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Ten Pathways to Death and Disaster - Learning from Fatal Incidents in Mines and Other High Hazard Workplaces

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Ten Pathways to Death and Disaster - Learning from Fatal Incidents in Mines and Other High Hazard Workplaces

Michael Quinlan

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Why do mine disasters continue to occur in wealthy countries when major mine hazards have been known for over 200 years and subject to regulation for well over a century? What lessons can be drawn from these disasters and are mine operators, regulators and others drawing the correct conclusions from such events? Why is mining significantly safer in some countries than in others? Are the underlying causes of disasters substantially different from those that result in one or two fatalities? This book seeks to answer these questions by systematically analysing mine disasters and fatal incidents in five countries (Australia, Britain, Canada, New Zealand and the USA) since 1992. It finds that there are 10 pattern causes which repeatedly recur in these incidents, namely:

engineering, design and maintenance flaws, failure to heed warning signs, flaws in risk assessment, flaws in management systems, flaws in system auditing, economic/reward pressures compromising safety, failures in regulatory oversight, worker/supervisor concerns that were ignored, poor worker/management communication and trust, and flaws in emergency and rescue procedures.

The vast majority of incidents entailed at least three of these pattern causes and many exhibited five or more. The book also demonstrates these pattern deficiencies are not confined to mining but can be identified in other workplace disasters including aircraft crashes, oil-rig explosions, refinery and factory fires, and shipping disasters. At the same time, the examination finds no evidence to support other popular explanations of mine safety which focus on behaviour, culture or complex technologies. It finds that there is little to differentiate the failures that lead to single death or multiple deaths and `disaster’ studies would benefit from also examining near misses. The book examines why pattern causes have proved so resistant to intervention by governments while also identifying instances where lessons have been learned. How, for example, do governments strike a balance between prescriptive regulation and risk management/system-based approaches? Only by understanding and modifying the political economy of safety can these problems be addressed. It concludes by proposing an agenda for change that will address pattern causes and contribute to safe and productive work environments. The book is written for those studying OHS, mine safety and risk management as well as those involved in the management or regulation of high hazard workplaces. In the news…

Ten steps from disaster, The International Trade Union Confederation – Health & Safety News, 20 April 2015 Read full article… Disasters in high hazard workplaces are `predictable and preventable’, Hazards Magazine, March 2015 Read full article… Mine Accidents and Disaster Database, Mine Safety Institute Australia, March 2015 Read full article… OHS Reps – Research News, SafetyNetJournal, 12 February 2015 Read full article… The 10 “pattern” causes of workplace disasters, OHSAlert, 11 February 2015 Read full article… New book challenges current OHS trends, SafetyAtWorkBlog, 2 February 2015 Read full article… Tasmania needs more mines inspectors, Australian Mining Magazine, 2 October 2014 Read full article… Australian mine deaths preventable if warnings heeded, WorkSafe seminar hears, ABC News, 2 October 2014 Read full article… Lessons from Tasmania’s mining industry for all workplaces,, 1 October 2014 Read full article… Auditor Says Tasmanian Mine Safety in need of Urgent Review, Australasian Mining Review, 16 July, 2014 Read full article… Damning report on Tasmanian mine safety finds inspectors over-stretched, poorly paid, ABC News, 15 July 2014 Read full article… Call for support for grieving families backed, The Examiner, 22 April 2014 Read full article…

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