Incident Investigation (LFI)

The conventional approach in incident investigations is to analyse the sequence of events of an incident to determine the causes. Although this is indeed effective in uncovering the direct and technical causes to the energy release, it does not provide us with a deep level understanding of the various intrinsic motivators to individual, workplace and organisational factors that gave rise to the incident.

Historically we know that incident statistics have decreased consistently in the mining industry over the last decade or so, but that we still encounter seemingly unpredicted major or catastrophic events on a regular basis. Could it be that our lack of full understanding of the incident causes is our limitation in preventing repeats?

HS&A developed a unique methodology for major incident investigations. It is based on the premise that an incident would not have occurred if the risk control measures were effective. By its pure definition, the risk management process is intended to prevent unwanted events, therefore a failure in prevention of unwanted events inevitably indicates a failure in the risk management process. The million-dollar question is: “Where in the risk management process did we fail?”

The HS&A Cohesive Risk Analysis Method (CRAM®) unpacks and analyses the details of the risk mechanics failures, based on the design and implementation of the Critical Control Management (CCM) plan.

The CCM plan is considered in two dimensions.

Incident Investigation

The second dimension is to determine whether the individual controls performed as per their designed effectiveness and if not, why not. This is an evaluation of the control integrity. The value for control integrity is determined through evaluating the adequacy of the control performance standards and the control monitoring plans. Once a weakness in either of these areas are identified, it can be addressed.

The final chapter in the analysis of the risk mechanics is to identify and classify the factors that motivated the weaknesses in either risk controls effectiveness (Dimension 1) or integrity (Dimension 2). These factors can be systemic or behavioural in nature. Both the systemic and behavioural spheres are analysed to identify the aspects in the Personal, Workplace and Organisational spaces that gave rise to the inadequacies. In the mining industry, roughly 60% of critical controls are dependent on critical behaviours, which operate at an approximate maximum reliability of 85% in ideal conditions.


To identify and classify the Significant Deviated Behaviours (SDB) is therefore essential in understanding how behavioural factors influenced the incident occurrence. By further analysing the SDBs, a heat map can be composed to indicate the areas in the Workplace, Organisation and External Environment that motivated the deviated behaviours. This will provide a focused approach for the design of cultural and behavioural interventions, effectively improving the effectiveness of the CCM plan.

These factors are the true root causes to incidents – embedded deep within the organisation’s fibre. Once the root causes are isolated and well described, interventions can be designed to adjust or tweak the associated organisational factors to prevent the same CCM plan failure from recurring.

Oftentimes the organisational factors that motivated the incident were there all along, but went unnoticed until the incident occurred as a symptom. The incident, however, is very likely not the only symptom of the organisational factors and therefore improvements in the business process is not limited to safety performance when their factors are adequately identified and corrected.