Major Utilities Company Discovers an Opportunity for Improved Serious Incident Focus

Oct 4, 2023

Client Snapshot

Sentis was engaged in 2019 by Unitywater, a major water utility company in Queensland that had recently undergone significant structural changes. Unitywater provides round-the-clock service across the Moreton Bay, Noosa, and the Sunshine Coast regions. Whether they’re providing water and sewerage services or responding to emergencies, Unitywater’s purpose remains the same: to keep communities healthy and safe.


To strengthen Unitywater’s approach to the management of high-risk activities through an in-depth review of all incidents that had serious injury or fatality potential (SIFp) (also known as hi-potential near misses).


To understand the causes of these SIF potential events and improve the management of Unitywater’s high-risk activities and safety culture, Sentis reviewed all incidents and hazards reported that occurred over a two-year period.

Applying a holistic safety lens, our experts analysed over 650+ incidents and near misses as well as over 1000 hazards using our Meta Incident Analysis® (MIA) methodology.

The determination of whether an incident can be classified as a SIF potential incident requires a calibrated decision tree and a thorough understanding of the risk context in which the work is undertaken.

As part of this analysis the enablement of critical controls for each incident was also explored. Controls are important for the prevention of incidents and are an act, object or system intended to prevent or mitigate an unwanted event.

As a result of this analytical process, several results, learnings and recommendations were provided to Unitywater as outlined below.


Categorisation of incidents

Risk matrix approach to internal rating of severity potential underplays the real risk, which means many incidents fly under the radar.

On the flip side, several incidents may have been over-emphasised or attracted unwanted attention and/or investigation depth.

The analysis also uncovered some interesting yearly trends.

  • 1.0% reduction in work hours year on year.
  • 7.5% reduction in recordable incidents (‘vehicle
    incident’ and ‘injury’ event categories) year on year.
  • 7.0% increase in near misses reported year on year
    (note 32% of SIFp incidents were categorised as ‘near miss’).
  • 34.2% reduction in SIFp Incident Exposure year
    on year, demonstrating ROI on safety initiatives.

Unintended operator errors accounted for 55% on average across all SIFp incidents (slips, lapses or mistakes, rather than intentional workarounds).

30% of human error factors attributed to worker being in “auto-pilot” (The task was performed from habit without conscious thought).

32% of incidents contributed to by operational non-responsiveness to known past exposures.

Quality of risk assessments contributed to 28% of incidents.

Plant & equipment design (safety in design) and maintenance vigilance were key factors in 22% of incidents.

System improvements

Refine reporting and incident classification, including a new high-potential category.

Enable the frontline

Improve understanding of critical controls and engagement of crews in high-risk work.

Leadership capability and involvement

Strengthen capacity, capability and role clarity for operational leadership roles.


Introduce leading indicators for improving and assuring critical control management.

Informed by these findings, Unitywater has initiated a long-term and shorter-term approach to their safety strategy. In the immediate future, they’ve expeditated their focus on strengthening critical controls in the most prevalent high-risk activities. This also involves strengthening safety leadership.

Unitywater has improved their safety culture maturity to Public Compliance from Counterproductive, reengaging stakeholders and transforming their culture from unhelpful to constructive. We’re looking forward to continuing our positive partnership and helping strengthen their safety processes and mindsets into the future.

Ready to learn more about the Sentis approach and how we can help you better manage high-risk activities? View our critical control assurance solutions here.

Sign up to our newsletter

"*" indicates required fields

By clicking submit and supplying my contact details, I agree for Sentis to contact me, including via email, to keep me informed about Sentis products and services. I understand that I can opt-out at any time. For more information, please see our Privacy Policy.

This field is for validation purposes and should be left unchanged.

Related case studies

This website uses cookies to improve your online experience and to provide site functionality. By using this website you agree to the use of cookies as outlined in our privacy policy. Learn More