Please read this before using presentation

1. 1 Please read this before using presentation This presentation is based on content presented at the 2006 Mines Safety Roadshow held in October 2006 It is made available for non-commercial use (eg toolbox meetings) subject to the condition that the PowerPoint file is not altered without permission from Resources Safety Supporting resources, such as brochures and posters, are available from Resources Safety For resources, information or clarification, please contact: ResourcesSafety@docep.wa.gov.au or visit www.docep.wa.gov.au/ResourcesSafety

2. Toolbox presentation: Role of safety and health representatives in investigations October 2006

3. 3 What does the Act allow? One of the statutory functions of a safety and health representative (SHR) is ‘… in the event of an accident, a dangerous occurrence, or a risk of imminent and serious injury to, or imminent and serious harm to the health of, any person, immediately to carry out an appropriate investigation in respect of the matter …’ (s. 53(1)(b), Mines Safety and Inspection Act 1994).

4. 4 What is appropriate for an SHR? Safety and health representatives may not have investigative experience Not all safety and health representatives will want to be involved in an investigation It may be difficult for non-specialists to appreciate the role of human behaviour in accident or incident causation A good accident or incident investigation compares what should have happened with what actually happened to identify areas that need changing Aim is to prevent a recurrence of the accident or incident

5. 5 Running the practical investigation Scope largely depends on seriousness and/or complexity of accident/incident Legal restrictions – it is an offence to: disturb the site of a serious accident without the authority of the District Inspector of Mines disturb the site of a fatality without the authority of the Coroner An inspector may request that a safety and health representative participates in the inspector’s own investigation Safety and health representatives may be included in an employer’s investigation but are also able to conduct their own investigation

6. 6 Principles of investigation The most important processes are: observation information interrogation The standard of investigation will depend on the skills and persistence of the investigator Luck plays a part – but is often nothing more that a combination of opportunity and preparation Investigation requires: induction – assembling available evidence deduction – derive solutions to problems, answers to questions

7. 7 Principles of investigation continued Aim is to search for truth in order to prevent further harm Investigator is collector of evidence – facts must present their own conclusions The shorter the time between the event and investigation, the better the prospects of a satisfactory outcome Write notes as you go – if it’s worth a mental note then it’s worth a written note Physical evidence is real evidence and not subject to the vagaries of human memory

8. 8 Principles of investigation continued The evidence of witnesses is subject to human frailty – obtain corroboration if possible Science and technology are aids to, and not substitutes for investigation – submit physical evidence to experts Cultivate and nurture all sources of information that may assist

9. 9 What to look for during an investigation Focus on causes – not blame Focus on causes – not injury Building the chain of events: Events leading up to the incident Facts of the incident itself Facts concerning what occurred immediately after the incident Essential factors and causes Design components Environmental components Behavioural components

10. 10 Checklist to establish facts Who What When Why Where How I kept six honest serving men They taught me all I knew Their names were WHAT and WHY and WHEN And WHERE and HOW and WHO Rudyard Kipling

11. 11 What should the report provide? Accurate, clear and complete information including: Description of sequence of events leading to accident/incident Correct identification of all causal factors Description of all causal factors Corrective actions already taken Further recommendations for corrective actions Proper review Timeliness

12. 12 Resource material See Resources Safety’s publication for safety and health representatives on investigating incidents