An enduring legacy of the Pike River disaster has been a significantly increased focus for boards and senior managers on improving risk management, particularly when it comes to their people at the front line.  


Our client, Transpower, is committed to reducing human error incidents.  Their challenge was build real engagement with workers around safety management and to unpick the ‘why’ rather than just the ‘how’ when incidents happen so the right corrective actions could be put in place.

Igniter was engaged to develop a model for human error incident investigation and supporting tools to improve risk assessment at the front line.

Igniter’s Approach

Igniter’s approach recognised that a series of conditions is generally required in order to produce an event, rather than just a single root cause.

Working with Transpower and its Service Providers, Igniter developed an integrated toolset for incident investigation that looks at the characteristics of the task, who is being asked to complete it, as well as the environment they are working in.  Transpower needed to have visibility around all these factors in order to understand, manage and thereby reduce the risk of incidents caused by human error.   

The toolset is based on a process of continuous improvement where lessons are learned and corrective actions put in place.  The toolset gives Transpower’s management team visibility of risks in the field, and the weak points in the organisation that allow errors to ‘slip through’.

Igniter’s toolset includes the ‘Bomb Workshop’ which aims to improve risk awareness and teamwork, and the Risk Meter, a simple, interactive tool which enables risk to be assessed by planners and technicians during the planning process and prior to starting a job.

Outcomes for our client

As a result of Igniter’s work, Transpower has:

  • seen a reduction in human error incidents
  • gained a greater focus on risk assessment
  • achieved a high degree of visibility, throughout the organisation, on the root causes of human error incidents, and
  • developed corrective actions accordingly.

This has supported a cycle of continuous improvement around safety management within the work place and has seen the Risk Meter adopted by a growing number of companies within the New Zealand energy sector