Masterarbeit, 2019
122 Seiten, Note: 100
1. Introduction
1.1. Study Background
1.2. Problem Definition
1.3. Motivation
1.4. Research Aim
1.5. Research Questions
1.6. Structure of the Report
2. Literature review
2.1 Background.
2.2 Introduction
2.2.1 Applicable laws for Mining Companies in Zambia
2.2.2 Mine Accident Statistics
2.3 Incident/Accident models and investigation
2.4 Learning from Incidents
2.4.1 Case Study
3. Methodology
3.1 Research design
3.2 Description of study sites
3.3 Questionnaire Development
3.4 Pilot study
3.5 Sample Size and sampling technique
3.6 Survey Questionnaire Response
4. Discussion
4.1 Internal Consistency of the Surveys
4.2 In which step of the LFI process are major barriers located?
4.3 Which Steps Are Formally Organised?
4.4 The Variances Between the Properly organised LFI Process and the Performance in Practice
5. Conclusion and Recommendations
5.1 Conclusion
5.2 Recommendations
This study aims to identify the primary barriers and underlying causes that hinder the "Learning from Incidents" (LFI) process within the Zambian mining industry, with the ultimate goal of formulating strategies to prevent recurring occupational injuries and fatalities.
2.4.1 Case Study
Short Description of Incidents:
On 15th April 2014, two underground rig operators were found unconscious in a seating position leaning against the water column near a drill rig at a working level underground by a supervisor. There were no visible indication of physical injuries however, the postmortem reviewed that the cause of death was electrocution
When the incident happened the eye witnesses did not report the matter immediately to the supervisors but instead disturbed the scene of accident and reported the matter as a case of heat exhaustion.
During the fact analysis, it was established that the two deceased did not die from heat exhaustion related conditions contrary to what was earlier reported. It was also established that the Boomer Drill Rig was connected to the faulty electrical source. What happened was that when the power was turned on, the boomer rig was live because the live phase and earth was swapped around at the electrical box. And in additional, the electrical box was not earthed as a result of this there was no completed circuit and the earth leakage could not pick up any mal functioning or that the wires were not correctly connected. The boomer rig was live because the live wires from the boxes were directly connected to the earth of the boomer however, it could not complete the circuit because of the large rubber tyres. When the duo touched the live machine drill rig, they completed the circuit to earth and 550 volts went through them.
1. Introduction: This chapter establishes the background of the Zambian mining industry, highlighting high fatality rates and the critical need for an effective Learning from Incidents (LFI) process to prevent repeat accidents.
2. Literature review: This section covers theoretical frameworks of accident causation models and reviews existing research on LFI, providing context for the challenges faced in the mining sector.
3. Methodology: This chapter details the research design, explaining the use of mixed qualitative and quantitative methods, including surveys, semi-structured interviews, and focus group discussions at three major mining companies.
4. Discussion: This chapter analyzes the survey and focus group data, identifying key barriers in the LFI process—particularly in reporting, investigation, and evaluation—and comparing formal organization against actual performance.
5. Conclusion and Recommendations: This chapter summarizes the research findings, confirming significant gaps in the LFI process, and offers practical recommendations, such as fostering a "just culture" and improving investigator competence, to enhance safety.
Learning from Incidents, LFI, Zambian mining industry, occupational health and safety, accident causation, incident reporting, safety management systems, bottleneck identification, root cause analysis, organizational learning, safety culture, workplace fatalities, corrective actions, industrial safety, risk management.
The research focuses on investigating why the Zambian mining industry struggles to learn from past incidents, specifically aiming to identify the barriers that lead to the recurrence of avoidable accidents.
The study centers on the "Learning from Incidents" (LFI) process, incident investigation methodologies, the impact of organizational culture on reporting, and the gap between safety policies and on-site implementation.
The primary aim is to identify the specific bottlenecks (barriers) in the LFI process within the Zambian mining industry and to propose effective strategies to overcome them, thereby preventing future fatalities and injuries.
The author utilized a mixed-methods approach, combining quantitative data from survey questionnaires distributed to staff and safety practitioners, with qualitative data gathered from focus group discussions and semi-structured interviews with Safety Superintendents.
The main body investigates the eleven steps of the LFI process, analyzes the reliability of safety surveys, discusses specific case studies of electrocutions to highlight investigation failures, and evaluates how well safety procedures are organized versus how they are performed in practice.
Key terms include Learning from Incidents (LFI), Zambian mining industry, accident causation, organizational learning, workplace safety, incident reporting, and safety management systems.
The study uses the Swiss Cheese model to explain systemic failures and latent conditions in the mining environment, helping to illustrate how multiple breakdowns contribute to incidents despite existing safety defenses.
The study found that incident reporting is a significant bottleneck due to fear of victimization, potential loss of production bonuses, disciplinary actions, and a lack of feedback provided to workers who report incidents.
The Accident and Incident Management System (AIMS) is identified as a valuable tool for registering and tracking incidents, yet the research notes that its effectiveness is limited by a lack of proper management and necessary staff training.
The evaluation step is identified as the biggest bottleneck (72% of respondents) because companies often fail to monitor the actual effectiveness of remedial actions, focusing only on whether a task was closed in the system rather than if it successfully prevented recurrence.
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