Learning from Our Mistakes to Ensure We Don’t Make Them Again

Safety Case Study

After the catastrophic accident on April 7, 2018, at our Ahafo Mill Expansion (AME) project in Ghana that took the lives of six colleagues, we recognized the need to have open and honest conversations with personnel across the globe on why the accident happened.

Following an in-depth investigation into the root causes, sites and office locations across our business held sessions on the accident’s critical learnings. More than 9,500 employees and contractors participated in the sessions, which encouraged everyone to speak up, ask questions and provide feedback.

A site on our global intranet provided a centralized location for information about the accident and materials to help facilitate safety discussions and focus on lessons learned and preventive actions to avoid future occurrences. The site includes a video from Alwyn Pretorius, our Regional Vice President for Africa, who discusses the causes and the following three critical lessons learned:
Learning 1 – Always identify, establish and enforce barricades and exclusion zones where there is a risk of personnel being struck by falling objects.

  • The area beneath the formwork (a temporary mold where concrete is poured) was not defined as an exclusion zone during the concrete pour and personnel entered the area to conduct work, exposing them to the risk of being struck by falling objects.
  • Recommendations from personnel include a more consistent application or understanding of the requirements for barricading and exclusion zones.

Learning 2 – Where we rely on temporary structures in high-risk work activities, these must be designed and verified as effective at all stages of the work.

  • The function and criticality of the formwork in this high-risk activity were not broadly appreciated or factored into the design and monitoring of the formwork and controls.
  • The need to better understand the requirements for certification and inspection of temporary structures was a frequent comment from personnel.

Learning 3 – When a task does not go as expected or changes occur, take time to establish what has changed and why. Assess the risk and seek additional expertise, applying controls if needed, before recommencing the work.

  • The formwork began to leak concrete and personnel entered the structure to conduct repairs. The pouring of concrete continued during the repairs, possibly contributing to the eventual failure of the formwork structure.
  • A key theme was a need to speak up and better recognize when a situation changes, resulting in unfamiliar or unsafe work.

Among the outcomes from the critical learnings sessions:

  • Each site identified priority actions and developed plans to address the actions and their effectiveness;
  • We began to develop global standards for barricading and exclusion zones to support regional standard operating procedures; and
  • We identified additional critical controls associated with our top fatality risks that must be in place every time a task involving the risk is undertaken.

Based on positive feedback from participants, we formalized our lessons-learned process and will apply it to the fatal accident in November at our Pete Bajo operation in Nevada.

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