Causes of Workplace Disasters
10 ‘Pattern’ Causes of Workplace Disasters
Renowned OHS academic Professor Michael Quinlan has identified 10 “pattern causes” that repeatedly recur in workplace disasters – and worker behaviour isn’t one of them.
The evidence doesn’t support the notion that worker behaviour or unsafe acts are a “predominant or pattern cause” of mining disasters, oil-rig explosions, factory fires, airplane crashes and other fatal work incidents, Quinlan says in his new book, Ten Pathways to Death and Disaster: Learning from Fatal Incidents in Mines and Other High Hazard Workplaces.
Prior to the New Zealand Pike River Coal Mine methane explosions that killed 29 men in 2010, for example, workers regularly bypassed methane trip-meters on machinery to continue production, but their actions need to be understood in a context where management failed to control methane levels or tackle “unsafe” behaviour, he says.
The machinery was tripping continuously because methane levels weren’t being managed, and workers were aware that the mine was under financial pressure that could threaten their livelihoods.
Further, miners had been offered significant cash bonuses for meeting certain production targets.
“Providing production bonuses in high-risk activities is in my view incompatible with the maintenance of the highest level of safety, but the mining industry is strongly wedded to such schemes,” Quinlan says.
Focusing on unsafe practices, he adds, can detract from other and more critical safety deficiencies at mines, such as “mining methods, the design of the ventilation system [and] the failure to provide a second egress from the mine, to name but a few of those identified by the Pike River Royal Commission”.
Flaws and failures
According to Quinlan, whose book focuses on mine disasters and other fatal incidents in Australia, Britain, Canada, New Zealand and the US since 1992, the vast majority of incidents involved at least three of the 10 pattern causes, or “pattern flaws”, while many entailed five or more.
The pattern causes identified by Quinlan are:
- Engineering, design and maintenance flaws – “Far from the world of unsafe behaviour and culture that mesmerises some safety researchers and practitioners, this book found design, engineering and maintenance flaws to be a significant pattern cause of fatal incidents at work,” he says.”[The] hazards associated with particular engineering and design options need to be carefully considered during the construction or major reorganisation of workplaces as retrofitting improvements is expensive and needs to overcome inertia. Having said this, change is possible.”
- Failure to heed warning signs – “What should concern those designing and implementing OHS management systems, and regulators too, is the apparent inability to learn from past errors… where a combination of communication problems, deficiencies in auditing systems, and a preoccupation with personal safety and routine risks, have contributed to the failure of OHS management systems.”One implication is that these [failed] systems were neither designed nor implemented in a way that gave sufficient attention to warning signals of low-frequency high-impact events.”
- Flaws in risk assessment – “[The] capacity of workers (suitably trained and empowered) to risk assess their immediate work environment is important but not a substitute for a safe system of work or thorough risk assessment at organisational level.”Flaws in the latter rather than misjudgments by workers were the underlying causes of disasters.”
- Flaws in OHS management systems – Comprehensive OHS management systems can effectively control hazards, but the characteristics of some systems contribute to fatal incidents, Quinlan says.Systems that focus on behavioural safety, LTIs and poorly selected KPIs, for example, can lead to companies becoming complacent about the management of major hazards.
- Flaws in system auditing – A study of the 1994 Queensland Moura mining disaster, which killed 11 workers, found the mine’s communication system had been audited according to the relevant Standard, but the process focused on ensuring the procedures were being adhered to, rather than “judging the effectiveness of the system or whether all critical areas of management were familiar with it (they were not)”.”This is not an uncommon flaw in quality auditing regimes, especially where auditors have insufficient knowledge of the industry or hazards.”
- Economic and reward pressures compromising safety – “There is long-standing research pointing to a connection between production and financial pressures and poor safety outcomes in mining and other industries,” Quinlan says.
- Failures in regulatory oversight – Examples of regulatory failure include “omissions or inadequacies” in safety legislation, logistical constraints (that affect the availability of suitably qualified inspectors, for example), and increasingly complex work arrangements (including the use of contractors) that place additional demands on inspectorate resources.”An inadequate level of inspectorate resourcing contributed to the fatal mine incidents in Tasmania and the Pike River disaster.”
- Worker or supervisor concerns that were ignored – Serious safety concerns raised by workers, their supervisors and consultants are often ignored because of “the hierarchical nature of work relations and the consequent downgrading of subordinates’ views or expertise to make judgements; the top-down nature of safety systems and inadequate feedback loops; overriding priorities like production deadlines; and unwillingness to accept unwelcome news”.
- Poor worker or management communication and trust – Factors that create a “climate of mistrust and poor safety communication” include workforce divisions, mixed messages from management, high turnover among senior managers, insular management style and aggressive anti-union tactics that undermine “participatory structures so essential for safety”, Quinlan says.At the Beaconsfield mine in Tasmania, where a rock fall killed one worker and trapped two for 14 days in 2006, a “periodic workforce survey administered by a behavioural safety consultant was preferred to a joint management-worker safety committee as a means of gauging worker views”.
- Deficiencies in emergency and rescue procedures – These deficiencies “were commonly found to be latent failures that only became apparent once a critical incident had occurred and then exacerbated its consequences”.”Some involved the failure to implement hard-learned lessons like the absence of an effective second egress from the Pike River mine. The need for a second egress had been recognised since a United Kingdom mine disaster in the 1860s.”
Professor Quinlan teaches OHS and risk management at the University of NSW’s school of management. He has audited the Tasmanian mines inspectorate and prepared reports for government inquiries into the Beaconsfield and Pike River disasters and safety in the long haul trucking industry.