RESUMO
Background: Learning from incidents for accident prevention is a two-stage process, involving the investigation of past accidents to identify the causal factors, followed by the identification and implementation of remedial measures to address the identified causal factors. The focus of past research has been on the identification of causal factors, with limited focus on the identification and implementation of remedial measures. This research begins to contribute to this gap. The motivation for the research is twofold. First, previous analyses show the recurring nature of accidents within the Ghanaian mining industry, and the causal factors also remain the same. This raises questions on the nature and effectiveness of remedial measures identified to address the causes of past accidents. Secondly, without identifying and implementing remedial measures, the full benefits of accident investigations will not be achieved. Hence, this study aims to assess the nature of remedial measures proposed to address investigation causal factors. Method: The study adopted SMARTER from business studies with the addition of HMW (H - Hierarchical, M - Mapping, and W - Weighting of causal factors) to analyse the recommendations from 500 individual investigation reports across seven different mines in Ghana. Results: The individual and the work environment (79%) were mostly the focused during the search for causes, with limited focus on organisational factors (21%). Forty eight percentage of the recommendations were administrative, focussing on fixing the problem in the immediate affected area or department of the victim(s). Most recommendations (70.4%) were support activities that only enhance the effectiveness of control but do not prevent/mitigate the failure directly. Across all the mines, there was no focus on evaluating the performance of remedial measures after their implementation. Conclusion: Identifying sharp-end causes leads to proposing weak recommendations which fail to address latent organisational conditions. The study proposed a guide for effective planning and implementation of remedial actions.
RESUMO
Accidents occur due to a series of interactions between deficiencies within the various levels of a sociotechnical system. Quantifying the relationship between upper and lower levels helps develop accident countermeasures focusing on significant organisational latent conditions. This study explores the relationship between the causal factors of accidents within Ghanaian mines using SEM. Data obtained from the analysis of incident reports using HFACS-GMI were quantified to enable its use in the SEM software, as SEM calculations cannot be done using a 0/1 description. The study also tests five hypotheses, including the basic assumption of the HFACS model. The case study results showed that organisational factors significantly influence workplace/individual conditions; upper causal categories do not only influence adjacent immediate lower causal categories, and partial correlations exist between causal categories with a particular level. Based on the SEM model from LISERL, an accident causation path diagram was developed. The diagram reveals that leadership flaws, the technological environment and adverse physiological/mental states were the mediating factors in accident causation within the mines. The operational process has a prominent position in the organisational factors tier and is an essential factor in the entire accident system. Therefore, accident countermeasures should be directed to addressing operational deficiencies.
