Industries like mining and energy know all too well that a health and safety disaster can cost shareholders millions and create untold legal and reputational liabilities. What may not be so well known is that disasters are often averted, not through prescient foresight, but by acting on the warning signs that precede most major health and safety incidents. Those warning signs are identified through one of the most potent tools in the occupational health and safety (OHS) arsenal: incident investigation.
This article discusses incident investigation in the context of mining companies operating in emerging markets, possibly seeking to comply with the requirements of the Equator Principles and IFC Performance Standards. To this end, we introduce a new process for investigation pioneered by OHS expert Michael Tooma in Australia, called the Positive Incident Investigation.
To leverage the investigation process as a tool for better OHS, business and reputational outcomes, and to meet legal and best practice expectations, companies must honestly evaluate whether their incident investigations ask the tough questions to promote a resilient learning organisation. This means asking not only why an incident has happened to understand root causes, but also evaluating what went right to prevent the incident from being worse. Such an approach will allow companies to get the most from incident investigations, towards legal compliance and beyond, to cutting edge best practice.
International Legal Context for Incident Investigation
Mining companies must comply with legal requirements in host countries requiring the assessment and management of risks to the health and safety of workers, contractors and local communities. These obligations are reflected in international legal instruments such as the Occupational Safety and Health Convention, 1981 (No. 155), or the Safety and Health in Mines Convention, 19995 (No. 176), promulgated by the International Labour Organisation (ILO). These conventions include express requirements on employers to ensure incidents are investigated with appropriate remedial action taken.
In addition to hard law expectations, mining companies seeking financing in emerging markets may be required to meet contractually imposed expectations of their financiers, especially those that adhere to the Equator Principles agreement. Equator Principles Financial Institutions may require compliance with the best practice health and safety standards set by the International Finance Corporation and World Bank Environmental, Health and Safety Guidelines (EHS Guidelines). The EHS Guidelines require incident investigations to be conducted which (1) establish what happened; (2) determine the cause; (3) identify measures necessary to prevent recurrence.
A Business Case for Going Beyond Causation Analysis
Beyond meeting these compliance requirements, there is a strong business case for global mining companies to get the most out of incident investigations. Most of the root causes of serious incidents are evidenced before serious incidents occur. These risks may show themselves in near misses or seemingly minor incidents.
An effective incident investigation approach will allow an organisation to uncover systemic deficiencies and opportunities for improved resiliency before future incidents occur. This requires understanding both what went right as well as what went wrong leading to an incident and discerning from this what system deficiencies and vulnerabilities exist that can be addressed to stop more severe incidents from ever happening. We call this the “Positive Incident Investigation” approach.
Case Study: San Jose Mining Collapse
On 5 August 2010, outside the city of Copiapó, northern Chile, the San José gold and copper mine collapsed, trapping 33 miners underground. Luis Urzúa, the duty shift supervisor, recognized the gravity of the situation and the difficulty involved in any potential rescue attempt. He gathered his men in a secure room called a "refuge" and organized them to ensure their survival over the coming weeks. The crew survived for a record 69 days deep underground before their rescue.
Problems at the mine had revealed themselves repeatedly prior to the August 2010 collapse. Most notably, in July 2010 a miner’s leg was severed in a rock fall. The mine was closed following that incident and the mining regulator required the implementation of ‘corrective measures’. On 28 July 2010, a health ministry official allowed the mine to reopen. Following the August 2010 collapse, the Chilean Congressional Commission investigation concluded that the mine’s owners were negligent in their management of the mine and largely responsible for the collapse. The commission also concluded that the mining regulator should have been more proactive in the enforcement of safety legislation and regulations. In addition to failures of regulatory oversight, the condition of the mine was found to have played a large part in contributing to the collapse.
All of this begs the question: could this catastrophe have been avoided with better incident investigation of the earlier rock fall? The answer is a probable “yes”. The San Jose mine collapse illustrates well how catastrophes may be foreshadowed by less severe incidents, which if properly understood can reveal deficiencies that may contribute to future incidents.
Applying the Positive Incident Investigation Approach
The July 2010 rock fall which preceded the August collapse was the ideal opportunity for the company and the mining regulator to appreciate and remediate the vulnerabilities and deficiencies of the mine to rock falls and collapses.
If the regulator and the company applied a Positive Incident Analysis approach at that time, their investigation of that incident may have revealed the inadequacy of the company’s preparedness for a future mine collapse, including deficient evacuation procedures and equipment. Considering alternative “what if” scenarios would have required an assessment of the mine’s emergency planning and response systems, including how to recover workers in the event of a more severe rock fall than the one that occurred in July.
These vulnerabilities, if adequately addressed, could have averted or lessened the severity of the August 2010 collapse. Considering what went right in the mine collapse is also highly informative. Supervisor Urzúa’s actions immediately after the incident is credited with keeping the men alive on an emergency food supply during their first 17 days without contact from the outside world.
This is an example of “what went right”, revealing the importance of properly resourced protected areas that can survive a collapse and support life until external help is organised. This learning could only be captured if investigation analysis goes beyond the causal chain of the accident, towards understanding what positive actions occurred that prevented a much worse outcome.
The San José mine disaster and its aftermath illustrate the importance of maintaining resilient safety systems. Resilience derives from compliance with laws and industry standards and going beyond compliance to instil a health and safety culture of questioning and learning.
Both compliance and resilience necessitate the effective use of incident investigation to identify and remediate deficiencies and vulnerabilities in health and safety systems which may form the basis of future incidents.
Taking a “positive” approach to incident investigations can achieve both objectives and protect the financial, legal and reputational interests of the global mining company, no matter where they do business.