ICAM – Investigation Process

Day 1
 Assemb
ly
Area
Before we start…

Alcohol free and smoking restricted environment

Please smoke in designated areas only
Page 2
What is ICAM?

“ICAM” stands for Incident Cause

Analysis Method
ICAM can be used for any incident investigation, but it must be used for all
high potential and actual incidents rated Level 4 and higher.

Page 4
Course Overview - 2 Day Programe
• Welcome, Safety Brief, Attendance Register
• Getting to know each other
• Course Aspects
– Context and Purpose (day 1)
– Learning objectives (day 1)
– Causes and Consequences of Incidents (day 1)
– Definitions (day 1)
– Interviewing techniques (day 1)
– 7-Step ICAM Method and Tools (day 1)
– Review of day 1 (day 2)
– Case Studies (Syndicated exercises) (day 2)
• Your Expectations?
• Rules of the Game?
• Parking Lot
• Plus Delta
• Course Evaluation
Page 5
Learning Objectives
• Upon completion of this course you will be able to:
– Recognise the need for an incident investigation
– Gather and organise relevant data
– Interview witnesses using key steps
– Carry out an ICAM investigation
• ICAM Objectives
– Establish the facts surrounding the event
– Identify contributing factors and underlying causes
– Review the adequacy of existing controls and procedures
– Recommend preventive and corrective actions
– Report the findings in order to share key learnings
– Not to apportion blame or liability to individuals or teams

Page 6
“I’m Gonna Live Until I Die”

Page 8
 What We Do Not Understand,
We Cannot Control Charles Reich

Page 9
 Cost Of Loss Iceberg

Injury And Illness Costs

Medical
RI-00 Lost Time
Compensation

Property, process, material, miscellaneous

R6-00 to R 53-00 costs
(6-53 times as much)
Production Loss
Building Damage
Plant Damage
Tools and Equipment
Material Damage
Legal Fees
Emergency supplies
Clerical costs
Replacement costs

Page 10
 Accident Causation Theory

• An observer generally assumes that someone

acting in a particularly foolish or harmful way is
doing so deliberately and with full knowledge of
the consequences.
• If the person in question is asked to account for
their actions, they will emphasise the contributing
factors that made them to do it.
• Outside observers tend to attribute behaviour to
the characteristics of the actor, while the actors
see their action as being mainly shaped by the
surrounding circumstances

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 Accident Causation Theory

• The observer and the actor each see only a part of

the truth. Any behaviour, such as unsafe act, is
driven by both personal and contributing factors.
• Neither one, nor the other is the whole story.
• Even if people were the master of their own fate
and so were completely responsible for their own
at-risk behaviour, the alternative remedies
available are to retrain, remotivate or discipline the
offenders.

Page 12
 Accident Causation Model
Swiss Cheese Model
developed by psychologist and human error expert
Hazards P ro Professor James Reason
blem
solvi
ng Path
way

Organisational
Factors
Task/ Env
Factors
Co Individual
n
Inc tribu
Incident
id
ent t ing or Team
C aus F act Actions
at ion or s Absent / Failed
P ath
w Defences
ay

Page 13
 Accident Causation Theory

Regardless of what is done to re-

educate or threaten people, they still
retain their human capacity for
making errors or committing
violations

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Error Tolerance

Errors will always be made. We cannot change

the human condition, but we can change the
conditions under which humans work and make
our organisation more error tolerant

(adapted from Reason, 2000)

“Risk taking is rarely punished with an injury or
even a near miss, instead its consistently
rewarded with convenience, comfort or time
saved.”
(Scott Geller. Psychology of Safety)

Page 16
 "To achieve progress every accident and
incident, no matter how minor, must be
considered as a failure of the system, or
organisation and not simply as the failure of a
person, or of people."
Dan Maurino, ICAO

Page 17
 HSEC performance improvement strategies

DEFENCES Error ORG.

Prevention FACTORS

Error
Trapping

Error
Mitigation
Zero Fatalities
to
Zero Harm
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Page 19
Page 20
 ICAM Investigation Guideline

The ICAM Guideline and the

associated toolkits are available
electronically on the BHP Billiton
Intranet site:

http://hsec.bhpbilliton.net/bp/safety/icam.asp

Page 21
 What is ICAM?

“ICAM” stands for Incident Cause

Analysis Method
ICAM can be used for any incident investigation, but it must be used for all
high potential and actual incidents rated Level 4 and higher. (see HSEC
Severity Consequence Ranking Table)

Page 22
ICAM Investigations

Investigations are
like football, a lot
depends on how you
view the game and
the result you want
Descriptive level

What happened,where & when?

Compliance level ( yellow,or red card )

Who broke which rule

or didn’t follow
procedures ?
Typical outcomes
Investigation level

Why & how it happened?

How can we prevent it from happening again?
ICAM level outcomes

Continual
Improvement of
The Game
Target Achieved !
 Rating Chart

Page 29
What can we do with ICAM ?

• Provide a consistent approach to incident investigation

• Provide repeatable results
• Focus on the human factor, both at the operational end and within the organisation
• Provide tools for learning the right lessons from an incident
• Identify “error tolerance” improvement opportunities
• Identify attainable and measurable safety targets
 Pro-Active ICAM Application

Task /
Organisational Environ. Individual/ Absent / failed
Factors conditions Team actions Defences No Incidents

Safety Nets Safe &

Sound Produce Reduced Redundant
Organisational Safe Errors & Risks Managed Efficient Task
Factors Workplaces Violations Errors Trapped / Completion
Mitigated

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 Definitions
• Incident - Any occurrence that has resulted in, or has the potential to
result in (i.e. near miss), adverse consequences to people, the
environment, property, reputation, or a combination of these. Significant
deviations from standard operating procedures are also classed as an
‘incident’. Ongoing conditions that have the potential to result in adverse
consequences are considered to be incidents.
• Near miss – Any occurrence or a situation which potentially could have
caused adverse consequences to people, the environment, property or
reputation, or a combination of these but which did not.
• Hazard – A source of potential harm, injury or detriment.

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 ICAM Methodology Overview

• Provide guidance to personnel empowered to complete

incident, or near miss investigations
• Systematic safety investigation analysis method
• Aims to identify local factors and failures within the
broader organisation and productive system
• Through analysis of of this information, ICAM provides the
ability to identify what really went wrong and make
recommendations on what needs to be done to prevent a
recurrence.

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 ICAM Methodology Overview (contd)

• Directed towards building ‘error-tolerant’ controls

against future incidents
• Provides tools for looking beyond the errors and
violations of individuals by examining the
contributing factors leading to these
occurrences.
• Helps to identify systematic safety deficiencies
• Can help to generate actions for improved safety

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W h at w w r o n g ?
en t r i g h W h
t? a t w en t
Why Investigate ?
 Incident Investigation

The basis for an effective investigation program can be

summed up in five short but powerful words:

Fact-Finding,
Not Fault- Finding

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 Why do we investigate incidents ?

• To comply with legislation (e.g. Section 11.1.(4) of the

MHSAct)
• To find out what happened (learn from mistakes)
• To evaluate the system deficiencies and to prevent
repeated accidents
• To avoid problems that remedial actions could create if
taken hastily
• Due diligence (Corporate Governance)

Page 40
 Goals for incident investigations

• Identification, not assumption

• Evaluation, not resignation
• Long-term thinking, not short-term fixing
• Showing concern, not condemnation
• Being proactive – not reactive

Page 41
 Qualities of Investigators

Integrity Imaginative
Objectivity Humility
Perseverance Intuition
Curiosity Tact
Observing Skill

Page 42
 Investigator’s Performance Test

This exercise will test your powers of observation. You will

need to concentrate and focus on the task at hand.

White Shirt Team Black Shirt Team

How many times are the How many times are the
basketballs passed in the basketballs passed by
air without bouncing ? bouncing them ?
Performance Test Video
 Questions
• Left Team
• How many times is the basketball passed in the air without
bouncing?
• Right Team
• How many times is the basketball passed by bouncing it?
• Both Teams
• How many lifts were they in front of?
• How many people in white T shirts and Black T shirts?
• What letter was written on the back wall?
• Did anyone see an animal at any stage?

Page 45
 Collecting Information

In addition to collecting physical evidence

after an incident, information collection will
be categorised into 5 main criteria:

• People
• Environment
• Equipment
• Procedures
• Organisation

Page 46
 Collecting Information

• People – Employees, contractors, customers, visitors, suppliers, the public.

• Equipment – All types of tangible property such as tools, machines, vehicles,
facilities, lifting gear, transportation systems, hand tools, personal protective

equipment, chemicals, feed-stock and other raw material, products, and supplies.

• Environment – All parts of the surroundings for the people at work as well as the
surroundings in which the site operates, including air, water, land, natural resources,

flora and fauna.

Page 47
 Collecting Information

• Procedures – Production and work methods used to produce the end product or
service. Procedure usually relate to actual physical processes; however with the

acceptance that a management systems approach is an effective means for

controlling incidents, management and administrative processes should also be

considered as part of this element.

• Organisation – Management holds the legal responsibility for the safety of the
workplace and workforce. Role profiles are developed and clearly defined.

Responsibilities were communicated to all stakeholders.

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 Collecting Information
• Identify conditions, actions, or deficiencies in each
of the PEEPO categories
• These could be contributing factors to the incident
• Ask broad questions: who, what, where,
when,why,why,why…..

Page 49
 Significant Incident Reports – what do they look like?

Page 50
 Incident reconstruction (re-enactment)

Incident reconstruction should be used only:

• When the information cannot be gained in another way
• When it is vital to the development of remedial actions
• When it is absolutely necessary to verify critical facts about the
incident
• Stop the reconstruction just as soon as you get the information
you need!

Page 51
 Dangers of Incident Reconstruction (re-enactment)
Oh Bugger!!

Page 52
 ICAM involves 7 steps

1. Immediate Actions Secure the site/Appoint Team

2. Investigation Planning Planning Meeting

3. Data Collection PEEPO

4. Data Organisation Timeline & 5 Whys

5. ICAM Analysis ICAM Chart

6. Preventive & Corrective Actions Recommendations

7. Report ing the findings Report

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Page 63
 DIFFICULT

NOT WORTH THE

EFFORT DIFFICULT

Ease of Change
QUICK WINS COMPETITIVE
NEED

EASY
LOW HIGH
Pay-off / Impact

Page 64
 DIFFICULT

NOT WORTH THE

EFFORT DIFFICULT

Ease of Change
QUICK WINS COMPETITIVE
NEED

EASY
LOW HIGH
Pay-off / Impact

Page 65
 DIFFICULT

NOT WORTH THE

EFFORT DIFFICULT

Ease of Change
QUICK WINS COMPETITIVE
NEED

EASY
LOW HIGH
Pay-off / Impact

Page 66
 7-Step
I nvestig
ation P
r ocess

Page 67
 ICAM Step 1

1. Immediate Actions Secure the site/Appoint Team

2. Investigation Planning

3. Data Collection

4. Data Organisation

5. ICAM Analysis

6. Preventive & Corrective Actions

7. Report the findings

Page 68
 Step 1: Immediate Actions
1. Immediate
Actions
• These are the things that should be done immediately following an incident.
2. Investigation
Planning
• Emergency Response
3. Data
Collection
– Make sure hazards are addressed (Hierarchy of Controls)
4. Data
Organisation
• Securing the Site
5. ICAM
Analysis
– Make the site safe
6. Preventive &
Corrective
– PRESERVE THE INCIDENT SITE
Actions

7. Report the
– Identify and implement immediate corrective actions to prevent further
findings
incidents
– Drug and Alcohol test
– Notify Management
– Photograph, Video, Measure, Draw, Survey, etc.
– Document emergency response actions for analysis later
– Complete initial Incident Report

All of the immediate actions should be carried out

as soon as possible.
Page 69
 Appoint Investigation Team – get the right people
1. Immediate
Actions • Responsible line manager selects team
2. Investigation
Planning

3. Data
Collection • Team members should not be placed in situation for
4. Data
Organisation
potential conflict
5. ICAM
Analysis

6. Preventive &
Corrective
Actions
• Members must have time made available
7. Report the
findings

• Possible team structure on next slide

– Refer to HSEC Toolkit T28

– Refer to page 9 ICAM Investigation Guideline

Page 70
 Appoint Investigation Team – get the right people
Investigation Team
Position Description
Positions
Independent Senior Line Manager or best qualified
Team Leader
person with the appropriate experience and skills
Senior Site Representative Senior Line Manager
Senior HSE or Line Manager with ICAM facilitation
ICAM Facilitator
skills
Technical Specialist Specific skills relevant to investigation

Line Managers and workforce representatives with

Other Site Representatives technical skills, investigative skills and / or experience
relevant to the nature or the environment of the event.

Other Independent
Independent subject matter experts
Members

Page 71
 ICAM Step 2

1. Immediate Actions

2. Investigation Planning Planning Meeting

3. Data Collection

4. Data Organisation

5. ICAM Analysis

6. Preventive & Corrective Actions

7. Report the findings

Page 72
 Step 2: Investigation Planning
1. Immediate
Actions Appointed Investigation Team to:
• Attend overview by management
2. Investigation
Planning

3. Data

• Establish scope or boundaries for the investigation

Collection

4. Data
Organisation

5. ICAM
Analysis • Plan the investigation (Including site visit)
6. Preventive &
Corrective
Actions
• Locate Investigation Room that is not going to be disturbed
7. Report the

• Establish Document Management

findings

• Take possession data already collected

• Agree on expected due date for report

– Refer to HSEC Toolkit T29

– Refer to page 10 ICAM Investigation Guideline

Page 73
 Time Table – investigations require time
1. Immediate
Actions

2. Investigation
Planning
Activity versus Time Taken
Corrective
3. Data
Collection
Data Collection Data ICAM Preventive Report
Actions
4. Data
Organisation
Organisation
Total
Potential SI 2 days ½ day ½ day ½ day ½ day 4 days
5. ICAM
Analysis

6. Preventive &
Corrective
Actions

7. Report the

RWC / LTC ½ day ½ day ½ day 2 hours ½ day 2 days

findings

Actual SI 2 days 1 day 1 day ½ day 1 day 5 days (or more)

Note: not all team members are involved at all of the stages above and the times are indicative only

Page 74
 ICAM Step 3

1. Immediate Actions

2. Investigation Planning

3. Data Collection PEEPO

4. Data Organisation

5. ICAM Analysis

6. Preventive & Corrective Actions

7. Report the findings

Page 75
 Step 3: Data Collection
1. Immediate
Actions • Gather relevant facts
• Understanding what happened
2. Investigation
Planning

3. Data

• Data collection is divided into:

Collection

4. Data
Organisation

5. ICAM
Analysis
– People
6. Preventive &
Corrective
Actions
– Environment
7. Report the
findings – Equipment
– Procedures and Documents
– Organisation

– Refer to HSEC Toolkit T30

– Refer to page 13 ICAM Investigation Guideline

Page 76
 Data Collection – what it looks like
Data Category Collection Method

P People

E Environment
n s to r m
t o b rai llec t
E EP O to c o
E Equipment
P
Use a you nee ageable d
a t da t o m a n
wh k it in t
to b r ea n k s
P Procedures or c h u

O Organisation

Page 77
 Data Collection: People Category
1. Immediate

• Purpose to obtain a picture of what happened.

Actions

2. Investigation
Planning

• What evidence would you need to collect:

3. Data
Collection

4. Data
Organisation

5. ICAM
Analysis – People Involved
6. Preventive &

– Positions of injured workers

Corrective
Actions

7. Report the
findings

– Presence and location of witnesses

– Experience and training received
– Physical limitations
– Stress, time pressures
– Similar incidents that may have happened

Page 78
 Why interview Witnesses?
1. Immediate
Actions • To allow information to be gathered about the incident
2. Investigation
Planning

3. Data
Collection
• Interviews should be carried out as soon as possible to
4. Data
Organisation prevent bias
5. ICAM
Analysis

6. Preventive &
Corrective
Actions
• They are not for legal purposes
7. Report the
findings

– Record date, time and who was present

– Does not have to be signed

– Does not need to be written by witness

– Give a copy to the witness and verify

Page 79
 Legal Guidelines for ICAM Investigations
1. Immediate
Actions

The actions taken by an ICAM investigation team immediately after

2. Investigation
Planning

an incident can have significant legal implications for individuals

3. Data
Collection

4. Data
Organisation

5. ICAM
and the Company.
Analysis

6. Preventive &
Corrective
Where a fatality or serious injury has occurred, it is particularly
important that BHP Billiton Legal is contacted prior to the taking of
Actions

7. Report the

witness statements.
findings

BHP Billiton Guideline G59 (Issued 8 December 2006) must be

consulted before an investigation into a serious injury or fatality.

Page 80
 Legal Guidelines for ICAM Investigations

Page 81
Interviewing Techniques for Investigators
 Witness Types
• Operators
• Work colleagues
• Family members
• Industry personnel
• Members of the general public

Page 83
 Interview Techniques
1. Immediate
Actions
• Identify key witnesses and prioritise whom to interview first
2. Investigation
Planning
(if statements have not already been taken)
3. Data
Collection

4. Data
• Interview individually
Organisation

5. ICAM
Analysis • Let them do most of the talking
6. Preventive &
Corrective

• Consider expertise
Actions

7. Report the
findings

• Assess credibility
• Record the interview (with permission)
• Follow-up if necessary
• Health and Safety (Or Union) Representative can be present
• Witnesses should be available during the investigation to clarify
information for the investigation team

Page 84
 Hierarchy of Questioning Techniques
Examples :

Unstructured free recall “In your own words can you tell me what
happened”
Open-ended questions “What happened then?”
Encouraging responses “Uh-huh”, head nod, eye contact etc.
Paraphrasing “You’re saying he was quite upset about
failing the exam?”
Closed Questions “Exactly where were you standing?”
(Multiple Choice)
Leading “You’re saying he had a history of taking
short-cuts to be able to finish early?”
Questions

• You have two ears and one mouth. Use them in that ratio
Page 85
 Example Questions

Adequate Inadequate

“Can you tell me where you were last night “You were watching the football in the crib
and what you were doing?” room weren’t you?”

“Can you run me through what occurred Did you cause the incident?
during night shift leading up to the incident
from your location?”

“So just let me run through what you have “I’ll run through the story and you can tell me
told me so far. You saw…” (at the end of the if I have got it right”. (at the beginning of the
interview) interview)

Page 86
 Brain Teasers

Page 87
 What Do You See?

Page 88
 What Do You See?

Page 89
 What Do You See?

Page 90
 What Do You See?

Page 91
 ALZHEIMERS' EYE TEST

Count the number of F’s in the following text:

FINISHED FILES ARE THE RE

SULT OF YEARS OF SCIENTI
FIC STUDY COMBINED WITH
THE EXPERIENCE OF YEARS...

Page 92
 ALZHEIMERS' EYE TEST

Did you find all 6F’s?

FINISHED FILES ARE THE RE

SULT OF YEARS OF SCIENTI-
FIC STUDY COMBINED WITH
THE EXPERIENCE OF YEARS...

Page 93
 Can you read this?

I cdnuolt blveiee taht I cluod aulaclty uesdnatnrd waht I was

rdanieg. The
phaonmneal pweor of the hmuan mnid, aoccdrnig to a
rscheearch at Cmabrigde Uinervtisy,

it deosn't mttaer in waht oredr the ltteers in a wrod are, the olny
iprmoatnt tihng is taht the frist and lsat ltteer be in the rghit
pclae. The rset can be a taotl mses and you can sitll raed it
wouthit a porbelm.

Tihs is bcuseae the huamn mnid deos not raed ervey lteter by
istlef, but the wrod as a wlohe. Amzanig huh? yaeh and I awlyas
tghuhot slpeling was ipmorantt!

if you can raed tihs psas it on !!

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 What do you see?

It’s easier when we know what

we are looking for...

Page 98
 What you see depends on what you are concentrating on.

Page 99
 Witness Interviewing

Are all witnesses reliable?

Page 100
 Perceptions Differ

Page 101
 Perceptions Differ

Page 102
 Limitations to the accuracy of eyewitness testimony

Stimulus factors
(event characteristics)

Personality and
perceptual factors

Elapsed
time since
MEMORY the event

Page 103
 Limitations to the accuracy of eyewitness testimony

External
MEMORY Information

Personality and
motivational factors

Communication
(interviewing) factors

RECALL/OUTPUT
‘THE TESTIMONY’
Page 104
 Are all witnesses reliable?
1. Immediate
Actions

2. Investigation
There were two planes, but
the sun was in my eyes
Planning

3. Data
Collection

4. Data
Organisation

5. ICAM
Analysis

6. Preventive &
Corrective
Actions

7. Report the
findings

There was only one

plane and I had a
clear view

Page 105
 General Principles
– Preparation Is everything
1. Immediate
Actions

2. Investigation
Planning

3. Data
Collection – Timeliness Memories are perishable
4. Data
Organisation

5. ICAM
Analysis
– Location Use environmental cues to aid recall
6. Preventive &

– Rapport Put at ease; interviews can be uncomfortable

Corrective
Actions

7. Report the
findings

– Status De-emphasise officialdom and/or status

– Language Avoid technical terms, jargon and acronyms
– Emotional State Allow for anxiety, stress, confusion

Page 106
 Commencing the Interview
• Set the right tone for co-operation:
1. Immediate
Actions

2. Investigation
Planning

3. Data
Collection
– Introduce yourself
Use a non-threatening environment
4. Data
Organisation
–
5. ICAM
Analysis

6. Preventive &
Corrective
– Establish a rapport with the witness
Actions

7. Report the
findings
– Describe your role in the investigation
– Describe the purpose of the interview
– Ask permission to take notes during the interview

Page 107
 Activity 1: Interviewing Techniques
Context:
• Incident investigation requires relevant facts to be gathered to understand the incident and
the events which led to the incident. Witnesses can provide a lot of the facts.
Purpose:
• To conduct an interview about what the other person has just seen in a DVD
Quality:
• Using the interview techniques discussed, perform an interview on a witness
Quantity:
• 1 interview performed (in pairs)
Resources:
• Work in a group of 2 – 1witness, 1 interviewer
• ICAM Investigation Guideline and Training Manual
• Trainers Handouts
• DVD watched whilst you were outside
Time:
• 30 minutes

Page 108
Interviewing Exercise

Interviewers, please leave

the room for 5 min
 Data Collection: Environment Category
1. Immediate
Actions

2. Investigation
• Purpose to consider what environmental conditions were evident
Planning

3. Data
Collection at the time of the incident
4. Data

• What information would you need to consider:

Organisation

5. ICAM
Analysis

6. Preventive &
Corrective
Actions
– Weather conditions
– Time of the day
7. Report the
findings

– Housekeeping
– Conditions such as noises and lighting
– Dust, fumes, toxic substances
– Photographs of the scene prior to disassembly
– Time Pressures

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 Data Collection: Equipment Category
1. Immediate
Actions • During an investigation seek out possible causes resulting from
2. Investigation
Planning equipment and materials being used:
3. Data
Collection

4. Data
– What materials were being used
Organisation

5. ICAM
Analysis – Damage to equipment
6. Preventive &

– Position of relevant pieces of equipment

Corrective
Actions

7. Report the
findings

– Position of valves, switches, controls, barriers etc.

– Evidence of equipment failures - how did the safety devices work
– Evidence of loss of containment
– PPE
– Also consider associated procedures, maintenance and modifications

Page 111
 Data Collection: Procedures and Documents Category
1. Immediate
Actions • Examine documents used at the time of incident to see if they
2. Investigation
Planning contributed to the incident:
3. Data

– Safe Operating Procedures – was there one, was the correct one being
Collection

4. Data
Organisation

5. ICAM
used, was it known?
Analysis

6. Preventive &
Corrective
Actions
– JSA / THA / JHA etc.
7. Report the
findings
– Training and medical records
– Material Safety Data Sheets (MSDS)
– Permit to Work
– Equipment manuals and procedures
– Incident reports, audit reports and inspection reports

Page 112
 Data Collection: Organisation Category
1. Immediate
Actions • Management’s responsibility to provide a safe workplace must
2. Investigation
Planning be considered during an investigation and lead to questions such
3. Data
Collection
as:
4. Data
Organisation

5. ICAM
Analysis
– How are safety rules communicated?
6. Preventive &

– Are procedures written and how are they enforced?

Corrective
Actions

7. Report the
findings

– Adequacy of supervision in place?

– What training was given and how?
– How previously identified hazards were corrected?
– Have similar incidents occurred in the past?

Page 113
 Example 1: PEEPO
Data Category Collection Method

Interview Interview Interview Positions of

P People leading hand people?
contractor mechanical
coordinator

E Environment
Inspect the area Time pressure? Time of Difficult area to Normal job role
day/roster/shifts work? or practice

E Equipment
Equipment Isolation
choice? device Warning
signs?
P Procedures
Training Work Isolation
Records Procedure? Risk
Assessment Procedure

O Organisation

How is How is the

FRCP how it is How is task
training procedure implemented
conducted enforced allocated

Page 115
 Investigations can be messy… Example of PEEPO

Assign responsibilities to
PEEPO. Decide who
needs to collect what?

Page 116
 Activity 1: PEEPO
Data Category Collection Method
Interview TA Interview Training,
P People Position of Statement from
– Lower and supervisor workers witness (3rd Quals,
Upper person) Experience

E Environment Similar Inspect both How high was Condition of area

Incidents levels the worker eg dark, messy

E Equipment
Inspect Check protection Available
Helmet used equipment

P Procedures
Review Risk SIMOPS Procedures
Review JSA /
Assessment THA for the task procedure available and
used?
O Organisation
How is What supervision
training is provided HSEC
provided on Communic-ation
SIMOPS

Page 118