A systems approach to accident causation in mining: an application of the HFACS method.Accid Anal Prev. 2012 Sep; 48:111-7.AA
This project aimed to provide a greater understanding of the systemic factors involved in mining accidents, and to examine those organisational and supervisory failures that are predictive of sub-standard performance at operator level. A sample of 263 significant mining incidents in Australia across 2007-2008 were analysed using the Human Factors Analysis and Classification System (HFACS). Two human factors specialists independently undertook the analysis. Incidents occurred more frequently in operations concerning the use of surface mobile equipment (38%) and working at heights (21%), however injury was more frequently associated with electrical operations and vehicles and machinery. Several HFACS categories appeared frequently: skill-based errors (64%) and violations (57%), issues with the physical environment (56%), and organisational processes (65%). Focussing on the overall system, several factors were found to predict the presence of failures in other parts of the system, including planned inappropriate operations and team resource management; inadequate supervision and team resource management; and organisational climate and inadequate supervision. It is recommended that these associations deserve greater attention in future attempts to develop accident countermeasures, although other significant associations should not be ignored. In accordance with findings from previous HFACS-based analyses of aviation and medical incidents, efforts to reduce the frequency of unsafe acts or operations should be directed to a few critical HFACS categories at the higher levels: organisational climate, planned inadequate operations, and inadequate supervision. While remedial strategies are proposed it is important that future efforts evaluate the utility of the measures proposed in studies of system safety.