Resources Policy 77 (2022) 102774

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Resources Policy
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An integrated 4Cs safety framework for the diamond industry of

Southern Africa
Urishanie Govender a, b, Gary van Eck b, Bekir Genc a, *
a
The School of Mining Engineering, University of the Witwatersrand, Johannesburg, South Africa
b
The De Beers Group, Johannesburg, South Africa

A R T I C L E I N F O A B S T R A C T

Keywords: The integrated safety framework offers the diamond industry a novel and innovative approach to pioneer safety
Pioneer maturity that embraces four Cs viz. Culture; Competence; Cultivate and Connectedness. This integrated 4Cs
Brilliant safety approach brings new knowledge around these linkages to drive a maturity journey to inherent and thereby
Integrated
improve safety. The approach differs from previous work as it focuses beyond cultural maturity and embraces
Culture
Competence
proactive hazard identification, systemic analysis and managing leading metrics based on people being the
Cultivate strongest link. Previous approaches generally focussed on culture, reactive accidents and incident investigations
Connectedness and lagging human factors analysis. This Integrated 4Cs Safety Framework was fully introduced in January 2021,
Beyond zero amid the COVID 19 pandemic, starting with the onboarding of the leadership and the development of integrated
work programmes. There was a high focus on including 100% of the frontline personnel. The scope of the work
was nine active diamond mines in Southern Africa in three countries viz. South Africa, Botswana and Namibia.
This work brings new knowledge, based on recent developments and industry applications. Five months of data
related to identified leading and lagging metrics was collated and trended in 2021. The current performance was
compared to the previous period. The safety maturity showed evidence of improvement, including improved
competency to identify hazards and respond to risks. Lagging indicators also showed improvements as risks were
better understood and more in control. The analysis of High Potential Hazards, a leading indicator, revealed a
four-fold improvement in reporting. The results indicated that focussing on the 4Cs of the Integrated Safety
Framework does shift the organisation towards brilliant safety performance. A similar approach can be taken by
other mines. Further research is underway as new insights are discovered.

1. Introduction opportunities include sustainable workforce transformation into the

The diamond industry was impacted by the COVID-19 pandemic in
terms of revenue decline due to several stores being closed. There was
also production pressure as a result of extended lockdown periods of the
mines. While the outbreak of COVID-19 has been disruptive, the mining
sector dealt with these impacts extremely well, leading to an effective
response due to their safety-first culture that prioritized people’s health
and well-being (Ernst & Young (E&Y), 2021).
Licence to Operate, including mining safely and adopting an envi­
ronmentally restorative and socially distributive sustainability
approach, is the number one risk on the top business risk register in the
global Mining and Metals Sector (E&Y, 2021). The attention to Licence
to Operate and the need for changes in the corporate culture, following
the COVID-19 pandemic, created new opportunities. These
new world of work and accelerating culture-related transformational
projects that would reframe the mining and metals sector for the future.
The 1980s and 1990s are the foundational decades for safety
research and were known, and later referred to, as the Golden Age of
Safety Research (Turner, 1978; Braithwaite, 1984; Perrow, 1984; Ras­
mussen, 1986; Hale and Glendon, 1987; Wildavsky, 1988; Reason, 1990;
Hollnagel, 1993; Roberts, 1993; Rees, 1994; Woods et al., 1994;
Vaughan, 1996; Flin, 1996; Reason, 1997; Hopkins, 1999; Rasmussen
and Svedung, 2000; Hoods et al., 2001; Weick and Sutcliffe, 2001;
Putnam, 2008; Wurzelbacher and Jin, 2011; Hinze et al., 2013; Neamat,
2019; Tiwari, 2021). These early approaches to safety and the later work
focussed on reducing accidents, reporting on the number of incidents,
and then going on to classify the agencies and share lessons learnt which
included the standardisation of work, procedures and specifications

* Corresponding author.
E-mail addresses: Urishanie.Govender@debeersgroup.com (U. Govender), Gary.VanEck@debeersgroup.com (G. van Eck), Bekir.Genc@wits.ac.za (B. Genc).

https://doi.org/10.1016/j.resourpol.2022.102774
Received 14 January 2022; Received in revised form 12 May 2022; Accepted 15 May 2022
Available online 24 May 2022
0301-4207/© 2022 Elsevier Ltd. All rights reserved.
U. Govender et al.
(Busch, 2011; Bonsu et al., 2017; Schütte, 2015; Patterson and Shappel,
2010). Additional areas researched and explored in safety included
safety culture, cultural maturity, cognitive engineering, safety regula­
tions, high-reliability organisations and accident investigations (Le
Coze, 2019; Hudson, 2007).
Fig. 1 shows mine fatality performance between 2000 and 2021. In
South Africa, mine fatality performance regressed during 2017 by 23%
from 2016 and for the most of 2018 ending in 81 loss of lives (Minerals
Council South Africa, 2022). There is also a regression in the fatalities
from 2020 to 2021 by 23% (Minerals Council South Africa, 2022). The
Minerals Council South Africa, together with the Chief Executive Offi­
cers (CEOs) of the mining companies responded by agreeing to commit
to a journey to Zero Harm. The Zero Harm pledge was intended to
highlight the personal role of CEOs in bringing about the step-change
necessary to turn around the performance trend and track the lagging
indicator of loss of life due to mining activities and the resultant fatality
rate (Minerals Council South Africa, 2021).
The human factor analysis methodology is aimed to focus on people
rather than only on systems and processes when managing errors
(Albrechtsen and Besnard, 2013; Shorrock et al., 2004; Dekker and
Lundstrom, 2006; Karanikas, 2015; Minerals Council South Africa,
2021). There are identified causal and contributory factors that are used
as part of the human factor analysis for incident investigations (Minerals
Council South Africa, 2021). Givehchi et al. (2017) studied the rela­
tionship between leading indicators related to the number of inspections
and safety-related non-compliances and safety climate levels. They
concluded that increasing non-compliances relative to previous records
in a department or section was indicative of a degrading safety culture.
They also added that organisations culture benefits from encouraging
the reporting of hazards while dynamically balancing acceptable and
unacceptable behaviour through a just culture approach.
Gaps of the previous approach to safety performance improvement
are that most of the work adopted a reactive or rear-view lens approach
where lagging metrics were tracked as well as systems and processes
were positioned, as the required effective controls for injury manage­
ment. The human factor analysis approach (Albrechtsen and Besnard,
2013; Shorrock et al., 2004; Dekker and Lundstrom, 2006; Karanikas,
2015) tended to result in a defensive team where there was fear of
reporting, as people’s error was the focal point of the investigation.
Putnam (2008) and Neamat (2019) supported that further work was
required in the diamond mining industry on leadership enrollment and
leading indicators. Sheehan et al. (2016) highlighted that leading in­
dicators were valuable to enable organisations to identify and address
deficiencies to prevent or mitigate injuries. The work of Givehchi et al.
(2017) on leading indicators focussed on culture, with very little infor­
mation on the other connectedness and cultivating values.
A safety framework includes controls to prevent or mitigate hazards
and unwanted events. The International Council on Mining and Metals
(ICMM, 2021) defines the term control as either an act (performed by
Fig. 1. Mine fatality performance in South Africa (Minerals Council South Africa, 2022).
2
Resources Policy 77 (2022) 102774
people), an object (engineered) or a system (combination of act and
object). The previous approaches focus on objects and systems to
improve safety. This does not deliver on the full potential of brilliant
safety, taking the diamond industry beyond zero and making people the
strongest link in the safety framework. The Integrated 4Cs Safety
Framework was developed by applying an integrative, multidisci­
plinary, collaborative approach and embracing the purpose and values
of the diamond industry. This integrated approach that connects culture,
competency, connectedness and cultivated values is novel and provides
new knowledge in the much-needed area of proactive and inherent
safety management.
2. Towards the integrated 4Cs safety framework
A safety framework considers the people, processes and systems of
the organisation (Le Coze, 2019), providing a consistent means of
managing these elements. Monitoring and measuring of the metrics for
safety improvement are pre-defined and tracked. A baseline risk
assessment is undertaken through a process of evaluating the risks
arising from hazards, considering the adequacy of any existing controls
and deciding whether or not the risks are acceptable. The risk analysis
process follows which is a systematic approach to understanding the
nature of the risk and deducing the level of it. The process considers the
Likelihood of the event and Maximum Reasonable Potential Conse­
quences, should the event occur, using a 5 × 5 Matrix as shown in Fig. 2
(IEC/ISO 31010, 2019; ISO 31030, 2021). For high potential events
classification, only safety consequences 4 (single fatality or
life-changing disability) and 5 (multiple fatalities or life-changing dis­
abilities) are considered (ISO 31000, 2018; ISO 31030, 2021). Fig. 2
shows the metrics utilised in this study.
2.1. Lagging and leading safety indicators
Neamat (2019) highlighted that a safety management system is
recognised by safety lagging and leading indicators and their correlation
with injury rates. A lagging indicator is a retrospective set of metrics
based on incidents that meet an established threshold of severity e.g.,
fatalities and lost time injuries. The lagging indicators and their defi­
nitions, as used in this study are described below:
• Loss of Life is a fatal injury/death, as a result of work-related activity.
• Total Recordable Case Frequency Rate (TRCFR) is a rate per
1,000,000 h of fatal injuries, lost-time injuries, and medical treat­
ment cases. The calculation is the sum of the number of contractor
and employee medical treatment cases, plus the lost time injuries and
fatal injuries multiplied by 1,000,000 then divided by the total
number of hours worked.
• Rolling TRCFR graphs indicate tends in 12-months and 3-months
rolling averages.
U. Govender et al.
Fig. 2. 5 × 5 Risk Matrix (IEC/ISO 31010, 2019; ISO 31030, 2021).
• Lost Time Injury Frequency Rate (LTIFR) is a rate per 1,000,000 h of
lost-time injuries due to all related causes for both employees and
contractors.
• Lost Time Injury Severity Rate (LTISR) is the sum of lost days due to
an injury, multiplied by 1,000,000, divided by hours worked.
• All Injury Frequency Rate (AIFR) is a rate per 1,000,000 h of fatal
injuries, lost-time injuries, medical treatment cases and first aid
cases. The calculation is the sum of the number of contractor and
employee first aid cases, plus medical treatment cases, plus the lost
time injuries and fatal injuries multiplied by 1,000,000 then divided
by the total number of hours worked.
• High Potential Incident (HPI) is an incident with an actual conse­
quence of an injury or lower but possessing a reasonable worst-case
potential consequence of either a fatality/fatalities or severe injuries.
A leading indicator refers to a forward-looking set of metrics that
indicate the performance of the key work processes, operating disci­
pline, or protection layers that help prevent potential incidents (Centre
for Chemical Process Safety (CCPS), 2021). These have also been
described as “predictive, proactive and preventative” by Hinze et al. (2013)
and Wurzelbacher and Jin (2011). This study expands the leading
metrics to include hunting and reporting for risks such as high potential
incidents and hazards.
A High Potential Hazard (HPH) is a condition or situation which
could materialise into an unwanted event with a consequence of a fa­
tality or severe injuries. These are identified and actioned at a site level,
analysed and trended at the Group level. This research further unpacks
HPHs into hidable and non-hidable hazards.
Hidable HPH is a subset of the HPHs that are analysed at the Group
level to identify the transparency of the risks reported. Hidable HPHs are
defined as those HPHs which are:
• Observed by 1 person, or
• No other people in the vicinity, or
• No visible evidence of the incident, or
• The observer could have walked away and done nothing (could have
walked away with no personal consequences), or
• Not identified during an audit or leadership walk-throughs, or
• Not reported through technology.
The industry best practice Hidable to Total HPHs reported, based on
the Elimination of Fatalities (Maynard, 2019) audits across over 30
mines worldwide indicated a ratio of four hidable HPHs to everyone
reported HPH. Historical incident data, together with industry reports,
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Resources Policy 77 (2022) 102774
were analysed and a set of 45 High-Risk Areas (HRA) where significant
incidents commonly occurred was identified (De Beers, 2018). These
areas include transportation, working at heights, fall of ground, un­
wanted ignition etc. This list was used as the basis for risk (as reported
through HPHs and HPIs) analysis and trending to identify dynamic risks.
2.2. Integrated 4Cs safety framework
Diamond mines worldwide are in various phases throughout their
life cycle starting with exploration and the final phase being sustainable
closure. This work focuses on active (operating) mines due to there
being: the highest number of high-risk activities the greatest opportu­
nities for learnings as well as driving step-change in safety improvement.
To advance safety performance, safety must go beyond the mine
fence to include communities and people taking safety home. The cul­
ture of brilliant safety also requires a high level of trust and respect
between people at all levels (horizontally and vertically) and increased
transparency in behaviour and reporting, as shown in Fig. 3 (Hudson,
2007). Culture is a human phenomenon. It lives in and through people.
To change culture means to transform the human system (Mare, 2021).
Stemn et al. (2019) found that in the mining industry, culture was an
important area to be considered in the development of a safety frame­
work. Stemn et al. (2019) further added that mines with lower incidence
rates consistently had higher safety maturity scores than mines with
higher incidence rates. Importantly, for this study, maturity requires
transformation towards hazard identification and readiness to respond
to risk competence, at the front line, and not only the reduction of
incidents.
The diamond industry supports the CEO’s Zero Harm initiative,
taking it so seriously as to go beyond just driving down the lagging
metrics and introducing the concept of Beyond Zero. This Integrated 4Cs
Safety Framework was developed in 2020. The Framework enables the
diamond mining industry to transition to a maturity where safety is
inherent in all that is done. The Framework also provides the means to
integrate various efforts to get to Beyond Zero, beyond focussing just on
numbers, and align to a common vision, harmonising all the mines in
Southern Africa to align on safety initiatives and objectives. The high
impact areas considered when developing the framework included:
• Reflections on the role of leadership in effecting a step-change in
safety maturity.
• Discussions around the impact of mental health and wellness on
safety maturity.
U. Govender et al. Resources Policy 77 (2022) 102774

Fig. 3. The culture maturity progression from Basic to Inherent (adapted from Hudson, 2007).

• Sharing how values are lived to ensure a safe environment for all,
across the business and everywhere i.e., at work, at home and in the
community.

As illustrated in Fig. 3, the foundation of the Framework is to have

people who are ready to respond to risks dynamically by being the
strongest link, 365. It included defining activities at the strategic,
tactical, and operational levels, and will be co-constructed at the site
level in each facet.
The mines are leveraging on existing initiatives to achieve break­
through thinking and related behavioural change. The safety facets are
designed to shift and transform the way safety risk is managed. The
framework is co-created and considers local attributes of cultures and
context to improve the receptiveness and relevance of the programme at
the site level. Excitement is created to discover threats and opportunities
and continue to build advanced capabilities, focussing on simplicity, co-
construction and achievability.
Innovation in risk management and human factor engineering from
world-class safety performance industries are incorporated in the Inte­
grated 4Cs Safety Framework. These will be sustained through the
alignment of leadership practices to support a safety journey to mature
to inherent (or resilience).
The Framework has four facets (4Cs), as shown in Fig. 4:

• Competence of all people.

• Cultivate value in and by people through dynamic risk awareness.
• Connectedness of people and systems.
• Culture of leadership in people.
The four C facets of the Safety Framework translate into the
following operational actions:
• Care for All
• Can do work safely
• Commit to improve
• Couple safety in every task.
Maturing safety in an integrated manner in all 4 facets will increase
safety maturity, risk awareness and competency, and make people ready
to respond to dynamically changing risks. This supports the notion that
people are the strongest link and provides a more sustainable outcome
than focussing purely on safety culture.
Versteeg et al. (2019) highlighted from their work on utilizing safety
indicators to measure safety performance that future research must
Fig. 4. The four C facets of Safety Framework (De Beers, 2020).
improve the focus areas that form the basis of safety promotion and be
relevant to the companies that the promotion is designed for. Extensive
internal engagements were therefore completed to inform the selected
facets. The components of the Framework were carefully selected
following the CEOs Executive Summit outcomes, workshops and
engagement with frontline teams. These components are further
unpacked in Table 1 with the expected shifts towards maturity, where
the 4Cs drive the shift with safety improvement based on the actions
taken by the frontline.
The journey undertaken aims to create a new mindset and new ca­
pabilities that will unleash the discretionary energy of the people at the
front line and activate behaviours that create shifts towards maturity.
The description of the expected behaviour at each of the maturity levels
is shown in Fig. 5.
The opportunities presented by this Framework is that it enables the
organisation to adopt a proactive and integrated approach where:

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Table 1 through periodic pulse surveys and will be further validated after
The expected shifts at the frontline when the 4Cs of the Safety Framework are approximately three years, through a follow-up baseline assessment.
actioned. There is no dependency on external audits to drive safety. People feel
4C of the Framework Operational Actions Expected shifts towards safety psychologically safe to Speak Up, support their colleagues to work safely
taken at the improvement and ask for assistance when they are unwell. The trending and gaining
Frontline insights from the real time sentiments of the front line, is a novel
Culture of Leadership Care for All People trust and respect one improvement to understanding the psychological safety levels of the
in People another and are psychologically people and the extent to which systemic actions are addressed.
safe to be transparent in all respects
Competence of Can Do Work Safely People can identify hazards and
People work collaboratively on root causes 2.3. Culture maturation
and systemic actions.
Connectedness of Couple Safety in Integration and leveraging of Culture enablement involved leadership enrolment at the site level.
People and Every Task people, risk and operational
Systems efficiencies, as part of the core
Authentic dialogue sessions were set up in which leaders and facilitators
planning engaged in deeply respectful dialogues where there was an appreciation
Cultivate Value in Commit to Improve Continuous creation of value in the of the local context. Local elements of values, strategy and existing
and by the People company and people through initiatives are concurrently integrated through conversations with direct
adopting a futuristic view, with
links to safety. Each mine has the opportunity to operationalise the In­
mitigation of risk and discovery of
opportunities tegrated 4Cs Safety Framework to be locally internalised and practically
adopted. Dialogue takes a near-experience form of the values, including
Putting Safety First, into action. Conversations are structured to create
• Leadership has the platform to define and articulate a strong and an experience that taps into their local world of work within their team
ambitious safety mandate. (Mare, 2021). These conversations generate shared understanding and
• The organisation can transition from a reactive to a proactive cul­ practical ideas about the 4 Cs that can also enhance and energise existing
ture, in a structured manner. Safety improvement programmes. The journey is a sponsored and
• The entire staff and contractor teams are empowered to be part of the resourced process to transfer the purpose and emotive energy for values
journey and to build competence to be the strongest link, as safety and safety to the front line workers, which is foundational for commit­
leaders. ment to safety practices and initiatives.
• People become more committed to the organisation, and its values. The positive experiences and storytelling create a shift in energy and
• Technology is embraced as the connected way of work where con­ a catalyst for leaders to change belief and commitment towards
trols are integrated into the operating model. improving maturity. These leaders become the forerunners for pio­
neering brilliant safety. The epistemology of social construction theory
The desired end state or expected final outcome after the successful (Dekker et al., 2010; Gergen, 2001) that is utilised, where there is an
completion of the safety maturity journey to Inherent is detailed in inclusive understanding of the beliefs and values to deliver positive re­
Fig. 5. The journey to inherent is based on continual improvement and sults, supports this desired shift where leaders are motivated to create
emphasizes achievements rather than failures, as supported by Sultana the change with their teams and the front line. Values and safety become
et al. (2019), who also encouraged further work to investigate to what a decentralised commitment that is deeply embedded in the social fabric
degree connectedness or systems engineering controls, were comple­ of the whole business with local ownership. A flywheel effect of mo­
mentary to the desired End State. mentum is created and ultimately the entire site shifts towards improved
The end state supports taking safety into the broader local context i. maturity become risk-aware, hunts for risk and ultimately yearns for
e., home and community. Beider (2021) also emphasised the value of improvement in safety performance.
including external local context into a safety management system and A comparative baseline safety maturity assessment was undertaken
indicated that safety was a situated science - situated in time and the at one site in 2017 and 2020 and then rolled out to all sites from late
broader context of the local socio-economic environment. Therefore, 2021 into 2022. This baseline assessment uses both quantitative and
Beider (2021) added that any future safety initiatives must go beyond qualitative survey methods to establish a baseline maturity across all 4
the work environment. This work defines the end state as a function of Cs and identify specific enablers and disablers that either assist or pre­
the 4Cs. The organisation is in the Inherent Phase when it has broken vent each site from increasing safety maturity.
through the “near-zero” plateau mindset and transitioned its maturity
through a level of ownership to where safety has become a way of life. 2.4. Developing competency
People are competent and ready to respond to dynamic risks and there is
a yearning for continuous self-enhancement progress on all of the 4Cs. Competency can be defined by knowledge, experience, training and
The sentiments on the 4Cs are measured against a baseline assessment qualifications. The primary purpose of developing competency in safety

Fig. 5. The expected behaviour at each of the maturity levels (adapted from Hudson, 2007).

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U. Govender et al. Resources Policy 77 (2022) 102774

is to ensure that people possess and exhibit behaviours to achieve
operational and occupational safety goals. Givehchi et al. (2017)
cautioned that counting the number of manhours spent on safety
training is not an indicator of effective training. This work on compe­
tency, therefore, considered the level of the people undertaking the
work and their risk exposure.
Risk training, ranging from Executive through to the front line, was
developed with content based on work levels and linked to specific roles.
These were rolled out across the organisation. The training aims to
improve the understanding of Operational Risk Management so every
individual understands the risks in their area of work and can implement
effective controls to work safely.
Knowledge-based training focussed on catastrophic and fatal risks
was provided through the Technical Academy. Maiti and Bhattacherjee
(2000) supported that safety performance improves when people are
trained in high-risk areas in their work environment. The Technical
Academy’s e-learning offerings included Confined Spaces, Working at
Heights, Isolation of Energies, Light Vehicles, Lift Operations, Surface
Traffic Management and Management of Change. Brilliant Safety
Leadership Training was provided at different levels and covers lead­
ership styles, safety values and vision, culture change and behavioural
change. For supervisors, the content covers communication, risk culture,
elimination of risks, work routines and situational awareness.
SafeSentry is a novel programme developed to build competence for
front line people to act as safety leaders in their workplaces. Front line
workers are trained to identify hazards and confidently and openly
engage peers and supervisors on solutions. Maiti and Bhattacherjee’s
(2000) study results highlighted that more inspections lead to fewer
accidents. The intent of the SafeSentry programme is that inspections
and the identification of solutions is inherent in the daily tasks of
front-line workers, creating an environment of being ready to respond.
3. Methodology
The scope of the work covered nine active diamond mines in
Southern Africa, in three countries viz, South Africa, Botswana and
Namibia. Quantitative safety incident and risk identification data was
collated over five months (January to May 2021) and trended, together
with qualitative data on culture maturation from one site. The mines
operate on a 24/7 basis, mining diamonds using either two or three
shifts per day. The predominant mining methods are open cast and
marine mining. These mines were impacted by COVID-19 across the
study period.
required resources. The journey was then contextualised with the Ex­
ecutive Committee of each operation. This was a face-to-face engage­
ment that co-designed the journey for each operation by firstly defining
the operation’s needs, wants and existing initiatives. Values were ana­
lysed and framed in terms of desired leadership behaviours. The
outcome of this process for each operation was journey enablement and
support alignment. Lower-level leaders (managers and supervisors)
were then onboarded through facilitated workshops to understand their
role and start to own the journey. They were provided with development
and tools to engage their teams. The final step comprised workforce
enrolment through a series of leader led activations (small team dis­
cussions) based on the organisation’s values and the 4 Cs of the Safety
Framework.
3.2. Developing competence
Competence interventions were identified through analysis of the
top risks on-site and within the Group, as well as incident trends.
Training programmes were assigned at a site as per Table 2.
Attendance rates were monitored and feedback from the different
sites was used to continuously improve the module content.
3.3. Analysing existing data
A scorecard that measured safety performance (lagging metrics) was
developed. The metrics included Loss of Life, TRCFR, LTIFC, LTISR,
AIFR and HPI. Data was collated from nine diamond mines in Southern
Africa and used to compare the changes over 12 months.
3.4. Analysing existing data (lagging and leading) differently
The rolling TRCFR over 12 months and 3 months was calculated and
trended. The dynamic trending of risks was undertaken by unpacking
the risks related to the HPHs reported.
3.5. Identifying new data and metrics that can enhance business decisions
It was recognised that lagging metrics are not a good measure of how
Table 2
Training programmes to advance competency.
Training Programme Target Audience Focus Area

The six key areas that were advanced through the Integrated 4Cs Operational Risk Executive to the front Focus on tools and methodologies
Safety Framework are shown in Fig. 6. management line
Technical Academy Executive to the front Focus on top catastrophic and
e-learning line fatal risks per site and people’s
3.1. Culture enrolment modules functional roles
Brilliant Safety Site executive to Safety leadership awareness; and
Leadership middle management personal leadership style analysis
The culture enrolment process commenced with the engagement and level
enrolment of executive leadership. Exco’s vision to pioneer brilliant Brilliant Safety Supervisors Safety leadership, supervisor
safety was articulated and created the desire for the safety maturity Leadership routines
outcome. This process also mandated the change and provided the

Fig. 6. The six key areas advanced through the Integrated 4Cs Safety Framework.

6
U. Govender et al.
safe an organisation is (the absence of reported incidents does not imply
that safety is present). Recent research was scrutinised to identify other
metrics that could be determined to predict future safety trends and
thereby enhance decisions.
Closeout of Level 4 and 5 consequence actions, as identified through
audits and HPI and HPH investigation reports, using the 5 × 5 matrix as
shown in Fig. 2. Such actions include procedural updates, work design
changes, engineering modifications and competency building. The ac­
tions are prioritized as Consequences 4 and 5 based on the severity of the
risks associated with high potential incidents and hazards. The rate of
the closeout of the actions is determined to monitor how fast the actions
are addressed as a leading indicator.
Data was obtained for people in acting positions from the Human
Resources system to identify the percentage of people in acting roles per
site.
The production target pressure is experienced at sites. Supervisors
need to be coached in managing these conflicts between production
pressure and safe work to ensure that people are empowered to Speak
Up and that there is safe and efficient production. Employees are
currently incentivised for meeting production and safety lagging indi­
cator targets. This is not conducive to creating an open and transparent
environment, and ways of basing bonus remunerations on leading
metrics are being developed.
3.6. Adapting processes and behaviours
Using the methodology identified, processes were adapted and
people engaged to modify behaviours to support the transition. The
following interventions were implemented:
• SafeSentry: Front line workers are trained to identify hazards and
engage peers on solutions. Daily feedback is provided to supervisors
on hazards identified, cultural behaviours observed and proposed
solutions.
• Speak Up: Leading providing an environment where people feel
empowered to Speak Up and even stop work. There is a recognition
around the role of bullying and harassment to prevent speak up and
policies have been developed to guide the business to prevent these
negative behaviours. All employees also have access to anonymous
support calls.
• Small-Group Engagements: Team engagements in small groups,
building personal relationships and collective accountability for
safety.
• Addressing mental wellbeing as part of the safety messages: Always safe
being the strongest link - being mentally well and contributing to
psychological safety as well as technical safety.
• Learning from Incidents: Promoting structure investigation process
that uncovers the root cause of the incident. Sharing the learnings
efficiently and effectively.
• Technology 4 Safety: Use of technology to improve safety perfor­
mance in a high-risk area.
The validation of the integrated 4Cs safety framework for the dia­
mond industry was established by comparing the lagging and leading
metrics over the five months period, for the nine active mines in the
three countries. The improvement in these metrics over time, demon­
strated by a green status per metric, validates that the focus on the 4Cs,
as per the Integrated 4Cs Safety Framework, does indeed improve safety
performance.
4. Results
Qualitative and quantitative data was collated in each of the six key
areas, shown in Fig. 7. The results in some of the key areas were influ­
enced by interventions in other areas which supports the value of an
integrated safety framework.
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Resources Policy 77 (2022) 102774
4.1. Cultural enrolment
Cultural enrolment was piloted at one of the operations. A baseline
culture assessment was completed in 2017 at one site. The Integrated
4Cs Safety Framework principles and practices were piloted over an
initial 2.5-year period and the assessed cultural shift is shown in Fig. 7.
The white bars in Fig. 7, indicate the results from the 2017 responses.
Feedback from the workforce (at all levels) indicated an over­
whelming shift from the first baseline assessment towards higher
maturity levels of Citizenship (34%) and Inherent maturity levels (14%),
coupled with a significant reduction in the Participative level at the
latest assessment (65%–22%). This indicates that the approach of the
integrated 4Cs when implemented, leads to an increase in personal
accountability for safety and does indeed shift the maturity of an
organisation.
Behavioural changes identified to support the improved maturity
level included that learning from incidents were shared at all levels
through a Virtual call with the applicable teams and immediate learn­
ings rolled out; risk assessments integrated into the operating model in a
phased approach; active hunting and reporting of hazards; solutions for
hazards proposed by the teams on the ground; and there was continuous
development of competencies at the front line to master SafeSentry
levels. The novel link of maturity journey to be supported by compe­
tence and connectivity is emphasised at the learning and sharing
sessions.
4.2. Developing competencies
There has been an improvement (year-on-year) in the number of
people trained at all levels of the mines in Operational Risk Manage­
ment. This has contributed to improved risk awareness and risk man­
agement. Training in the investigation of incidents has also been
conducted, thereby improving the quality and applicability of resultant
corrective actions and embedding the systemic learnings.
Technical Academy training was launched at the start of 2021. It is
recognised that this initiative is still in its infancy phase and will
continue to add value throughout the safety journey. To date, over 70
training modules have been completed at various levels with active
uptake by all participants throughout the organisation. The Technical
Academy provides a valuable service for addressing gaps in the com­
petency of people. Completion of the modules ensures that high-risk
activities at the workplace are understood and the required controls
are top of mind when undertaking the tasks.
4.3. Analysing existing data
The results from the data collated for the period under review from
the mines in Southern Africa is shown in Table 3. It is important to note
that safety is not the absence of incidents. The aim of this novel approach
is to go beyond the numbers and anticipate the next risk and incident
and be ready to respond based on competence and connected eco-
systems.
The green status is indicative of year-on-year improvements being
achieved. The results from the lagging indicators reveal that there was
a/an:
• Reduction in all lagging indicators. This implies that injuries are
prevented, people are more risk aware due to improved competence
and critical controls being effectively connected to the tasks.
• Increase in HPH reporting, indicating greater awareness of hazards
and freedom to report.
• LTISR is reduced which implies that people are recovering and
returning to work faster.
Based on the green status of the leading and lagging metrics, as
shown in Table 3, the Integrated 4Cs Safety Framework was validated.
U. Govender et al. Resources Policy 77 (2022) 102774

Fig. 7. Cultural shift assessment (one site).

categories (Fig. 9). The data has also confirmed that notwithstanding the
Table 3 short sample time, risks change dynamically. In the study, the top risk
Safety lagging metrics for nine Southern African diamond mines.
area changes with time e.g., Surface Mobile Equipment (SME) in 2020
METRIC 2021 YTD 2020 YTD % Var Status FY 2020 and Working at Heights in 2021. This emphasizes the importance of a
(May) a b
(12mth) c d
dynamic risk management process. The top five risk areas are, however,
Loss of 0 0 0% 0 relatively constant year-on-year.
Life The organisation must ensure that risk management processes are
TRCFR 1.47 1.78 17% 1.45
LTIFR 0.52 0.68 24% 0.57
not static in nature but set up to identify dynamic risks, and appropriate,
LTISR 28 36 22% 27 timeous responses.
AIFR 4.69 5.59 16% 4.86
HPH 351 184 91% 390
4.5. Identifying new data and metrics that can enhance business decisions
a
2021 YTD January 2021 to May 2021.
b
2020 YTD January 2020 to May 2020. Table 4 shows the closeout of the high risk (Level 4 and 5) conse­
c
% Variance in May 2021 compared to May 2020. quence actions. There were zero overdue actions, as of May 2020. This
d
Full Year 2020 in January 2020 to December 2020. increased to nine overdue actions at year-end of 2020 (ascribed to
people being on leave and operational priorities) and dropped again to
This validation is further supported by the improvement in Leading zero as of May 2021. This maintenance of zero overdue actions year-on-
Indicators, as reflected in Table 4. year demonstrates a strong focus on attending to safety-critical actions.
The number of people in acting roles, throughout the operations, was
4.4. Analysing existing data (lagging and leading) differently less than 2%, with year-end 2020 temporarily increasing to 10% due to
people going on annual leave. The number of people operating at an
Safety performance is deemed to be within control, as the three- acting capacity, as a measure of safety maturity, is therefore deemed to
month TRCFR rolling average moved below the 12-month rolling have a negligible impact on the results of this study.
average as shown in Fig. 8. The long-term average TRCFR is reducing, The management of the recommended leading metrics is a novel
and so is the 12-month average. The COVID-19 spikes are clearly seen in approach to shifting leadership conversations away from lagging metrics
the May 2020 and the January 2021 bars. These periods also correspond relating to injuries and focussing on the leading decisions relating to
with the return of people to work. resource planning and scheduling decisions that can support shifts to
The dynamic risk analysis is based on reporting of HPH and HPI risk Inherent.

Table 4 4.6. Adapting processes and behaviours to support the transition

Leading indicator performance at the Nine Active Southern African Mines.
METRIC 2021 2020 % Var Status FY The current processes were adapted to include the SafeSentry pro­
YTD YTD b (12mth) c 2020 d gramme as well as empower people to Speak Up. Learning from in­
a
(May)
cidents was given due attention to ensure root cause analysis was
# Potential 0 0 0% 9 undertaken and systemic actions implemented.
Consequence 4/5 The SafeSentry programme was developed and rolled out as a pilot at
Overdue
Hideable HPH 4.7: 1 23: 1 80%
one site. This programme entails appropriately trained front line
Risk training YTD 81/72/ 70/72/ 77/ workers patrolling work areas, engaging with their peers, and looking
(Competency) 80 79 73/84 for fatal and catastrophic risks. Guidelines in terms of those critical
Advanced Driver Assist 95% 15% 533% 95% controls managed by the workforce were developed and training was
System (ADAS)
completed. To date, approximately 50 front line operators have been
Completion
Days Lost 594 592 0% 1208 trained as master SafeSentries and are currently training other front-line
Number of People in 2% 2% 0% 10% workers.
Acting Roles Mental wellbeing as part of the safety messaging is actively
a
2021 YTD January 2021 to May 2021. addressed. The ongoing awareness training to leaders and managers on
b
2020 YTD January 2020 to May 2020. psychological safety, building trust and respect and creating an envi­
c
% Variance in May 2021 compared to May 2020. ronment where people are empowered to engage and reach out for
d
Full Year 2020 in January 2020 to December 2020. support.

8
U. Govender et al.
Fig. 8. TRCFR rolling average for 3 and 12 months.
Fig. 9. HPH and HPI high-risk areas.
Flowing from the creation of an empowered environment, colleagues
are able and confident to share when they are unfit to work (for any
reason) and Speak Up when they see any non-conformances or potential
hazards. Small team engagements ideally no more than ten persons, with
the team leader talking with the team is most effective, not to the team.
Severe incidents are systemically investigated to identify the true
root causes and these learnings are widely and rapidly shared
throughout the organisation. Investigation report submission rates are
monitored as a measure for effective Learning from Incidents and have
improved, represented by the Green Status, as shown in Table 5. Leaders
present investigation reports at Leaders Calls chaired by the CEO and at
the monthly Transformation Steering Committee.
Identification of technology for safety that enhances preventative
and recovery controls is undertaken throughout the Group. Safety
technology is identified, and pilots are initiated at selected operations.
Where pilots demonstrate successful enhancements, the technology is
rolled out across the Group. An example of such a technology is ADAS –
Advanced Driver Assistance System (as shown in Table 4) where there
was a 533% improvement in the technology improvement year-on-year.
Table 5
Investigation report submission rates.
Report Submitted 2020 Submitted YTD 2021 Status
Initial Report 100% 100%
Final Investigation Report 77% 100%
9
Resources Policy 77 (2022) 102774
Other technology being developed includes the digitalisation of high-
risk work processes, critical control monitoring, and the use of auto­
mated robots to conduct safety critical inspections. Future work will
report on these connectivity areas of the framework.
5. Discussion
This study investigated the impact of using an integrated safety
framework based on the 4Cs to transition safety maturity at nine active
diamond mines. True transformation will only be achieved if culture,
competence, connectedness and cultivation of value are achieved in an
integrated manner.
To this end, it is clear that a safe organisation cannot be defined as
one with an absence of reported incidents, in other words, low lagging
metrics. Such organisations are often identified as those striving for
“zero harm” in their messaging. This is counterproductive as it can
suppress an open and transparent reporting culture. In driving this safety
transformation, a culture of Beyond Zero must be driven – where people
anticipate the next hazard and are ready to respond to it, thereby
creating value. Messengers are rewarded, not punished. A safe organi­
sation should be determined across all four C’s.
It is recognised that a culture shift is a long-term process. In the
interim, the available data revealed an increase in trust levels between
management and workers, in that significantly more hazards are being
reported, and increasing openness to understand the real root causes of
incidents (also linked to Competency). Risk secrecy, whilst still present,
U. Govender et al.
is diminishing. Leaders are being trained and encouraged to create an
environment where there is trust and respect up, down and laterally, and
employees are free to report and discuss hazards and incidents. The
organisation is becoming more aware that incidents do and will happen
and people are developing competency to anticipate and respond to
them.
Safety transformation is a journey. This concept has been captured in
the evolution of key messaging which was initiated using the phrase “I
will be the strongest link”, developed to “I am the strongest link” and at
the inherent level will manifest as “We are the strongest link”. The
emphasis is that in any safety system, the human or people is the
strongest link, and not the system itself, or the technology. In the long
term, people will be encouraged to take risks responsibly, and deal
proactively with hazards – as exemplified in “I am the strongest link,
every day”. People must be competent, confident, and enabled to apply
themselves to dynamic risk situations as it is impossible to develop a pre-
set procedure to deal with each and any incident that could materialise.
The appropriate maturity requires trust, and trust requires account­
ability – management cannot just blame workers for incidents, but must
also address the systemic issues, and likewise, workers cannot just blame
management for unsafe conditions. An agreed accountability framework
that defines the impact of positive or negative behaviour is very
important in establishing and maintaining trust.
The comparison of the rolling TRCFR has provided an effective
means of tracking the trends and detecting if short term issues are
influencing the longer-term trend. These periods are indicated when the
3-month rolling average exceeds the 12-month rolling average and
drives deeper investigation and analysis of issues at operations, to
identify both short term and systemic improvements.
Analysis of dynamic risks has revealed that relying on annual base­
line reviews to monitor risk is insufficient and the organisation must be
set up to respond to dynamic or changing risk priorities. These can be
influenced by the nature of work being conducted in any period, tar­
geted interventions at sites, as well as awareness of HPHs identified.
This research work identified new data and metrics that can be used
to measure how safe an organisation is. Continuous focus on the closing
of actions related to potential consequence 4 and 5 incidents and ob­
servations visibly demonstrates that management is serious about
eliminating fatalities and life-changing injuries. These statistics are re­
ported at the monthly Transformation Steercom, chaired by the Group
Technical Executive with the aim of driving transformation throughout
the Group, to ensure they are visible at the highest levels in the orga­
nisation. Material outcomes from this committee are reported to Board
sub-committees.
The significant increase in reporting of hidable HPHs demonstrates a
level of comfort and confidence in colleagues to Speak Up and report
hazards that they have either experienced or identified. This points to a
shift in culture towards inherent. HPHs and HPIs must be used as
learning and improvement opportunities. Leaders must pro-actively re­
view investigations and learnings not only from their own but other
operations to drive a culture of reducing incidents, especially repeat
incidents.
Several opportunities have been identified to adapt processes. The
feedback on the dynamic monthly risk areas must be used as focus topics
for shift change discussions. Applying a small group engagement
approach rather than large mine-wide stoppages enhances learning and
sharing. The deep focus must be on enabling people to Speak Up and
celebrate successes when there are identified shifts in the culture.
The confirmation of the positive safety outcomes at the frontline
when the 4Cs are managed in an integrated manner is novel.
6. Conclusion
Improved safety maturity to a desired endpoint state, is not an
outcome but rather a process the organisation constantly engages in,
through applying the 4Cs in an integrated manner. It is recreated every
10
Resources Policy 77 (2022) 102774
moment and every day. It is the journey of maturity to inherent where
there is a yearning for safety improvement in all tasks and decisions.
Culture is very important, but culture alone is insufficient to result in
a resilient safety maturity level. An organisation must develop a learning
culture through careful introspection of incidents, and continuously
challenging itself. Organisations must shift the focus on safety reporting
and performance measurement from lagging indicators to leading in­
dicators. It is the focus on the integrated 4Cs that will deliver the best
improvements in the organisation’s safety performance. The work on
this Integrated 4Cs Safety Framework provides new knowledge as it:
• Advances the research on leading safety indicators.
• Provides a framework based on 4Cs, for mines to improve their safety
culture maturity to inherent.
• Supports work by the Elimination of Fatalities Taskforce that there
should be a ratio of four hidable HPHs reported, for everyone non-
hidable, to predict improved safety performance outcomes and
improving safety maturity level towards Inherent.
The integrated Safety Framework describes how and why changes
can be made in a large organisation in order to improve safety perfor­
mance and provides a platform that enables the organisation to strive for
continuous improvement. Brilliant Safety Leadership Training covering
leadership styles, safety values and vision, culture change, behavioural
change, risk awareness, elimination of risks, work routines and situa­
tional awareness is a critical component of building competencies to
drive safety transformation.
This paper advances the principle that for an organisation to strive to
go beyond zero, it requires the presence of a mature or maturing culture,
a safety management system that connects safety to all tasks, drive
excitement in competency building and continues to cultivate the values
of caring and putting safety first! There must be a focus on leading
metrics and dynamic risk management. The results demonstrated that
the wide variety of deliberate business decisions, processes and activities
taken by the mines to transition to be brilliant, is directly correlated to
safety outcomes. Future work will explore regional differences with the
implementation of this Integrated 4Cs Safety Framework, outcomes
from embedding the SafeSentry programme and the impact of safety
technology on safety maturity.
Data availability
The authors do not have permission to share data.
Acknowledgments
The work presented in this paper is part of a Postdoctoral research
study in the School of Mining Engineering at the University of the
Witwatersrand, Johannesburg, South Africa.
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