That's the headline finding from new research by J. Lezdkalne, and perfectly summarised (as always) by Ben Hutchinson (PhD), that I've been chewing on for a few days.

The study reanalysed 62 incident investigation reports using a bespoke tool that combines energy-based thinking, barrier analysis, and human factors analysis (HFACS).

Here's what stood out to me.

• 𝟯𝟵 𝗼𝗳 𝟲𝟮 𝗶𝗻𝗰𝗶𝗱𝗲𝗻𝘁𝘀 (𝟲𝟯%) 𝘄𝗲𝗿𝗲 𝗺𝗶𝘀𝗰𝗹𝗮𝘀𝘀𝗶𝗳𝗶𝗲𝗱. Twenty-five (40%) were under-classified, originally recorded as minor accidents or near misses despite involving credible fatal potential. Fourteen (23%) were over-classified.
  
• 𝗧𝗵𝗲 𝘂𝗻𝗱𝗲𝗿-𝗰𝗹𝗮𝘀𝘀𝗶𝗳𝗶𝗲𝗱 𝗶𝗻𝗰𝗶𝗱𝗲𝗻𝘁𝘀 𝘀𝗵𝗮𝗿𝗲𝗱 𝗮 𝗽𝗮𝘁𝘁𝗲𝗿𝗻. They were characterised by degraded, bypassed, or human-dependent controls, with frequent procedure-to-practice gaps. The barriers were there in the paperwork. They weren't there in the work.
• 𝗧𝗵𝗲 𝗽𝗮𝗽𝗲𝗿 𝗶𝘀 𝗯𝗹𝘂𝗻𝘁: misclassification is "𝘴𝘺𝘴𝘵𝘦𝘮𝘢𝘵𝘪𝘤 𝘳𝘢𝘵𝘩𝘦𝘳 𝘵𝘩𝘢𝘯 𝘪𝘯𝘤𝘪𝘥𝘦𝘯𝘵𝘢𝘭". The way investigators handle human and organisational factors during classification is a big part of why.

Now connect that to the Qld mining context.

Since 2000, we've had 𝟱𝟴 𝗼𝗳 𝟲𝟬 𝗳𝗮𝘁𝗮𝗹𝗶𝘁𝗶𝗲𝘀 in Qld mines and quarries as single-fatality events. Each of those events almost certainly had precursors that walked through the system as near misses or minor incidents first. If 40% of those precursors were under-classified, then officers, SSEs, and risk owners were receiving incident information that systematically understated the fatal risk.

Two uncomfortable questions worth sitting with.

1. When was the last time you reviewed a "near miss" in your operation and asked, honestly, whether the energy and barrier degradation present meant it could have killed someone?
2. Are your investigators competent to assess fatal potential separately from realised injury severity, or are they classifying by what happened rather than what could have happened?

The research closes with a recommendation worth quoting: 𝘙𝘦𝘢𝘭𝘪𝘴𝘦𝘥 𝘪𝘯𝘫𝘶𝘳𝘺 𝘴𝘦𝘷𝘦𝘳𝘪𝘵𝘺 𝘴𝘩𝘰𝘶𝘭𝘥 𝘣𝘦 𝘴𝘦𝘱𝘢𝘳𝘢𝘵𝘦𝘥 𝘧𝘳𝘰𝘮 𝘧𝘢𝘵𝘢𝘭 𝘱𝘰𝘵𝘦𝘯𝘵𝘪𝘢𝘭. Events with no injury may still represent high fatal risk if energy exposure and barrier degradation are present.

That's a different lens to the one most mining incident systems are built on.

If you want a pressure test on how your investigation process actually classifies fatal potential, give me a call.

Check out my carousel here: PFI

Scott Graham

Founder and Managing Director, Mineplex 

0400 820 250 

sgraham@mineplex.com.au