Internal Incident Investigations in Industrial Safety: Not a Punishment, but a Development Tool

Incident investigation in industrial safety is a crucial tool for improving the safety management system. Every investigation should be aimed at identifying systemic causes rather than finding someone to blame.

Implementing a procedure for internal investigation and analysis of systemic causes of HSE incidents allows not only to avoid penalties from regulatory authorities but also to preserve the lives and health of employees, minimize economic damage, and ensure the sustainable development of the organization in the long term.

For a qualified and effective internal incident investigation, the following is necessary:

• Registration, investigation, and analysis of the systemic causes of all incidents;
• Timely organization and prompt execution of the internal investigation;
• Appropriate competence of the individuals involved in conducting the internal investigation;
• Completeness, consistency, and objectivity of the internal investigation;
• Development, implementation, and monitoring of the actual execution of corrective actions, taking into account cause-and-effect relationships;
• Dissemination of lessons learned and proposals for improvements in the HSE management system throughout the Company;
• Development of a unified approach and uniform requirements for the incident registration and internal investigation process.

Internal incident investigation and analysis of systemic causes do not replace the investigation of accidents, emergencies, incidents, fires, traffic accidents, and occurrences conducted in accordance with legal requirements.

Incidents of all categories are subject to internal investigation. At SUEK, they are divided into four categories, approved by the instruction on the transmission of operational information regarding HSE incidents:

• Catastrophic;
• Major;
• Significant;
• Minor.

To prepare personnel for conducting internal incident investigations, commission members must undergo training on the internal investigation procedure. This aims to enable them to identify incidents according to a unified incident classifier and apply the corresponding requirements for each category, specifically regarding:

• Recording the circumstances of incidents;
• Initiating and conducting internal investigations;
• Developing corrective actions;
• Documenting the results of the internal investigation;
• Developing lessons learned from incidents;
• Monitoring the implementation of actions and evaluating their effectiveness;
• Evaluating the quality and completeness of the investigation.

During the preparation of personnel for conducting internal incident investigations, we train our engineering and technical personnel (ETP) in the following methods:

Timeline of events and conditions - used to build a chain of events in chronological order, visualize the conditions under which these events occurred, and identify critical factors (immediate and systemic causes of the incident). It allows identifying gaps in the sequence and description of events.

Barrier analysis (Bowtie) - barrier analysis is conducted to determine whether all barriers related to critical factors were planned, available, and effective. Barriers can be physical as well as organizational/administrative.

The "Why" method - asks the question "Why did this situation arise? Why did this happen?" for each critical factor, and for each missing or ineffective barrier. The answers turn into a second "Why?" question, and so on, until the systemic cause is identified. The answer reached when the stopping rule is applied is one of the systemic causes of the incident.

Cause tree - allows bringing together all the branches of answers to the "Why?" questions, structuring them, breaking them down into levels, seeing the interrelation of causes, and determining the systemic causes of the incident.

Ishikawa diagram ("fishbone") - in this method, causes are divided based on their impact into 5 cause categories: man, machine (equipment), methods, material, and environment. Each of these five categories can, in turn, be divided into more detailed causes, which can subsequently be broken down into even smaller ones. It allows for a structured identification of all incident causes, but the method does not cover the causes in their interaction and temporal dependence.

All HSE events are subject to internal investigation and analysis of systemic causes in accordance with the unified incident classifier approved by the SUEK Instruction on the transmission of operational information regarding HSE incidents.