PART 3: MANAGEMENT OF CHANGE
This is Part 3 of our four-part series on “How to prevent mining and other workplace accidents”. You can access Part 1 (the “Pearl Harbour Syndrome”) here and Part 2 (Getting Back to Basics – The Six Key Principles) here.
In Part 3 we address one of the most critical elements which, if complied with, contributes significantly to avoiding incidents and accidents – Management of Change.
Regardless of the methodologies used to investigate incidents and accidents and identify the causes and underlying causes, the reality is that, if one digs deep enough, most incidents and accidents can be attributed in some way, to a change that was not identified, or, where the changes were identified, the risks associated with the change were underestimated, and, in certain cases, ignored completely.
In most, if not all incidents and accidents, one or more changes created a “chain of events” which ultimately led to the incident or accident, because the changes were not identified or were not appropriately addressed.
Risk assessment methodologies often prompt participants to consider various factors to a greater or lesser extent. It is however important for a structured, facilitated approach to be implemented so that changes can be identified and addressed, holistically. Typically, changes must be identified taking into account a range of considerations including the workplace, the team (people) carrying out the work, machinery and equipment, and systems of work (how the work will be carried out in the workplace using the machinery and equipment). Unfortunately, often, the focus is only on the workplace and machinery and equipment, and changes to personnel, the composition of teams, the way in which work is planned (particularly where this is not face-to-face), and the implementation of the applicable codes of practice, standards, procedures, and instructions, can be overlooked, with disastrous consequences.
We have found that the more recent incident and accident trends (over the last two to three years) show that the impact of absenteeism on working teams, and the impact of socio-economic and other factors, (including mental health aspects) have been underestimated. The reality is that absenteeism has increased, and work team composition has been affected. Sometimes insufficient team members have reported for duty, and work continued when it should not have. Similarly, supervisors who do not report for duty, create a significant gap, unless a competent person is appointed to act in their place.
Our analysis of incidents and accidents over many years has confirmed the importance of Management of Change. The cumulative impact of small changes can easily be demonstrated by an example. A service provider is contracted by a mine to carry out certain services at the mine. In accordance with the contractor management system in place, the service provider carries out a hazard identification and risk assessment and prepares a methodology to carry out the work (Safe Operating Procedure). The Safe Operating Procedure requires the work to commence at 08h30. The service provider arrives at the mine at 09h30. The service provider’s vehicles are full of tools and equipment, which have not been checked and approved by the engineer. Because of the time pressure, the service provider persuades the security guard to let the service provider onto the mine, with all of these tools and equipment. When the work commences, there are various delays. It starts raining and eventually gets dark. This was not part of the plan. Alternative arrangements are made to provide lighting so that the team carrying out the work could see what they were doing. Eventually, late at night, an electrocution occurs. The sequence of events and changes included starting late (time pressures), being allowed onto the mine with tools and equipment that had not been checked (and use of these tools and equipment when things changed), environmental / workplace changes (rain and darkness), and rushing to get the job done. This is of course a simplification of a very complex accident, but the point remains – there were various opportunities to step back, re-assess the work being done within the context of the changes, and prevent the unfortunate outcome (fatal accident).
Every day, in every workplace, changes occur, and it is vital for all employees, supervisors, and managers to be empowered not only to identify changes but also to have the necessary authority to stop work when required.
We have also found that the cumulative effect of anxiety resulting from factors such as fear about job losses and other socio-economic changes, has had a significant impact on the way that teams work and operate. This is a material change and influences human behaviour in the workplace, and it must therefore be acknowledged and addressed through appropriate employee wellness programmes.
In Part 4 of our four-part series “How to prevent mining and other workplace accidents” we will address another key element, namely conducting proper and comprehensive investigations so that the true causes of an incident or accident are identified. Unless the true causes of an incident or accident are identified, the remedial measures that are put in place to prevent a recurrence, may not be effective.
For more information, please contact Warren Beech at warren@bv-inc.co.za.