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       Hazards special online report, March 2015
Disasters in high hazard workplaces are ‘predictable and preventable’
In an era where we scarcely blink when a probe lands on an asteroid, why do major industries continue to kill in the same old ways? Professor Michael Quinlan warns a lack of will and not a lack of know-how is behind the ‘ten pathways to death and disaster’.

In mining, apart from electrocution and incidents with machinery, the ways miners are killed - fires and explosion, falls of ground, falls from height, inrush/inundations and asphyxiation - have been known for hundreds of years. They have also been the subject of regulation in the UK and other rich countries for more than 150 years.
With a litany of death and disasters to learn from, why are incidents like the fatal explosions at the Upper Big Branch mine in the US and Pike River mine in New Zealand, which both killed 29 coal miners in 2010, still occurring?

Even in workplaces with shorter histories, like oil rigs, repeat disasters still occur. These repeat incidents often arose from strikingly similar causes, or ‘pattern failures’. Failures or flaws are not error or deficiencies in safety ‘culture’ - a popular but ambiguous concept.

Failures or flaws arise from conscious decisions by those in charge of workplaces, by governments or those responsible for enforcing safety legislation.


Deadly patterns

In my book, Ten pathways to death and disaster, I reviewed the official investigations into 23 fatal mine incidents in five countries - Australia, Britain, Canada, New Zealand and the United States - between 1992 and 2011. The examination revealed 10 recurring pattern causes.

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

Almost every incident had at least three of these pattern causes. Well over half had five or more. Several, like Pike River, had all 10. This applied to both single fatality incidents and multiple fatalities.

HIGH PLACES  David Cameron’s government has fostered close links with oil giant BP. On 4 February 2015, former BP global head Lord Browne – hand-picked by the prime minister as lead non-executive director in the Cabinet Office, a post he held until 31 January – said the oil firms “need costs to come right down” and said companies would have to “slim down” to compete. The cost-cutting programme Browne introduced at BP was linked to the deadly 2005 Texas City refinery explosion.

The most common pattern flaws included design, engineering and maintenance failures, failures to heed warning signals, flaws in management systems, worker and other concerns that were ignored, poor emergency procedures, and failures in regulatory oversight.

The book also examined workplace disasters in other high hazard workplaces including airplanes/aviation, major hazard facilities, factories, oil rigs and refineries across a wider timescale, 1980 to 2011, and array of countries. 

Again, the same pattern failures played a recurring and conspicuous role in these incidents, including the fire at BP’s Texas City Refinery that killed 15 workers and the Deepwater Horizon oil rig disaster that killed 11 workers and did monumental environmental damage.


Clear lessons

Almost all these incidents arose from causes that were both predictable and preventable. In most cases there was clear evidence of serious flaws long before the incident that were ignored by management. The flaws were not addressed by regulators due to a lack of resources or effective enforcement measures.

There was often a clear interaction between pattern failures. One recurring connections was that cost-cutting and production pressures often underpinned failures in engineering and maintenance, as occurred at BP’s Texas City refinery in 2005. Other flaws like inadequate rescue and emergency procedures were evident at the Piper Alpha North Sea oil rig fire in 1988 that killed 167 workers and the Pike River coal mine explosion that killed 29 miners in 2010.

RIG CUTS  Jobs cuts across the UK offshore oil industry will compromise safety and lead to the loss of key skills, Unite has warned. The union said “the seeds of another disaster on the scale of Piper Alpha” could result from cutbacks linked to the oil price fall. [more]

Reliance on multi-tiered subcontracting, which encouraged cost cutting and fractured occupational health and safety (OHS) systems, was another recurring failure point. This was highlighted most graphically in the catastrophic fire at the AZF chemical plant in France in 2001, where 28 workers and one student died. Another 30 persons were seriously injured.

Changes to work organisation including downsizing and restructuring can rapidly corrode even initially robust safety regimes. The outsourcing and offshoring of aircraft maintenance in the USA was responsible for at least six serious airline incidents, including three multiple fatality crashes, between 1995 and 2009.


Not listening

The fatal incidents examined in the book also repeatedly pointed to serious flaws in safety management systems. This included a focus on routine risks, like relatively minor injury, behaviour and personal safety rather than process safety. This approach presumed - quite incorrectly - that managing routine risk would also minimise the chance of low frequency/high impact events (sometimes, like at Deepwater Horizon, referred to as ‘black swans’).

HUMAN REMAINS Clay Mullins (left) lost his brother, Rex, in the Upper Big Branch explosion; Gary Quarles lost his son, 33-year-old Gary Wayne Quarles. Reciting what miners believed was the company creed, Quarles said: “‘Production first, safety last, haul the coal or haul your a--’. You were just a number to them. If you were producing, fine. If not, you were just dirt under their feet.”

Systems were typically top down, with limited and ineffective feedback loops to report on problems or failures. Disempowering workers and marginalising unions exacerbated this problem.

The need for management to listen to safety concerns raised by workers, supervisors and others was a serious concern, although relatively few official investigations into incidents explored this issue. Legislation in Norway and Australia that gives worker representatives in high hazard industries, especially mines and oil rigs, the powers to better safeguard workers, remains the exception.

This highlights how disempowered workers are – the lack of respect given to their knowledge and concerns - even in industries where there is a significant risk of death, like dockwork, seafaring, construction, oil rigs and mines, and after a disastrous incident.

Some popular explanations of disaster and death at work didn’t stand up to scrutiny. The incidents didn’t arise from complex technology, unknown hazards, poor safety culture or simple human error.

‘Unsafe’ behaviour was at most the last failure point in a system that was already severely corroded and such behaviour was commonly both condoned and conditioned by management through poor training and supervision, production pressures or pay incentives and bonuses and the use of contractors.


Worker inspectors

My findings provide a clear guide for interventions. Unfortunately, the current political economy of safety makes this unlikely to occur in anything other than a sporadic and partial fashion.

In two countries, Australia and New Zealand, regulatory intervention after serious incidents did address many of the pattern causes of deaths in mining. This included improving enforcement systems and mandated requirements on management systems, including protocols to deal with potentially dangerous incidents, alongside detailed regulation on known hazards. The mines inspectorate was also overhauled to ensure regulations were enforced including regular auditing of safety systems and both the reporting and investigation of high potential incidents.

Another critical element of the new regime was empowering worker representatives in mines to take on most of the functions of government mine inspectors, including roving full-time union safety officers. This system, with origins dating back to the 1870s, provides an additional source of oversight and one clearly dedicated to protecting workers.

Since the introduction of this regime in the two major mining states in Australia in the late 1990s there has been no mine disaster at a time when there has been a substantial expansion of mining activities.

In at least two of the other three countries, Canada and the USA, there was no such learning and indeed the rise of neoliberalism has seen a progressive weakening of OHS by encouraging hazardous forms of work organisation, trying to marginalise unions/collective voice, undermining labour standards (with mantras about the need for flexibility and removing regulatory burdens on business), cutting resourcing to inspectorates and promoting ineffective forms of ‘light touch’ regulation.


Obscene rhetoric

In all five countries there was evidence of a pervasive mantra of the ‘need’ to reduce the regulatory burden on business or ‘red tape’ – an obscenity in the context of work safety laws whose goal is to stop the spilling of blood at work.

MINE  CHARGES  Unions and campaigners have welcomed the November 2014 indictment on criminal safety charges of the former head of a US mining firm with an “unmatched” record of fatalities and safety violations. Donald L Blankenship, former chief executive officer of Massey Energy Company, is charged with conspiracy to violate mandatory federal mine safety and health standards and a string of other offences. [more]

In the USA the effect of almost 30 years of regulatory erosion is evident in the repeated failures of regulatory oversight, like the 2013 ammonium nitrate explosion at the West Fertilizer Company in Texas that killed 15. In Australia, a union-hostile federal government is currently reviewing safety laws in the area of directors’ responsibilities, the powers of safety representatives and right of entry for unions.

The failure of governments to hold boards of directors accountable for their decisions affecting safety and their connivance in the weakening of unions and worker input, has also limited any incentive for learning. Prosecution let alone conviction or gaoling of directors whose decisions (including the failure to consider safety consequences) contributed to deaths is exceptionally rare (and then usually limited to smaller companies).

These facts are eloquent testament to the point that irrespective of the rhetoric, workplace safety doesn’t come first, or even second or third when it comes to the priorities of governments or most corporations.


Global catastrophe

While the book focused on five rich countries with longstanding regulatory regimes and some level (though corroding) of accountability the same pattern causes were identified in incidents in high hazard workplaces in low to middle income countries like Brazil and China.

The same point can be made with regard to the 2014 mine disaster in Soma, Turkey where 301 miners died and there was evidence of inadequate rescue and emergency procedures and poor inadequate regulatory oversight to name but two pattern causes.

While the same pattern causes appear to apply to these countries there are differences, most notably more endemic corruption of the political and regulatory apparatus and weaker accountability to the community, for example the failure to hold or make public official investigations.

The capacity of unions and community groups to raise safety concerns is often seriously compromised by repressive actions of the state. In states like China, this avenue is made almost impossible by the failure of the state to tolerate independent unions or community dissent.

Global supply chains are increasingly facilitating the erosion of safety standards by moving work to countries with minimal safety standards and no protocols for raising standards as part a free trade agenda. The 2013 Rana Plaza building collapse in Bangladesh which killed over 1,100 - mainly garment factory workers, many producing clothing for the West - exemplifies this.

Until these problems are redressed fatal incidents and disasters that are entirely preventable will continue to occur in both rich and poor/middle income countries even if the risk of death remains far higher in the latter.

Well-established knowledge about what causes these incidents and how they can be remedied will continue to be ignored while more fashionable but ineffective measures like promoting safety ‘culture’ and behaviourally based safety hold sway.



Going by the book

Michael Quinlan’s new book provides a devastating critique of failed safety management and regulatory practices in vogue at modern workplaces. In quotes:

It’s all about power
“…knowledge is not created in a social vacuum.”
“The political economy perspective argues that safety, including workplace disasters, can only be understood in the context of the distribution of wealth and power within societies, and dominant social policy paradigms that privilege markets and profit, production or economic growth over safety.”


All the credit, none of the blame
“Directors take credit for the financial success of organisations but very few appear to take a corresponding responsibility for failures that result in the death of those that work for them. That this bizarre situation is accepted as normal is telling about what the rhetoric about safety coming first really means.”


Don’t blame the worker
“…the examination finds no evidence to support other popular explanations of mine safety which focus on behaviour, culture or complex technologies.”
“dealing with routine hazards, especially through behavioural interventions aimed predominantly at workers, does not remedy the potential for a serious event and can detract attention from implementing more effective measures.”
“… the programmes based on these [zero harm or zero accident] goals commonly have a strong behavioural element (though to be fair most also consider system factors to a greater or lesser degree) stressing rules and approved procedures, training, incentives and behaviour modification, and reporting incidents…”


Deliberates not accidents
“‘Failure’ and ‘flaw’ are not interchangeable with the term ‘error’. Failures and flaws may include errors of judgment but to see failures and flaws only in terms of errors would be both too narrow and misleading. Errors suggest mistakes. As this book will show, the failures and flaws leading to mine disasters are more often the result of conscious decision-making and structured in the sense that they are the result of priorities, hierarchies, domains of authority and even ideologies.”

Whose safety culture?
“The problem is, however, not simply a lack of specificity but what the concept has tended to overlook, de-emphasise or disguise. Its general application has been one where factors that structure work – the pressure for profit and production, legislative regulation and the like – are treated at best in a fragmented way or more often ignored. The notion of culture implies shared corporate or organisational values but such a notion of ‘sharing’ is misleading.”


What we don’t know we know
“Belated or ineffective intervention was commonly enormously costly in social, economic and human terms because the problem had been allowed to escalate. The study [EEA’s 2001 Late lessons of early warnings] provided a powerful argument that major risks of this type could be foreseen and remedied at an early stage if the precautionary principle was applied – acting in ways that gave the benefit of doubt to caution once credible evidence for concern was found.”
“It has been through the progress of error that we have had evolutionary maturation. When things are uncertain, sometimes trial and error learning or the precautionary principle are all we have. We take calculated risks but don’t ‘know’ the outcome.”


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


Offshore job losses risk ‘another Piper Alpha’

Jobs cuts across the UK offshore oil industry will compromise safety and lead to the loss of key skills, Unite has warned. The union said “the seeds of another disaster on the scale of Piper Alpha” could result from cutbacks linked to the oil price fall.

The union was speaking out at a 1 February 2015 oil and gas industry summit in Aberdeen, hosted by the city council and attended by leading figures from across the industry and from both the Scottish and Westminster governments.  With oil companies set to reduce spending on investment and exploration by $170 billion - 37 per cent of spend - by 2017, Unite is urging the UK government to step in with support for the sector to help ensure that safety standards are upheld.

Unite regional officer John Taylor said: “The rush by firms to cut jobs and reduce costs is placing enormous pressure on the remaining workforce, and is harming the industry’s reputation. Unless something is done soon to stem the flow of job losses, key skills will be lost. Our worst fear is that these cuts could create the potential for another health and safety disaster on the scale of Piper Alpha.”

He added: “We are seeing already that in the shift to working three weeks on followed by three weeks off in an intensely harsh and demanding environment is taking its toll on workers. The climate of cost-cutting that is descending is not consistent with maximum public and worker safety.”

On 4 February 2015, Lord Browne – who stepped down as a non-executive director in the Cabinet Office on 31 January and whose cost-cutting programme when he headed BP was linked to the deadly Texas City refinery explosion – said the oil firms “need costs to come right down” and said companies would have to “slim down” to compete.

[back to main story]

Relief as US mine deaths boss is indicted

Unions and campaigners have welcomed the indictment on criminal safety charges of the former head of a US mining firm with an “unmatched” record of fatalities and safety violations.

Donald L Blankenship (above), former chief executive officer of Massey Energy Company, is charged by the Justice Department with conspiracy to violate mandatory federal mine safety and health standards, conspiracy to impede federal mine safety officials, making false statements to the United States Securities and Exchange Commission (SEC) and securities fraud.

The four year investigation into Blankenship followed the April 2010 disaster at the Upper Big Branch (UBB) coal mine which killed 29 workers. The miners died in a massive coal dust explosion which could have been averted by following fundamental safety precautions.

Page 1 of the 43-page November 2014 indictment notes that Blankenship habitually broke mine safety regulations “in order to produce more coal, avoid the cost of following safety laws, and make more money.”

A statement from Cecil E Roberts, president of the mineworkers’ union UMWA, noted that the “announcement that a federal grand jury has returned indictments against Don Blankenship means that the families of the 52 people who were killed on company property while he was CEO of Massey Energy are one step closer to a measure of justice.”

It continued: “The carnage that was a recurring nightmare at Massey mines during Blankenship’s tenure at the head of that company was unmatched. No other company had even half as many fatalities during that time. No other company compared with Massey’s record of health and safety violations during that time.”

University of Maryland law professor Rena Steinzor said: “US Attorney Booth Goodwin has set an example for every prosecutor in the country by indicting Don Blankenship, the venal, punitive, flamboyant, and reckless former CEO of Massey Energy. For years, Blankenship demanded updates on coal production every two hours and, the indictment reveals, browbeat senior managers to cut cost and violate crucial safety.”

he added: “The families of the 29 men who died can take some solace that this courageous prosecution, by a prosecutor from coal country, takes the strongest possible stand to protect miners from the most reprehensible kind of greed.”


[back to main story]




Search Hazards

Ten steps
from disaster

In an era where we scarcely blink when a probe lands on an asteroid, why do major industries continue to kill in the same old ways? Professor Michael Quinlan warns a lack of will and not a lack of know-how is behind the ‘ten pathways to death and disaster’.

Deadly patterns
Clear lessons
Not listening
Worker inspectors
Obscene rhetoric
Global catastrophe
Related stories
Offshore job losses risk ‘another Piper Alpha’
Relief as US mine deaths boss is indicted

Michael Quinlan's new book, Ten pathways to death and disaster, provides a devastating critique of failed safety management and regulatory practices in vogue at modern workplaces.

Read some killer quotes

Ten Pathways to death and disaster, Michael Quinlan, The Federation Press, ISBN 9781862879775, December 2014

Michael Quinlan is a professor in the School of Organisation and Management, University of New South Wales, Australia.

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