ISG deployed specialist skills to conduct an ICAM investigation and recommend effective workplace safety changes
Following a serious near-miss workplace incident, our client engaged us to investigate, identify the issues, and recommend corrective action. We used the Incident Cause Analysis Method (ICAM) to complete the work within three days. During this time, we also created new workplace policies and systems for our client, including a Work Health and Safety manual.
Our client was a Sydney-based utility contractor, providing services exclusively to a prime contractor in the energy industry. At the time of the incident, our client’s immediate concern was the risk of serious injury or death.
The Incident
Our client had deployed a small team of workers to a residential site for a standard service call. When the workers were part-way through the job, they encountered a separate emergency issue nearby. They prioritised the emergency and fixed the problem.
However, when they returned to the service call, they conducted a test without first completing an inspection of their previous work. Then they left the site. As a result, the home owner was exposed to a high risk of electrocution. The homeowner called their energy provider and the following day, the provider sent a response team to inspect. The response team identified the problem.
Although the incident was a near-miss, it was a serious safety issue because it could have caused injury or even death.
Our client immediately contacted us for help.
The Challenges
Our client’s main concern was worker safety. It was also worried that an unresolved safety incident would jeopardise its only source of work. Therefore, it instructed us to conduct the investigation sensitively, being mindful of the mental health and welfare of the workers involved.
Our Approach
After an initial discussion, we recommended an ICAM investigation because it would examine all possible causes. The client agreed and engaged our services because of our:
- ICAM credentials
- Availability to commence work
- Experience in investigating a range of workplace issues
We decided to use the following steps to conduct the investigation:
- Collect evidence
- Analyse the evidence
- Identify steps to address and fix the issues
- Identify steps to reduce future risk
To carry out these steps, we:
- Met with our client before and after the investigation to establish scope and expectations
- Ensured our lead ICAM investigator would work closely with the client’s investigation team leader and other members of its investigation team
- Allocated two days to visit the site for interviews and inspections, and a further off-site day for administration
- Interviewed all workers involved in the incident, and any witnesses
- Collected documents and took photographs
How our approach benefitted the client
ICAM investigations are standardised, meaning the same method is applied every time. However, our approach was tailored in other ways, including how we communicated with our client’s workforce.
The incident raised specific concerns about the welfare of our client’s workers, especially if the incident resulted in a loss of work from the prime contractor. As a result, we aimed to reassure all workers that:
- Human error was only one aspect of our investigation
- We would look at all possible contributing factors
- We would consider how to prevent similar incidents
When we investigated the policies and systems, we found that the client relied on documents from its prime contractor; it had few policies and systems of its own. As a result, the workers could not refer to a comprehensive written guide when doing the work. Nor were there documented training systems, which was particularly an issue for WHS training. This was critical to alerting workers to the risks and ensuring they took all necessary safety precautions.
“We had no measuring stick; no existing systems against which we could measure the performance, conduct and outcome. So one of the early indications was that we would need to recommend that new policies and systems be drafted and implemented,” said ISG Principal Investigator Andrew Davis.
Crucially, our client was stood down from providing services to the prime contractor until further notice. So our rapid response was necessary to help our client resume its work.
We were able to act as soon as the client contacted us. We met the 72-hour time frame and provided a comprehensive 120-page report once the ICAM investigation was finalised, along with new policies and systems.
The report included:
- Scope of the investigation
- Circumstances of the incident
- Method of evidence collection and investigation
- Our findings, including the main cause and contributing factors
- Recommendations
- Next steps
- Follow-up
- Key documents
Early in the investigation, it was clear that new workplace policies and systems were required. Therefore, we acted immediately to develop work systems specific to our client. For example, one system outlined safety protocols for live voltage work and overhead service changeovers.
The work systems outlined record-keeping requirements, supervisor and worker responsibilities, testing protocols, and procedures for:
- Pre-work start
- On-site arrival
- Installation and disconnection checks
- Replacement of service
- Reconnection checks
- Other specific details
We also developed a comprehensive Occupational Health Safety and Environmental (OHSE) Manual. This 67-page document included all OHSE issues required by law and dealt specifically with the client’s operations. It included:
- OHS policy
- Environmental policy
- Risk management
- Monitoring and review
- Incident and hazard reporting
- Emergency management
- Hazardous work
- Plant, equipment and structures
- Health and welfare
- Induction and training
Within two weeks of the investigation, our client had implemented all corrective action, including the new policies and systems. It had also trained its workforce in all aspects of the OHSE policy and safety protocols.
“This investigation was time-critical and had to be handled with great sensitivity, given the nature of the incident, the client’s relationship with its client and worker welfare. Our ability to respond quickly with qualified investigators and expert recommendations made a significant difference. It was ISG at its very best,” said ISG Principal Investigator Andrew Davis.
What’s ahead
Having implemented all recommendations, our client anticipates resuming work for the prime contractor in the coming weeks. We will remain in close contact with our client, ready to assist with any further changes as the prime contractor may require.
“A period in which a service provider has been stood down pending an internal investigation is often difficult and stressful. However, our client used the time to implement improvements, retrain its workforce and attend to the welfare of its workers. It was an excellent way to fine-tune its policies and systems, ready for long-term success in the utilities industry,” said ISG Principal Investigator Andrew Davis.
Do you need an independent workplace investigator?
If there has been a safety incident at your workplace, it is critical to act quickly. Contact us as soon as possible so we can do a thorough investigation and meet any deadlines. This is even more important if your organisation’s services are suspended.
