"The unapparent connection is often more powerful than the apparent one." Heraclitus ~5008C sor Pesanca Meaty Dect mooseTABLE OF CONTENTS INTRODUCTON. GUIDELINES. mereney Response and Securing he Sk Notation PLANNING THE VESTIGATION Determining he evel of nvestgation ‘oping ne Tse verve of tence Equipment «. “orravauDation 72 Contig the CAM Cra. 73. ThelcaMstepsin Ota 74 Concuson and Recommendation. 75, cau habs Ts. a, PREVENTATIVE AND CORRECTIVE ACTIONS 42 Werrchy of Contra 83, Tachig Recommendations 8a Payaltwatra pure 12 Sample Payet ati. impact and Potent Beet Asem 52 Reportweting. 93. Report Sgro - 10 USSONS LEARNED 102. Commorcaon of ncient Prange 8 OeamesINTRODUCTON Purpose “The purpose ofthis guide is to provide the necessary information to complete an Incident Cause Analysis Methos {ICAM) investigation that meets Company requirements. ‘The objectives of incident investigations are to + Estab the fats + Identify contbuting factors and latent hazards; + Review the adequacy of existing contrls and procedures: + Report the findings; + Recommend corrective actions which can improve ‘efficiency reduce risk and prevent recurrence + Detect developing trends that can be analysed to identty specific o recurring problems; and + Identify any key learnings for cistibution within the “organisation and externally as required ‘Scope “This guideline applies to alincident investigation team members who ate involved in conducting an ICAM investigation at Company-contolled sites. This incuses ‘employees, contractors, subcontractors, support service providers, cuppllers and visitors. “The Company’ sit incident investigation procedure and incident event reporting procedure should be read in conjunction with this guideline. Legislative Context ‘The following lagisiation, standards or guidelines provide the broad framework for which thie procedure operates and with ich it needs to comply 4 Legion, Standard Reverence, “fares Suey endiepeebon act | (Relevant stat) “Vines Stay endinepecion | Feyuaons Relevant State) Worcs Heath Say At (Relevant tt) Wrolics Heath & Se Rapulston loan Sit) (Relevant sta). “Pavacy A188 (Gonmeweatn)_|Definitions: Wardle Definition GUIDELINES ‘The process below isto be followed for CAM Investigations. inert Own —— “Tgatn Teen Sao aT Sera | ‘incident nvstaton thos waa nny theron casos of averse vets 8 ip Dato oc ie fatter toast n= a net mss) [bse conmauences pol, per, the Sturmer pastoral ese Ro (ea. {Shing st) nertape plan prducion {acombnaten of hese. Sean evans fom proceures 76 manage esponable ere worn ‘in nein ose Te person assgnad byte ren wor Tne Inonageosbove, 9 haat anlaed an een ea | Wok nya essa wree pean Seng ast fr a pers ofomo mena or moe. fry occare at ar ata reso 3 ok ‘agi 8. bove est or arson oman aout on ial astog teas + Mambo poles asodton 1 Momocrann of pfesson crtade ‘iogaog Ueneipemecersr pao 1 Shmnaienot rr == ea | EE Fiouet eH _s an | ae seems | ¥ tered (OR eto “Te ICAMnveatigationProzoss1. IMMEDIATE ACTIONS: 444 Emergency Response and Securing the Site Inthe event of an incident, the supervisor or senior person present must initiate the site emergency response procedure ‘were emergency services or evacuation to muster points is required. ‘The Incident area must be made safe andlor controled to prevent further injury, harm or damage. Where possible the incident site must be controled (erect barirs, turn off power and assign a quard over the st) as appropriate to preserve any incident evidence Immediate, appropriate medical attention must be arranged for injured persons. njured persons net taken from ste must be ‘veated a the ste medical facity. Injured parsons must be ‘treated as per the Company injury management procedure. ‘The supervisor or senior person present must ensure privacy {or the inured person and control access o external media ‘sources by mentoring private mobile phone usage atthe scene of the incident 4.2 Initial Investigative Actions Following an incident the supervisor or senior person present ‘oremergency response group co-ordinator shou + Account forall people: + Document the emergency response actions fr analysis by the Emergency Services Department HOHE EAT + Carry outa pretiminary assessment ofthe incident level + Identity preventative actions necessary to remove any Immediate danger of a re-occurence and ensure the safety ofthe arealsite; + Conducta test for substance abuse as appropriate as per ‘the Aleohol and Other Drugs Procedure; + Photographivdeo the scone before changes are made; + Ensure perishable evidence is preserved + Identify al the people who might have information about the incident and plan to conduct interviews; and + Make nial notitatons in accordance with the Company ‘te incident reporing procedure. ‘The supervisor’ inl incident notification report is based on the preliminary assessment. Thi report provides senior ‘management with information to decide the necessary level of investigation requires 1.3. Notification ‘Allemployees, contractors, subcontractors and vistors must promptly report all inidents to their ine manager. Reporting ‘must occur as soon af reasonably practicable, but at least vwitin the shit in which the ineidentevent occurred ‘Any incident that results in death, serous injury, ness or incapacty, or is daemed by the involved person to be potentaly lassifed as a significant incident must be immediatly reportes othe department managerIrthe worker and their hne manager are contactors, the ine ‘manager must also nay the contract owner as s00n 3s reasonably practicable but not ater than 24 hours from when the incdentevent occurred Reporting and recording of incidents must be as per the ‘Company inset event reporting procedure. 2, PLANNING THE INVESTIGATION 2A Determining the Level of Investigation [Any incident that reauit in death, 2ious injury illness or incapacity, or has a sk rating of "high" or greater must be investgated using ICAM, However, inthe case of anear miss, an assessment neads to be made ofthe potential isk to utise the opportunity for prevention ofa future occurence, ‘The decision to complete an ICAM investigation on a near ‘iss wi be made by the area manager or above, or by the health and safety manager or above “The scope and type of investigation should be determined based on the folowing + The actual consequence severty + Potential futur risk + Oportunty for earning rom the Incident or near misss 22 Appointingthe Team “The manager er above ofthe involved parson or areas the incident owner and must assign an investigation team leader SATE ‘The investigation tear leader may request the health and safely representatives (HSR), safely advisors), hygienist), ‘environmental advisors) or other professionals to assist with ‘he investigation. HSAs must be given the opportunity to paticipate in any phase ofthe investigation. ‘Team members should not have 2 potential fr conflict of interest withthe invesigation process or findings. This includes not having supervisory contol over the person or the ‘area involved inthe incident. Consideration shouldbe given to selecting atleast one ‘member fom a separate department or business unit that is not involved in the incident and a member fom the workforce (HOR), should not be necessary that these personnel have. snecfic expertise or ICAM experience as thee primary role wil be o assess the incident from an independent perspective and develop ICAM sills. Iti important the cove Investigation team is assembled promt to enable team membre to view the ste ofthe incident as early as practicable, CAM team sizes wal depend ‘on the typeof incident to ensure a thorough investigation is completed ‘The investigation team operates under the general guidance ofthe team leader. Other members are assigned tasks 2s the leader deems necessary but maj decisions made during the investgative process should be agreed upon by the majonty belore execution.2:3 Team Composition Potential members for an CAM investigation t rae Pomorie Witte rae Garrone | NSS (other skis that maybe required inthe team: + Administrative - to contol and og data + Legal -10 provide advice and review reports. Selection of legal counsel should be made in consutation wth the company corporate legal department + Constants and specialists — detalled and specialised knowiodge or skills that may be usefut during an incident Investigation should be included as appropriate Involvement may investigation. | ependen sbject mater opens 2g engens independent serine manager bes qualed parson wih appropiate experince and his, Sera ine manage (sparnendet rhe paaan whos the it eon fine CAM acs awh ‘ipeonc eanaucng ICANs (CAM ar eases anit sey avi) Teoria ped ih space as oevantio tne inesignn safely advises) a tnerorena air) fa neath ee ae eprocettves not be required forthe fll duration ofthe AEE TEE 234 Team Leader ‘The IGAM Team Leaders role i to + Lead the team through the sleps ofthe investigation; + Ensure investigation team safety; + Communicate and Halse with stakehoklers and external pais inline with ste poly, + Assign duties tothe team; + Obtain the services of specialist advisers as required, + Schedule ané co-ordinate investigation scvities and + Supervise preperation ofthe Investigation report; and + Brief management onthe team's fndings. ‘The ICAM Team Leader should “+ Have prior experince as an ICAM team member + Be shied ineffective management ofa smallteam; and + Be abe to act a liaison between senior management and the investigation team, 232 ICAM Investigation Team [Al members must beable to devote the necessary time to the Investigation. The leam's role i to: + Collect data, facts and evidence + Be responsible for their own safety and exercise care when ‘conducting the Investigation, fllowng al established procedures and warings signs designed to protect the health and safety of ste personne + Ensure enthusiasm forthe task at hand does not overcome safety awareness;+-Establiah the eoquonce-of ovonts leading te the event + Analyse and integrate avilable information tablsh conclusions + Analyse fraings and + Determine the significant findings: and + Prasent the report to management for information, review and acceptance, ‘The team should + Have members with open and logial minds who are thorough, able o maintain perspective anc can overcome preconceptions or bias, and be able to work effectively together with complementary team sks; and + Include or have access to personnel with subject matter ‘expertise in areas related to the incident, e. specialist ‘constants, advisers or technical personnel ‘The team should not + Be placed ina situation of potential confit of interest with the Investigation processor findings: and + Have members selected solely on avalabiy 23.3 Facilitator + “The factitator’s role isto guide the Investigation team through he ICAM process as outined inthis guideline and in particular through the ICAM analysis stage. +The facitator must be @ person who has had formal ICAM training and ie abl to facilitate the ICAM process, with previous experience as an ICAM team member. HAH at 24 Mobilising to Incident site Prior to arriving a the incident site, investigation teams should ‘endeavour o customise and take with them appropriate ‘equipment to meet the specific requirements ofthe incident ‘The site safety team should keep an equipped incident Investigation kt atthe ste administration offices. Equipment contained in the incident investigation kt + Digital Camera - mobile phones may be used as an altemative(intinsicaly safe cameras to be used in underground coal mines) + Extra personal protective equipment (PPE) — gloves, earplugs, safety glasses both clear and dark + High visibility barrier tapes (caution and danger) + Tape measure - 8m and 20m + Identification tags or labels + Specimen containers and zi-lock bags + Compass + "Outo-Use" and “Information” tags + Isolation lockout padlock and personal danger tags + Peemanent markers and whiteboard markers + Fluorescent spray paint (cannot be keptin a vehicle) + Torch and batteries + Note book | + Bicos, pencils and erasers + Clipboard and grid paper for mapping/sketching + Radio (hand-held mobile) + Postitnotes| ‘Specialist equipment may also be required28 Overview of the Incident | summary of he incident must be provided by line ‘management to the vestigation team. The incident overview should ince: + Intl repot rom area supervisor as entered into the Company database + Incident context + Operations overview + Data of incident covering al the relevant facts relating to the incident + Scope of the investigation + Estimated dates and times forICAM analysis and report, finalisation 2.6 Authorisation to Enter the Site ‘Authorisation tthe incident soene shouldbe sought fom the site management team to ensure: + The scene is safe: and + Evidence is nt disturbed without authorisation from the relevant regulatory authority. “Tha investigation team leader must become the awmer of the incident site during the invetigaton process and must authorise access fo the incident area, Upon camltion ofthe Investigation, the area reverts back othe conta of the site management team wha must ramave arty area controls and ensure a safe retin to operations. OAH EEA 3.__ SITE VISIT Eat assessment ofthe incident scene shouldbe made to + Obtain famiarisation + Fully understand the incident context + Be informed atthe planning stage + Ensure capture of any degradable physical evidence 3.1 Planning Meeting Depending on the comply ef the incident, the investigation team may need to conduct formal planning mestng prior to collecting data and interviewing personnel. The planning meeting would normally involve the follwing + Establishing an investigation cente and resources + Defining terms of reference + Developing an acton plan ‘+ Estabishing document and records contol + Estabishing team roles and responsibities 3.41 Establish Investigation Centre and Resources. Selecta secure area such a8 @ lockable meeting room for use by the investigation team for the duration ofthe investigation. Ensure an interview room is available forthe duration ofthe investigation. Identity any addtional resources requied forthe investigation auch as data projector. scwen, and computer with aocess to the steleompany databesse, whiteboard ip chart, pens, camera, and administrative or other assistance,3.4.2 Establish the Terms of Reference: Terms of reference define the boundaries forthe investigation and address the following + The purpoee ofthe investigation. The purpose needs to be claar and the investigation boundaries established. The ‘boundaries may be restieted tothe period over which the incident eocurred. They may however need to be reviewed during the investigation +The requirements of stakeholders. These may vary dependant onthe typeof stakeholier eg intemal, external, regulator, non government organisation (NGO), community ete +The requirements for legal privilege and confidentiality agreements with extemal tam members, + The scope ofthe teams jurisetion. In general, the team should not be unnecessarily restricted, Eliminating superfiuous information during the Investigation is much ‘easier than expanding the terms of reference during an investigation +The authority of the team leader and team members, + Operaticnaisite-speciic issues such as purchasing, budget, contractor engagement requirements, induction procedures and training + Expected date for competion ofthe report DOCH ATE 3:1.3._Development ofan Action Plan Develop an action plan of allocated tasks, timing and requirements such as: + Site inspection + Data collection — people, environment. equipment procedures and documents, organisation + Investigation process and analysis + Communication processes + Report witing + ldentifcation of preventative and corrective actions + Management review 3.4.4 Establish Document Control and Record Management ‘Set up contro, recording and reporting procedures for gathered evidence: + Estabish a process to ensure confidentiality of sensitive Informaton that may be gathered + Detine polices, procedures and templates to be used during the process + Define document management and distibution protocols, ensuring Company document contol procedures are followed + Estab intemalixternal communications authors + Minuto all meetings“4: DATA CATEGORIES COLLECTION METHOD. During the data colection phase the investigation team should aim to collect as many facts as possible. This will help in understanding the incident an the events leading up tit The collection of datas divided int five main categories: + People + Environment + Equipment + Procedures and Documents *+ Organisation (Data collected in the above fve main categories should be broadly derived from the folowing sources: + Site Inspection: This should look atthe nature ofthe task belng conducted and the local environmental conations The physical environment and possible sudden changes to that environment are facors that need tobe identified. The situation atthe ime ofthe incident is important, not what the “usual” conditions were. t's therefore important to visit the incident sane at approximately the same time of day 28 the incident occurred. + Photography: Both close up and contextual photographs ‘shouldbe taken for reference later inthe investigation process. See below for more information on photography techniques. + Physical evidence collection: Where physical evidence supports the investigation ensure this's collected by ‘methods that maintain the Integr of the sample for analysis. Tit HEA + Witness interviews: Tr to identity al the people who ‘might have information about the incident and conduct interviews with them as soon as possible. Interview people individually and away from distractons.f possible, interview them at the scene ofthe incident to confi “atthe ‘ene information. See below for more information on Interviewing techniques. + Document collection: Examine the work procedures and the scheduling ofthe work to ascertain whether they ‘contributed tothe incident. Examine the availabilty, suitably, use of, and supervisory requirements of standart ‘operating procedures of work instructions. Eneure tho fctval work procedure being used at he time ofthe incident 's explored + Records collection: Training records, qualifications, ime In poston, nours worked should be gathered, + Organisational information: May include factors such as shit rastes, sk and change management systems. “The investigation process involves continual review and verifleation of evidence as required, e.g interviewing adational witnesses may resultin changes othe data colactd that may require futher consicaraton For he incident investigation to be successful in Kenting all ofthe contributing faciors and underiving causes it willbe necessary to establish + Events leading upto the incident + Facts ofthe incident ise and + Relevant facts of what occurred immediatly ater the incientCategory ee — i Poop noted | Fehowe poke |___} condone ase gto Equipment [ Sipe: roeiatonal eure | Postoneored workers * Safe ata Stet 305), | bree wae yes F Phys itatins Stress. te pessros Siar nani ahve fheegape scree fare stn sae (eveas wore) Eeugment manus & MS downoad Satay sand tay a Fisk managers loraanisatin|- Sra racsiae writen arshow|, Outcome of previous si L temper | Incorpo | Gora management TAHT TE at 41. People 444 Interviews Interviews shouldbe conducted inalvidualy and should begin .00n after an incident o obtain information about the immediate events associated wit the incident, including how the activi involved in the incident was planned and conducted Interviews should include the following individuals: + Those direty involved inthe incidant + Supenisory personne! + Persone at the scene + Management + Emergency services personnel (involved) + Subject matter experts 44.2 Goneral Principles of Witness Interviewing ‘Timeliness: Conduct the interviews as soon 2s possible after the incident. Delays in conducting intarviows can affect the ‘quality and quantty of information colected as memories deteriorate of are contaminated by ouside infuences ie. media, other witnesses etc. Try to conduct all interviews before winesses cigcuss the incident among themselves. Do not alow emotional witnesses tobe interviewed immediately after the event, as they may be unjustly harsh on themselves. Preparation: Preparation is essential othe sucoess ofthe interview. Take the time to gather background information on the accidentineident prior othe interview. Give some‘consideration to information that fe required, questions that can be asked, how best o structure the interview, who wil be involved, ad the background of witnesses witnes ssmont: Prise the order of witness interviews according o availabilty or relationship to ‘ccurtence. Consider their experince and experi, i. how familar are they withthe equipment or operation. Assess their ‘mativation and cre, e.g. explore the possiblity they may be protecting someone. Locatlon/setting: Ensure witnesses are interviewed in a private setting wit no distractions, such as an HR interview ‘oom. I may be beneficial 0 Interview some witnesses atthe incident ste to alow the environmental context to ai recall. is beste interview each witness individually witha team of ‘wa interviewers ~ one to lead the interview and one to provide support and take notes. Ths will alow verification of statements made in the interview, required, at alter date. Use diagrams to assist the witness to recall the details ofthe incident. Winesses ar allowed to have a support person present such as @ HSR or fend, Record of interview: The record ofthe witness's testimony should accurately and completly reflect alinformation obtained. Keep a set of notes as detalled as possible, The record of the witness's testimony shouldbe verfed by the witness after the interview by having them read the document, ‘This will onsure correct interpretation nl accuracy. Legal organisational and personal issues should be considered prior to the use of ecligital recorder. Permission must aways be sought fusing a recorder, TEE Et Explanation of the interview process: To avoid intimidation ‘and enhance co-operation, introduce yourseif and explain the ‘aim ofthe interview prior to asking questions. Develop an ‘early rapport with witnesses, Reasse the winess thatthe main purpose isto fact-find what went wrong, ascertain how to prevent reoccurrence, promote Zero Haim, and not apportion lame or liabity Concentrate on the facts: When interviewing concentrate on gathering factual evidence and avold opinion. opinion is. recorded, make it ler in your notes that itis an opinion, e. "Witness saw the vehicle civing to the work area. He believed ‘twas going faster than the designated speed lit" Avoid ‘asking the witness wat they thought caused the incident o i there was something that thay balive could have been done Detter to prevent the incident fom occuring the witness begins to offer reasons, excuses or explanations, pltely decline that knowledge end remind them to concentrate onthe factual information, [Active listening: Active listening involves not just Istening, but attending, understanding and remembering. Actve listening inclides both verbal and non-verbal ncicatons which ‘encourage the witness to contiwe taking. Be attentive and ‘ensure your body language reflects your inlerest,€ 9, maintain ‘eye contact, facing the witness, nod the head, display Interest in facial expression, give feedback to indicate you are listening and understand what has been said e.g"! see” oF ‘Okay.” Avoid interrupting the witness, ‘Communication: Use everyday language. Try to avoid technical terms, jargon and acronyms to avoidmisunderstanding or confusion. Ask he witness to answer questions in as much deta as they can Understanding and empathy: Remain conscious of the witness's emotional state, eg, defensive, anxious, stressed, confused, angry or datressed. I the witness becomes ‘emotional, offer a glass of wate, a short break or reschedule ‘he interview. Ifthe witness would fel more comfortable with @ ‘rend or HR present, try to arrange this, Ending the interview: Aways end the interview on a postive note, Thank the witness fr ther ime and co-operation. Ensure they have your contact detals if they need to contact you postintervew. Follow up: After an interview, many witnesses spend tme thinking bout the event again and the information they related during an interview, and qute frequently wil recall addtional