High Potential Incident Intervention

Background

2

• The principle policy of Downer Blasting Services regarding to our staff is “Zero Harm”

• The success of this principle is measured by Lag and Lead indicators with targets based on the previous years achievements and industry best practice.

LAG Indicator Targets

3

• Total Recordable Injury Frequency Rate < 5.0

• Medical Treatment Injury Frequency Rate < 2.5

• Lost Time Injury Frequency Rate < 1.0

LEAD Indicator Targets

4

• 1 “Take 5” per operator per shift• 1 “Safety Behaviour Observation” per

supervisor per week• 1 “Hazard Report” per supervisor per week• 1 “Safety Toolbox Meeting” per supervisor per

week

LEAD Indicator Targets

5

• 1 “Safe Task Observation” per supervisor per month

• 1 “Site Safety Inspection” per supervisor per month

• Preliminary incidents investigation conducted by supervisor regardless of consequence level

Safety Statistics

6

• Total Recordable Injury Frequency Rate 4.2• Medical Treatment Injury Frequency Rate 1.4• Lost Time Injury Frequency Rate 0.0• All Lead Indicator KPI targets achieved

Safety Culture

7

• Based on the LAG and LEAD Indicator statistics the safety culture appears to be healthy.

• While reviewing the incident data a disturbing trend appeared “High Potential Incidents”

• “HPI’s” have low “Actual Consequences” but have high “Potential Consequences”

• The business was experiencing 1 HPI per month

HPI Review

8

• An evaluation of the Lead Indicator data identified “Quantity” not “Quality”

• Not all HPI’s investigations reflected the potential consequences

• Investigation findings not shared with the entire business

HPI Investigations Reviewed

9

• Failure to follow the procedure• Training focused on compliance• Risk Assessments failed to identify all

potential hazardous scenarios • Lack of supervision

HPI Intervention Strategy

10

• Lead Indicator KPI’s changed to focus on quality to achieve improvement

• All HPI’s are managed as an actual high level severity incident

• All HPI investigations are presented to the CEO

HPI Intervention Strategy

11

• The intervention requires two projects to run simultaneously

• Project 1: Conduct “safe Task Observations”

• Project 2: Complete restructure of “Training”

HPI Intervention Strategy“Safe Task Observations”

12

• Prioritised list for procedural review• Every operation conducts the same review • Week 1 the supporting risk assessment is

reviewed• Week 2 the procedure is reviewed during

application

HPI Intervention Strategy“Safe Task Observations”

13

• The data from the risk assessments and procedural reviews is collated and summarised

• This data is then feed to the Training Project team

HPI Intervention Strategy“Training”

14

• Process mapping• Improved document control• Consistency in the material• Updated Risk Assessments

HPI Intervention Strategy“Training”

15

• New Safe Work Procedures• eLearning development and

implementation• Support material – handbooks,

reference guides

HPI Intervention Strategy“Training”

16

• In field electronic tablets• Improved transition for staff between

sites• Minimal hard copy training records

Key Aspects of the Process Map

17

Identify the Risk Management Required

Identify the Critical Task

Identify the Document Type / Document Hierarchy

Identify the Key Content of the Document

Identify the Emergency Procedures

Critical Task Steps (what to do / Individual Activities)

Steps within the Individual Activities (how to do)

DBS Process Map Rules

18

• Critical Tasks must cover the key tasks associated with any process

• The map must include all of the individual activities undertaken within the collective critical task (horizontal flow)

• The process map should be limited to a single silo of steps within any individual activity (vertical)

• All document must match the safety management systems document hierarchy

• All critical tasks must end with the appropriate emergency management / contingency plan (what do I do if it goes wrong) document

Example Process Map “Explosives Loading Area Preparation”

19

<Fun

ctio

n>

Current Generic

Standard Work Prac

Critical Task:- Explosives

Loading Area Preparation

What are the Key Headings

in the SWP

1. Risk Assessment for the Work

Area

1. Confirm the Requirements of the Blasting

Plan

1. Risk Assessment for the Work

Area

2. Accessing the Explosives Loading Area

3. Preparing the Ground Surface - Personnel

5. Preparing Parking and

Turning Areas for Vehicles

6. Managing Surface Water

7. Ancillary Mining

Activities

8. Site Notification of

the ELA

1. Tools and Equipment Required

1. Tools and Equipment Required

1. Preparing to Prime the Blastholes

1. Preparing to Prime the Blastholes

1. Preparing to Prime the Blastholes

1. The Location of the Primers within the Blasthole

Profile

1. Identifying the Size of the

Gas Bag

1. Identifying the Presence

of Hot / Reactive Ground

1. Tools and Equipment Required

1. Recording the Dip Data

1. Backfill Material

1. Re-Drilling the Blastholes

2. Distribution of the

Detonators and Boosters

3. Assembling the Primer

4. Positioning the Primer within the Blasthole

5. Securing the Downlines

6. Removal / Recovery of the Primers

2. Distribution of the

Detonating Cord and Boosters

3. Assembling the Primer

4. Positioning the Primer within the Blasthole

5. Securing the Downlines

Removal / Recovery of the Primers

2. Distribution of the

Detonators and Boosters

3. Assembling the Primer

(Cast Booster)

4. Assembling the Primer (Packaged Product)

5. Positioning the Primer within the Blastholes

6. Securing the Downlines

7. Removal / Recovery of the Primers

4. Managing Lost /

Unaccounted for Explosives

Products

3. Identifying and Managing Defective or Deteriorated

Product

2. Primer Selection

5. Reconciling the Products

Used

2. Storage and Transport of Gas Bags

3. Inflating a Gas Bag

7. Use in a Product

Column to Separate products

4. Use in Blastholes Containing

Water

5. Use During the Deck

Loading of Blastholes

6. The Positioning the

Gas Bag within the Blasthole

(Deck) Profile

9. Use to Secure Partially Loaded

Blastholes

2. Measuring the

Temperature of the

Blastholes

3. Testing for Reactive Ground

4. Recording the Data

6. Recording the Data

5. Identifying and Managing

Water Recharge

Rates

4. Managing the Run off

Water

3. Dewatering the Blasthole

2. Positioning the

Dewatering Vehicle

2. Backfilling the Short Blastholes

3. Separation of Re-Drilling

operations and Blasthole

Loading

4. Recording the Data

2. Equipment Used to Backfill

Blastholes

4. Backfilling Blastholes Containing

Water / Mud

3. Backfilling Dry Blastholes

5. Recording the Data

2. Assessing The Dip data

9. Changing the Product Selection

(Sleep times)

7. Identifying Hot and / or

Reactive ground

6. Identifying Water within

the Blastholes

5. Identifying the Location of

the Mineral Body

4. Identifying Blastholes to be Backfilled

3. Identifying Blastholes to be Re-Drilled

6. Ancillary Mining

Activities

5. Manages Changes to

the Explosives Loading Area

Perimeter

3. Rules on Entry to the Explosives

Loading Area

4. Identifying Prohibited

Items within the Explosives Loading Area

2. Erecting Visual and Physical Barriers

9. Marking Abnormal Blastholes

6. Dipping Blastholes with Wet /

Muddy Sides

5. Dipping Blastholes

That Contain Water

4. Dipping Dry Blastholes

3. Traffic Management

Within the Explosives

Loading Area

2. Hazard Identification

10. Addressing

Areas of Concern

9. Site Notification of

the ELA

8. Accepting the Separation

Distances ELA /

Ancillary Mining Act

7. Accepting the Surface

Water Management within the ELA

6. Accepting the Areas for

Vehicle Parking and

Turning

3. Accepting the Ground Surface - Personnel

2. Accepting the Access to

the ELA

6. Addressing Areas of Concern

5. Identification of the Blast Outcomes

4. Managing the Product Selection

3. Reviewing the Blast Design

Parameters

2. Confirm the Quality of the Drilling Plan

Managing the Dewatering

of Blastholes (SWP)

Managing the Dip Data

(Standard)

Managing Hot and Reactive Ground (SWP)

Preparing the

Explosives Loading Area(Procedure)

The Use of Det Cord

Primers in Blastholes

(SWP)

Managing the Backfill of Blastholes

(SWP)

Delineating the

Explosives Loading Area

(SWP)

The Use of Electronic Primers in Blastholes

(SWP)

Is there a Site Specific JHA

for each of the documented

tasks

Verify the Blast Plan

(Procedure)

Is there a Generic Risk Assessment

for the Critical Task?

The Use of NonEl

Primers in Blastholes

(SWP)

Priming Blastholes(Standard)

The Use of Gas Bags

(SWP)

Acceptance of the

Explosives Loading Area(Procedure)

Emergency Procedures within the

Explosives Loading Area

Managing the Re-Drilling of

Blastholes (SWP)

Blasthole Preparation

(SWP)

8. Managing the Dip Data

7. Installation and Marking the Wooden

Pegs

8. Recording the Blasthole

Dip Data

8. Use During the Stemming of Blastholes

4. Preparing the Ground Surface - Vehicles

9. Addressing the Areas of

Concern

4. Assessing the Drill Pattern

5. Accepting the Ground Surface - Vehicles