ICAM Investigation Example.pdf

Or organisation there was ineffective work planning

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OR - Organisation: There was ineffective work planning, co-ordination and lines of communication for the task due to unclear responsibilities and ineffective attention paid to active supervision. TR - Training: There was no verification of competency for the maintenance personnel to ascertain their knowledge and understanding of the task on the specific aircraft. RM - Risk Management: There was no risk assessment conducted prior to the allocation of new work; being an unplanned task to discharge and remove the cylinder, resulting in ineffective risk management. 4 Safety Wise Solutions Pocket Investigation Guide s05 - Organisational optimising violation - commercial or production goals override safety goals.
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19 Prepared for the sole purpose for advancing safety. Confidential and subject to limited distribution. DE - Design: The cylinder warning placard information and position was ineffective in providing adequate instructions and warning of the hazard. MC - Management of Change: There was an ineffective process applied by the maintenance personnel to manage the change in the scope of work for removal of the cylinder. OC - Organisational Culture: There was m anagement tolerance to ‘get the job done’ without procedural compliance and/or utilising a robust risk management process prior to carrying out the work. 5.0 Recommendations The following recommended corrective actions are proposed for consideration. The recommendations address the Absent or Failed Defences and Organisational Factors identified as key findings of the investigation. These recommendations are applicable to Business Group or site and could benefit other Company group operations. 5.1 Communication via Safety Alert (Administration) Issue and communicate a Safety Alert (or other suitable communication method) to all personnel, including labour hire personnel, explaining what occurred, the basic cause, and the actions that have been taken, as well as those that are to be taken. Emphasise the importance of (i) conducting risk assessments (ii) understanding the risks around uncontrolled release of gas and applying the appropriate documented control measures; (iii) having good operational discipline to follow documented process (iv) knowing your responsibilities (e.g. supervision and accountability to follow process); (v) situational awareness and interaction with other work groups; and (vi) a good monitoring and review program across all activities to maintain the integrity of the safe system of work. 5.2 Risk Management and Training (Administration) Introduce a training program to address deficiencies in the application of the Take 5 and JSEA risk assessments including identification of hazards and associated risks, risk mitigation and application.
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