Safety and Health at Work

Occupational Safety and Health Research Institute, Korea Occupational Safety and Health Agency (산업안전보건연구원)
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Improving Remedial Measures from Incident Investigations: A Study Across Ghanaian Mines

  • Theophilus Joe-Asare (Environmental and Safety Engineering Department, University of Mines and Technology) ;
  • Eric Stemn (Environmental and Safety Engineering Department, University of Mines and Technology)
  • Received : 2023.08.04
  • Accepted : 2023.11.25
  • Published : 2024.03.30
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Abstract

Background: Learning from incidents for accident prevention is a two-stage process, involving the investigation of past accidents to identify the causal factors, followed by the identification and implementation of remedial measures to address the identified causal factors. The focus of past research has been on the identification of causal factors, with limited focus on the identification and implementation of remedial measures. This research begins to contribute to this gap. The motivation for the research is twofold. First, previous analyses show the recurring nature of accidents within the Ghanaian mining industry, and the causal factors also remain the same. This raises questions on the nature and effectiveness of remedial measures identified to address the causes of past accidents. Secondly, without identifying and implementing remedial measures, the full benefits of accident investigations will not be achieved. Hence, this study aims to assess the nature of remedial measures proposed to address investigation causal factors. Method: The study adopted SMARTER from business studies with the addition of HMW (H - Hierarchical, M - Mapping, and W - Weighting of causal factors) to analyse the recommendations from 500 individual investigation reports across seven different mines in Ghana. Results: The 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). 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. Conclusion: Identifying sharp-end causes leads to proposing weak recommendations which fail to address latent organisational conditions. The study proposed a guide for effective planning and implementation of remedial actions.

Keywords

Acknowledgement

We acknowledge the assistance of the seven mines for allowing the author to access their facility for the research. We would like to thank everyone who directly or indirectly assisted us in collecting data. Theophilus Joe-Asare was a beneficiary of UMaT staff development scholarship. Therefore, we extend our acknowledgements to UMaT for the funding for the research.

References

  1. Drupsteen L, Hasle P. Why do organizations not learn from incidents? Bottlenecks, causes and conditions for a failure to effectively learn. Accid Anal Prev 2014;72:351-8. https://doi.org/10.1016/j.aap.2014.07.027
  2. Lindberg A-K, Hansson SO, Rollenhagen C. Learning from accidents e what more do we need to know? Saf Sci 2010;48(6):714-21. https://doi.org/10.1016/j.ssci.2010.02.004
  3. Stemn E, Hassall ME, Cliff D, Bofinger C. Incident investigators' perspectives of incident investigations conducted in the Ghanaian mining industry. Saf Sci 2019;112:173-88. https://doi.org/10.1016/j.ssci.2018.10.026
  4. AlKazimi MA, Grantham K. Investigating new risk reduction and mitigation in the oil and gas industry. J Loss Prev Process Ind 2015;34:196-208. https://doi.org/10.1016/j.jlp.2015.02.003
  5. Zhang L, Wu S, Zheng W, Fan J. A dynamic and quantitative risk assessment method with uncertainties for offshore managed pressure drilling phases. Saf Sci 2018;104:39-54. https://doi.org/10.1016/j.ssci.2017.12.033
  6. Stemn E, Bofinger C, Cliff D, Hassall ME. Failure to learn from safety incidents: status, challenges and opportunities. Saf Sci 2018;101:313-25. https://doi.org/10.1016/j.ssci.2017.09.018
  7. Drupsteen L, Guldenmund FW. What is learning? A review of the safety literature to define learning from incidents, accidents and disasters. J Conting Crisis Manag 2014;22(2):81-96. https://doi.org/10.1111/1468-5973.12039
  8. Drupsteen L, Groeneweg J, Zwetsloot GIJM. Critical steps in learning from incidents: using learning potential in the process from reporting an incident to accident prevention. Int J Occup Saf Ergon 2013;19(1):63-77. https://doi.org/10.1080/10803548.2013.11076966
  9. Cooke DL, Rohleder TR. Learning from incidents: from normal accidents to high reliability. Syst Dyn Rev 2006;22(3):213-39. https://doi.org/10.1002/sdr.338
  10. Lukic D, Margaryan A, Littlejohn A. Individual agency in learning from incidents. Hum Resour Dev Int 2013;16(4):409-25. https://doi.org/10.1080/13678868.2013.792490
  11. Jacobsson A, Ek A, Akselsson R. Learning from incidents e a method for assessing the effectiveness of the learning cycle. J Loss Prev Process Ind 2012;25(3):561-70. https://doi.org/10.1016/j.jlp.2011.12.013
  12. Lukic D, Margaryan A, Littlejohn A. How organisations learn from safety incidents: a multifaceted problem. J Workplace Learn 2010;22(7):428-50. https://doi.org/10.1108/13665621011071109
  13. Lundberg J, Rollenhagen C, Hollnagel E. What-You-Look-For-Is-What-YouFind e the consequences of underlying accident models in eight accident investigation manuals. Saf Sci 2009;47(10):1297-311. https://doi.org/10.1016/j.ssci.2009.01.004
  14. Qureshi ZH. A review of accident modelling approaches for complex sociotechnical systems at 12th Australian Workshop on Safety Related Programmable Systems. In: In conferences in research and practice in information technology 2007. Australia, Adelaide.
  15. Swuste P, Gulijk C van, Zwaard W, Oostendorp Y. Occupational safety theories, models and metaphors in the three decades since World War II, in the United States, Britain and The Netherlands: a literature review. Saf Sci 2014;62:16-27. https://doi.org/10.1016/j.ssci.2013.07.015
  16. Hollnagel E, Speziali J. Study on developments in accident investigation methods: a survey of the "State-of-the-Art"; 2008. 45 p.
  17. Katsakiori P, Sakellaropoulos G, Manatakis E. Towards an evaluation of accident investigation methods in terms of their alignment with accident causation models. Saf Sci 2009;47(7):1007-15. https://doi.org/10.1016/j.ssci.2008.11.002
  18. Pasman HJ, Rogers WJ, Mannan MS. How can we improve process hazard identification? What can accident investigation methods contribute and what other recent developments? A brief historical survey and a sketch of how to advance. J Loss Prev Process Ind 2018;55:80-106. https://doi.org/10.1016/j.jlp.2018.05.018
  19. Sklet S. Comparison of some selected methods for accident investigation. J Hazard Mater 2004;111(1):29-37. https://doi.org/10.1016/j.jhazmat.2004.02.005
  20. Hopkins A. Failure to learn: the BP Texas City refinery disaster. CCH Australia; 2016.
  21. Kalantarnia M, Khan F, Hawboldt K. Modelling of BP Texas City refinery accident using dynamic risk assessment approach. Process Saf Environ Prot 2010;88(3):191-9. https://doi.org/10.1016/j.psep.2010.01.004
  22. Cooke DL. A system dynamics analysis of the Westray mine disaster. Syst Dyn Rev 2003;19(2):139-66. https://doi.org/10.1002/sdr.268
  23. Miller K. Piper alpha and the Cullen report. Ind Law J 1991;20:176.
  24. Drysdale DD, Sylvester-Evans R. The explosion and fire on the Piper Alpha platform, 6 July 1988. A Case Study. Philos Trans R Soc A 1998;356(1748):2929-51. https://doi.org/10.1098/rsta.1998.0304
  25. Pate-Cornell ME. Learning from the Piper alpha accident: a postmortem analysis of technical and organizational factors. Risk Anal 1993;13(2):215-32. https://doi.org/10.1111/j.1539-6924.1993.tb01071.x
  26. Reid M. The Piper alpha disaster: a personal perspective with transferrable lessons on the long-term moral impact of safety failures. ACS Chem Health Saf 2020;27(2):88-95. https://doi.org/10.1021/acs.chas.9b00022
  27. Stemn E, Hassall ME, Bofinger C. Systemic constraints to effective learning from incidents in the Ghanaian mining industry: a correspondence analysis and AcciMap approach. Saf Sci 2020;123:104565.
  28. Rollenhagen C, Alm H, Karlsson K-H. Experience feedback from in-depth event investigations: how to find and implement efficient remedial actions. Saf Sci 2017;99:71-9. https://doi.org/10.1016/j.ssci.2016.12.003
  29. Cothran HM, Wysocki AF. Developing SMART goals for your organization. EDIS 2005;2005(14).
  30. MacLeod L. Making SMART goals smarter. Physician Exec 2012;38(2):68-72.
  31. Lazarus A. Reality check: is your behavior aligned with organizational goals? Physician Exec 2004;30:50-2.
  32. Subrt T, Brozova H. Multiple criteria evaluation of project goals. In: Trzaskalik, Wachowicz T, editors. Multiple criteria decision Making'12 T. Katowice: Scientific Publications; 2012. p. 179-88.
  33. Stemn E, Hassall ME, Bofinger C. Planning and implementing remedial measures from incident investigations: a study of the Ghanaian mining industry. Saf Sci 2020;127:104735.
  34. Lundberg J, Rollenhagen C, Hollnagel E. What you find is not always what you fixdhow other aspects than causes of accidents decide recommendations for remedial actions. Accid Anal Prev 2010;42(6):2132-9. https://doi.org/10.1016/j.aap.2010.07.003
  35. Chen S-T, Wall A, Davies P, Yang Z, Wang J, Chou Y-H. A Human and Organisational Factors (HOFs) analysis method for marine casualties using HFACSMaritime Accidents (HFACS-MA). Saf Sci 2013;60:105-14. https://doi.org/10.1016/j.ssci.2013.06.009
  36. Theophilus SC, Esenowo VN, Arewa AO, Ifelebuegu AO, Nnadi EO, Mbanaso FU. Human factors analysis and classification system for the oil and gas industry (HFACS-OGI). Reliab Eng Syst Saf 2017;167:168-76. https://doi.org/10.1016/j.ress.2017.05.036
  37. Joe-Asare T, Stemn E, Amegbey N. Causal and contributing factors of accidents in the Ghanaian mining industry. Saf Sci 2023;159:106036.
  38. Keating CB, Katina PF, Bradley JM. Complex system governance: concept, challenges, and emerging research. Int J Syst Syst Eng 2014;5(3):263-88. https://doi.org/10.1504/IJSSE.2014.065756
  39. Keating CB, Bradley JM. Complex system governance reference model. Int J Syst Syst Eng 2015;6(1-2):33-52. https://doi.org/10.1504/IJSSE.2015.068811
  40. Ellis k. Putting people in the mix: part I; 2014 [cited 2024 Novermber 13]; Available from: https://www.neimagazine.com/features/featureputtingpeople-in-the-mix-4321534/.
  41. Mosey D. Looking beyond the operator; 2014 [cited 2023 November 13]; Available from: https://www.neimagazine.com/features/featurelookingbeyond-the-operator-4447549/.
  42. Montibeller G, von Winterfeldt D. Cognitive and motivational biases in decision and risk analysis 2015;35(7):1230-51. https://doi.org/10.1111/risa.12360
  43. Brocal F, Gonzalez C, Komljenovic D, Katina PF, Sebastian MA. Emerging risk management in industry 4.0: an approach to improve organizational and human performance in the complex systems. Complexity 2019;2019:2089763.
  44. Roelen A, van Aalst R, Karanikas N, Kaspers S, Piric S, de Boer RJ. Effectiveness of risk controls as indicator of safety performancevol. 1(1). Amsterdam University Press; 2018. p. 175-89.
  45. Karanikas N, Roelen A, Piric S. Design, scope and focus of safety recommendations: results from aviation safety investigations. Policy Pract Health Saf 2019;17(1):14-31. https://doi.org/10.1080/14773996.2018.1539385
  46. de Dianous V, Fievez C. ARAMIS project: a more explicit demonstration of risk control through the use of bowetie diagrams and the evaluation of safety barrier performance. J Hazard Mater 2006;130(3):220-33. https://doi.org/10.1016/j.jhazmat.2005.07.010
  47. Svedung I, Rasmussen J. Graphic representation of accident scenarios: mapping system structure and the causation of accidents. Saf Sci 2002;40:397-417.  https://doi.org/10.1016/S0925-7535(00)00036-9