organizations use the term as a substitute for emergency response management; an incident sounds so much less scary than accident or emergency.
HEALTH AND SAFETY
In a magnificent book that you can purchase from the SME or through the InfoMine e-Store called Mine Health and Safety Management
edited by Michael Karmis is a superb chapter on the principles and implementation details of incident management in the health and safety field of mining. In a mere ten pages, Douglas Martin and H.L. Boling write of Mine Incident Reporting and Analysis.
They justify an incident analysis and management program in these words:
Established procedures for evaluating causes of incidents should be in place at all companies and organizations. Incident analysis should be followed the implementation of controls to prevent future similar occurrences. Comprehensive procedures should also include the analysis of near incidents. Potential causes can be controlled before an incident occurs. All incidents that result in fatalities or serious injuries to more than one person should have the analysis conducted under the direction of corporate safety and with legal advice.
Clearly they are going way beyond mere graffiti out-painting in extending the scope of incident analysis to fatalities. But the principles remain the same: Incident analysis should always be conducted as a fact-finding mission, not a fault-finding one.
To them an incident is an occurrence or event that interrupts normal procedure or precipitates a crisis. They note the following types of incidents that warrant analysis: near incident; property damage; illness; first aid injuries; medical treatment injuries; lost-time injuries; and fatalities.
They summarize the incident analysis process under these headings:
Purpose: improve workplace safety; determine root cause; uncover defects in safety management systems; and demonstrate commitment to continuous performance improvement.
Team: establish a team that may include the front-line supervisor, the hourly employee, management, and the safety department.
Information: collect pertinent information fro interviews and observations.
Root cause analysis: validate root causes via fact finding (not fault finding)
Determine corrective/preventative actions; use all available resources and close the loop.
Management responsibilities: direct participation; oversight; final approval; evaluation of analysis performance; and case studies.
Evaluate incident reports for thoroughness, timeliness, specificity, remedy identification, and assignment of responsibility.
Implement corrective and preventative actions: eliminate root causes; eliminate underlying causes; eliminate the hazard; construct a barrier; institute new procedures; and train employees.
There are many software that help you track reports and collate the data gathered as part of any incident management system. Here is a link
to a general site that lists many of the suppliers of such software. Following are my selection of some of the software I read about. This is not a comprehensive list; I simply try to select a few that look reasonable and that provide text that further elucidates the nature and processes of incident analysis and management.
Cube Consulting has the INX Incident Reporting, Health and Safety Suite that includes: flight and travel scheduling; accommodation; risk management; health and safety; compliance; procedures; competency; trainings; and security.
Environmental Expert's Events Manager "provides advanced event management for organizations with the ability to collect, view, and analyze Environmental Health & Safety incidents from across the enterprise. Event Manager also streamlines incident data collection process with a user-friendly wizard interface while at the same time increasing the accuracy of event reporting."
Sparta Systems Inc has TrackWise EH&S Incident Management Solutions. Their write up makes it sound easy: "TrackWise enable companies to reduce risk and resolve EH&S issue faster and more effectively by capturing and tracking all EH&S incidents, automating workflow processes and ensuring that all required reporting and follow-up activities are completed. With TrackWise, nothing is left to chance. The user-friendly graphical interface guides your personnel through all the required steps, including impact analysis, root cause investigation, corrective action, detailed reporting, and corrective action to prevent future occurrences. Customized reports can also be generated directly from the system and provided to management and oversight agencies.
The Syntex IMPACT Enterprise software sounds most impressive. It includes the following: facilitates the discovery and removal of exposures to risk that result in organizational loss; tracks incidents, investigations and responsibilities; encourages the creation of remedies, for pro-active and reactive situations; facilitates assessment of corrective actions; and provides site-level and enterprise-level views of performance.
I suspect most consultants will tell you they can undertake an incident analysis-especially if they have read this review. You will have to decide yourself if you believe them or consider they have the capability to learn and apply. Here are three I found that do appear to know what they are talking about.
ABS Consulting provides training courses and consulting services in root cause analysis and incident investigation. They define an incident as: an actual loss event or a near miss that should be investigated so that effective actions can be taken to prevent the same or similar losses from happening again. To them root causes are: "management system weaknesses that allowed the causal factor to occur. Management systems are the processes a company has in place to control the work process and to encourage personnel to take the appropriate actions and discourage them from taking inappropriate actions. Examples of typical management systems include: Equipment Design Process; Procedures; Supervision; Standards and Policies; Training; Communication Practices; and Maintenance Practices."
John T Boyd Company describes their services thus: "Providing support in incident (accident) investigations and analysis of the underlying causal factors leading to the incident. Key in BOYD's approach is our ability to look for contributing factors (facts) rather than the traditional approach of finding fault. Taking this approach leads to effective re-occurrence measures, a critical component of prevention."
1984 Enterprises Inc will file mandated reporting forms including incident, accident, and first aid occurrences for specific work site and follow-up incidents.
Finally take a look at this link that lists many other consultants in this and other related fields.
has an incident investigation program. I like this justification for their program:
Along with health programs, safety education, risk assessments and regular safety inspections, we utilize incident investigation and analysis as a tool to bring us closer to our goal "to have every employee go home in good health and uninjured, after every shift, each and every day".
The Rio Tinto Incident Management Standard Operating Procedure is available for download at this link. It is detailed and applicable in the mining industry world-wide.
BHP describes their Incident Reporting and Investigation program thus-and I repeat it in its entirety as it pretty much summarizes all we have written about in this review.
As directed by our HSEC Management Standard 13, all HSEC incidents, including near misses, at BHP Billiton controlled sites and activities are reported, investigated and analyzed. Corrective and preventive actions are then taken, and learnings are shared.
Incidents defined by the BHP Billiton Consequence Severity Table as a potential or actual significant HSEC incident are investigated using the Incident Cause Analysis Method (ICAM), a tool developed by safety representatives from across the Company with the assistance of the Australian Transport Safety Bureau.
ICAM provides a process to identify what led to the event, so that effective corrective and preventive actions can be implemented to prevent recurrence. It does not apportion blame or liability. The Company has, on average, four trained ICAM investigators per 100 site-based personnel. Investigators are drawn from all areas of the business, with a range of experience and knowledge.
In the event of a significant incident, it is our policy that associated work does not resume until actions have been taken to reduce the risk of recurrence and authorization to resume work is given at the appropriate level.
Information gathered from near miss and significant incidents is analyzed to identify lessons and to monitor trends and is reported to management to improve standards, systems and practices. Learnings are shared across the organization and with stakeholders and others as appropriate. Systems are in place at all our operations to ensure that all remedial actions, including changes in procedures, are documented, communicated, followed up and completed.
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