TEN PATHWAYS TO DEATH AND DISASTER – LEARNING …

1 BOOK REVIEWTEN PATHWAYS TO DEATH AND DISASTER LEARNING FROM FATALINCIDENTSIN mines AND OTHER HIGH HAZARD WORKPLACESTen PATHWAYS to DEATH and DISASTER LEARNING from Fatal Incidents in mines and Other HighHazard Workplacesby Michael Quinlan (The Federation Press, 2014) ISBN: 9781862879775,pages is a surprising book. I was expecting a dry as dust academic treatise full offacts and figures, charts and graphs, and impenetrable jargon. Instead what I gotwas a revolutionary critical analysis that took me back to the heady days of the1980s and my political economy studies at Sydney University led by suchluminaries as Frank Stilwell and the late, great Ted Wheelwright. I had to go tothe attic to get my copy ofDas Kapitaland my Che Guevara t-shirt to really getinto the am still a little shocked. Reading this book was a little bit like opening theowner s manual on my Holden Commodore and being instructed to fix that rattlein the dashboard by blowing up the vehicle and going back to the drawing the face of it, Professor Quinlan, as a renowned occupational health andsafety (OHS) academic, expert and author, has identified 10 pattern causes he sees as recurring inmining and other workplace disasters across the Anglosphere of Australia, the United Kingdom,Canada, the United States (US) and New Zealand (a variation, perhaps, of the Anglo-Saxon economicmodel, the critical analysis of which is beloved of European, particularly French economists), whencompared to the welfare capitalist economic model of northern and continental Quinlan identifies the pattern causes as:1.

2 Engineering, design and maintenance flaws;2. failure to heed warning signs;3. flaws in risk assessment;4. flaws in management systems;5. flaws in system auditing;6. economic reward pressures compromising safety;7. failures in regulatory oversight;8. worker or supervisor concerns that were ignored;9. poor worker or management communication and trust; and10. flaws in emergency and rescue , Professor Quinlan finds no evidence to support worker behaviour as a cause for Quinlan is very well placed to comment on these matters. Among other things, he wasengaged by the New Zealand Department of Labour to prepare background reports on mine safety inthe wake of the Pike River Coal Mine Explosion in New Zealand in 2010 that tragically killed29 miners. Closer to home, Professor Quinlan was appointed to the independent investigation into thefatal rock fall and entrapment of two miners at the Beaconsfield Gold Mine in Tasmania and in 2010he was engaged by Work Standards Tasmania to audit the Tasmanian mines , eg, Chabal E, The Rise of the Anglo Saxon: French Perceptions of the Anglo-American World in the Long TwentiethCentury (2013) 31 French Politics, Culture and Society24.

3 (2015) 6 WR 7575 2015 Thomson Reuters (Professional) Australia Limitedfor further information visit or send an email to note that this article is being provided for research purposes and is not to be reproduced in any way. If you refer to the article, please ensure you acknowl-edge both the publication and publisher appropriately. The citation for the journal is available in the footline of each you wish to reproduce this article, either in part or in its entirety, in any medium, please ensure you seek permission from our permissions officer. Please email any queries to book is organised broadly as follows:1. Chapter 1 a critical review of the research on DEATH and DISASTER at work and setting out theapproach and method used in the Chapter 2 setting the context by examining the regulatory frameworks in the mining industrythe five countries examined from 1970 to 2011. The author looks at the regulatory context in thefive countries identifying broad trends as well as differences and explaining why only a limitednumber of countries have been Chapter 3 patterns of DISASTER and DEATH through an examination of fatal mine incidents in thefive countries involving a review of incidents and identifying pattern Chapter 4 do the patterns apply to fatal incidents in other workplaces?

4 Professor Quinlanextends his analysis to see if similar patterns can be identified in industries other than mining andconcludes that sufficient evidence exists to suggest that the parallels warrant Chapter 5 LEARNING from failure: some practical implications. The author argues that awarenessof pattern failures can help managers, insurers, unions, regulators, workers, and communitygroups, as well as others, better prevent fatal workplace events and possible remedies areidentified that have limited Chapter 6 LEARNING from failure. Broader policy implications as well as regulatory lessons aredrawn from the pattern causes and an examination of why regulatory interventions have failed orcorroded and possible Quinlan favours words such as failure and flaw to describe acts or omissionsleading to DEATH and DISASTER in mines . He dislikes accident and error which suggest mistakes. InProfessor Quinlan s view, failures and flaws leading to mining disasters are more often the result of conscious decision-making (but not by workers) and structured in the sense that they are the resultof priorities, hierarchies, domains of authority, and even Quinlan has another reason for disliking words like error in this context.

5 It suggestshe says, that the remedy is some form of behaviour modification which is popular because it doesnot question the more critical issues about how work is organised (and the interests and powerunderpinning this) and how this contributes to probabilistic forms of events .3 Professor Quinlan is also critical of concepts like safety culture and safety climate where thefocus mistakenly:is entirely intra-organisational and disembodied from .. power, authority, interest and decision-makingboth in the organisation and wider Professor Quinlan, safety system failures are more likely due to structural problems like:1. a failure to consider all relevant factors for a particular hazard;2. the hierarchical nature of the safety system; and3. a failure to heed workers Quinlan argues that:The poor safety practices in some of the mines and workplaces examined in this book were not theoutcome of a culture within that workplace as much as the outcome of poor supervision, risk-takingthat was condoned or even encouraged by management and other influences such as productionpressures and M,Ten PATHWAYS to DEATH and DISASTER LEARNING from Fatal Incidents in mines and Other High HazardWorkplaces(The Federation Press, 2014) p , n 2, p , n 2, p , n 2, p , n 2, p REVIEW(2015) 6 WR 7576 Surely, poor supervision , inappropriate risk-taking and leadership that allows productionpressures and incentives to take priority over safety could be described as examples of anunacceptable workplace culture ?

6 While, as a former political economy student, I have some sympathy for the view that there arestructural reasons implicit, as Professor Quinlan argues, in workplace safety compromises, to deny, orat least downplay, the impact of worker behaviour on risks to workplace health and safety seems tosuggest, on one view, that individuals are mere automatons, devoid of the capacity to exercisejudgment or discretion. Surely worker behaviour may be a relevant factor if, for example, anindividual fails to follow or deliberately flaunts safety systems or procedures?Professor Quinlan suggests that his pattern flaws should form a priority check list for anyorganisation wishing to assess workplace health safety management with a view to preventing seriousevents in the future. Some of Professor Quinlan s observations on this topic Engineering design and maintenance flaws:far from the world of unsafe behaviour and culture that mesmerises some safety researchers andpractitioners, this book found design, engineering and maintenance flaws to be a significant patternof cause of fatal incidents at Failure to heed warning signs a key question for Professor Quinlan is why did management notrespond to warning signals?

7 He says:What should concern those designing and implementing OHS management systems, and regulatorstoo, is the apparent inability to learn from past errors .. where a combination of communicationproblems, deficiencies in auditing systems, and a preoccupation with personal safety and routinerisks, have contributed significantly to the failure of OHS management systems in mines and otherhigh hazard workplaces. One implication is that these systems were neither designed norimplemented in a way that gave sufficient attention to warning signals of low-frequency,high-impact Flaws in risk assessment Professor Quinlan says risk assessment, while a critical task, is nosubstitute for implementing controls when the nature of the hazard and suitable remedies arealready well known. A risk assessment should be used where there are uncertainties. Essentialfeatures of effective risk assessment include:(a) use of a team with varied and relevant experience to conduct the risk assessment;(b) detailed and systematic risk identification;(c) use of a comprehensive checklist of possible problems;(d) defining the key questions to be answered before conducting a risk assessment;(e) defining the safety standard to be reached; and(f) comprehensive monitoring and auditing Flaws in OHS management systems Professor Quinlan says that the recent shift to OHSmanagement systems has the potential to establish a more comprehensive and effective approachto controlling hazards but that some systems actually contribute to fatal incidents, for example:(a) management systems that focus on personal or behavioural safety and routine risks (forexample, measured by injury incidents and frequency rates) are not compatible with a processsafety approach which is more suited to addressing low-frequency high-impact events.

8 (b) the top-down nature of some management systems involves the absence of critical feedbackloops; and(c) complex forms of work organisation like multi-tiered subcontracting, downsizing and therelocation of key staff undermine more effective management safety Flaws in system auditing Professor Quinlan identifies deficiencies in the nature of audits andwho undertakes them as possible contributing factors to disasters. For example, a study of the1994 Moura mine DISASTER that killed 11 workers, found that while the mine s communicationsystem was audited to Quality Assurance Standard AS3902, the focus was on identifying7 Quinlan, n 2, p , n 2, p REVIEW(2015) 6 WR 7577procedures and ensuring that they were being adhered to rather than judging the effectiveness ofthe system or whether or critical areas of managements were familiar with it (they were not).Similarly, the Beaconsfield mine fatality in Tasmania in 2006, involved an insurance audit of themine which lacked the expertise to critically assess the adequacy of management s assessmentand response to serious rock fall incidents that had occurred six months before the fatal rock to Professor Quinlan, effective system auditing needs to:(a) be genuinely independent and those conducting it to be suitably qualified with a reputationand record for rigour;(b) be undertaken with regard to the entire safety system not just parts of it;(c) examine paperwork and work processes at different phases, for example, operation andmaintenance; and(d) explicitly address the 10 pattern failures.

9 6. Economic and reward pressures compromising safety Profession Quinlan says:There is long-standing research pointing to a connection between production and financialpressures and poor safety outcomes in mining and other is this to be remedied? According to Professor Quinlan:(a) organisations need to adopt corporate structures and decision-making processes that givemeaning to prioritising safety;(b) production and profit-based reward systems should not be used in mines and other highhazard workplaces;(c) regulators need to pay closer attention to the issue;(d) compromising safety for economic reasons needs to receive closer attention in investigations,for example, the Pike River Royal Commission in New Zealand; and(e) unions should pay more attention to the issue including opposing incentive-based Failures in regulatory oversight examples of this type of failure according to Professor Quinlaninclude:(a) omission or inadequacies in legislation regulating mine or workplace safety;(b) logistical restraints on the inspectorate in terms of the number and availability of suitablyqualified and trained inspectors, infrastructure support and inspection tracking systems.

10 (c) deficiencies in inspectorate approach to inspection and enforcement; and(d) increasingly complex patterns of work organisation, including the use of contractors, canweaken the regulatory framework and place additional demands on inspectorate resourcesand require a rethink of enforcement Worker or supervisor concerns that were ignored examples given by Professor Quinlan includePike River in New Zealand and Beaconsfield in Tasmania. The reasons given by Profes-sor Quinlan are:(a) the hierarchical nature of work relations and the downgrading of subordinates views orexpertise;(b) the top-down nature of safety stems and inadequate feedback loops;(c) overriding priorities like production deadlines;(d) an unwillingness to accept unwelcome news; and(e) workers concerns before an incident are largely ignored in many official investigationsafterwards and do not become a contributory factor in the discussion of , n 2, p , n 2, pp REVIEW(2015) 6 WR 75789.