INCIDENT AND ACCIDENT INVESTIGATION

Understanding What Went Wrong and Why

When an incident or high-potential event occurs, the quality of the investigation determines whether the operation learns from it or repeats it. Mineshield provides structured investigation support that goes beyond immediate causes to identify the system and control failures that allowed the event to occur.

The Investigation Challenge

Most investigations find the immediate cause, but few find the real one.

When something goes wrong on site, the pressure to identify a cause and close quickly is real. The result is a finding that names what a person did, or failed to do, in the moments before the event. What it does not name is the chain of decisions, conditions and system failures that put that person in that position.

Where findings stop

Findings that identify human error without examining the conditions that created it are accurate but incomplete. They describe the last link in the chain, not the chain itself. Corrective actions built on incomplete findings do not prevent recurrence.

The independence problem

An investigation conducted inside the organisation cannot always follow the evidence where it leads. When findings point at decisions made by people still in the building, the pressure to stop short is real.

The risk calculation

Findings that stop short do not reduce exposure. A shallow report followed by a recurrence is harder to defend before a regulator than findings that went where the evidence led.

Not confident the findings will hold up?

Independent review before submission

Mineshield can review a completed investigation report before submission, assessing whether the methodology was sound, whether findings identify causal factors or just immediate causes, and whether corrective actions are tied to those causes or are surface responses. Engaged before submission, it gives the SSE confidence the report is defensible. Engaged after a recurrence, it identifies what the original investigation missed.

What Mineshield Investigates

Mineshield provides investigation support across the full range of operational events, from high-potential incidents to system-level failures.

High-Potential Events

Investigation of incidents and near misses with the potential for serious injury or fatality, with a focus on critical control performance and causal analysis.

Operational Incidents

Structured investigation support for incidents involving injury, equipment damage, environmental impact or operational disruption.

Control Failure Analysis

Examination of why critical controls failed or were absent, including assessment of control design, implementation and verification practices.

Corrective Action Review

Assessment of existing corrective actions from previous investigations to determine whether they address identified causes and have been implemented effectively.

System-Level Failure Review

Broader review of operational systems where a pattern of incidents suggests an underlying systemic issue rather than isolated events.

Review of Completed Investigation

Independent review of a completed investigation report before submission, assessing methodology, findings and corrective actions. Identifies gaps before they reach a regulator.

The earlier the engagement, the better the findings.

Mineshield can be engaged at first notification, during an active investigation that needs support, or to review completed findings before submission. Where a previous investigation is suspected to have stopped short, a review can be commissioned independently of any new event. Scope is agreed at first contact to match what the operation needs.