Key learnings from a High Potential Incident.
HPI OSH Alert #469
Date of incident: 14 September 2015
Safety Flash issued: 16 September 2015
A Water Corporation operator was driving a four-tonne service truck along a gravel road which was in good condition. At approximately 1:30pm the truck left the road and collided with a DN400 steel pipeline. The truck was extensively damaged and there was minor damage to the pipeline.
No injury was sustained but there was potential for serious injury or death.
Why did this happen?
There is no evidence to indicate a conclusive cause of the incident. However, the hypothesis that the driver experienced a micro-nap or fell asleep (due to inadequate fatigue management) and lost control of the vehicle is consistent with the available evidence.
What will the business area involved in the incident do to stop this from happening again?
- The Service Delivery Manager will implement a plan to improve the way the impacted business area reviews and monitors fatigue management.
- The Regional Management team will review workload and adequacy of resources for the impacted business area over the last two years to ensure resourcing levels are sufficient. The team will also implement the recommended actions following the review.
What will our organisation do to stop this from happening again?
- Investigate the practicality, options and business need for a trial of dash mounted fatigue sensors, using the Region where this HPI occurred as the trial area. Recommendations will be presented to Regional Managers upon conclusion of the trial.
- Review the practicality, options and business need for proven individual pre-start fatigue assessment tools, and present recommendations to Regional Managers.
- Investigate with HR the development of a standard report to monitor working hours against S333 Fatigue Management and Working Hours.
- Implement leader led communication across the business to reinforce required control measures for reducing risks associated with our Safety Essential “Road Safety”. Communications will include the requirement for Journey Planning with JSEAs for High Risk Routes, Fatigue Management and Working Hours tracking, and the use of the Lone Worker Monitoring System (LWMS).
What key learnings can you discuss with your team to stop this from happening again?
Driving is acknowledged as a high risk activity for regional areas
- Consider the amount of exposure (likelihood) and the consequence of a driving incident for our team.
- Where do you rate the risk associated with driving compared to our other work tasks?
- What can we do to reduce the risks of driving for our team?
Monitoring fatigue and working hours is important to reduce the risk of injury, particularly when involved in high risk activities e.g. driving for long periods of time and/or distances
Fitness for work culture – If you are feeling fatigued or tired, it is okay to stop work and say so
- Are you aware of the signs of fatigue? What signs of fatigue does your body show?
- What causes our team to become exposed to risks of fatigue?
- What can our team do to better monitor, recognise and avoid fatigue?
- Do you think the culture in our team would encourage a person to stop and rest if feeling tired? Does the team culture need to change?
- What are the consequences of continuing when fatigued verses stopping when fatigued? What are the options to still achieve the desired outcomes if you stop and rest?
- At what point will you decide to stop if you are fatigued?
If you would like further information about anything included in this HPI OSH Alert, please contact Senior OSH Analyst Incidents Charis Neumann on (08) 6330 6629.