Recent fatalities on Queensland Mines, a burning platform, or more of the same?

Recent tragic losses of life on mines and quarries in Queensland (QLD), have devastated families, friends, co-workers. The following 6 fatal incidents have occurred in under twelve months, all in the same area of QLD, two of them, occurring within just two weeks of each other:

1. 7/7/19 - Operator caught between EXC body & descending access stairs, Baralaba Mine.
2. 26/6/19 - Mine wall collapsed on an excavator, Middlemount Mine.
3. 20/2/19 - Grader collided with personnel carrier, Moranbah North Mine.
4. 31/12/18 - Dozer went over the crest of a bench and rolled 20m, Saraji Mine.
5. 15/11/18 - Worker entangled in rotating tail drum of a conveyor belt, Fairfield Quarry.
6. 29/7/18 - Artic dump truck lost control down a ramp and rolled, Quarry, Collinsville.

Is this a new or emerging crisis?

Shortly after the 6th incident in QLD, urgent “crisis talks” were held amongst industry stakeholders. But is there a new or emerging crisis? Is there some change or phenomenon occurring we don’t know about? Put simply, no there is not. In fact, 6 mine workers were killed on QLD mines in the 11 months to March 2015. Australian mining had 15 fatalities in 2006 and then 17 fatalities in 2013-14. In 2014, the media called that a “safety crisis in mining”. Regulators in several states, demanded action from industry and the regulator in the state of New South Wales promised that they would “seek a deeper, holistic examination of current circumstances’’ (whatever that means, seriously, what the…).

Is it a QLD or Australian mining safety problem?

Australian mining has had on average 10 deaths per year over the last 20 years. Different states have spikes in some years and the 20-year nationwide graph shows peaks and troughs coinciding with the boom years. The peak in 2014, coincided with low commodity prices, many reports saying that it was caused by mining companies trying to do more with less. So no, its not a QLD problem. Australian mining has a lower fatality rate than transport, agriculture, construction, manufacturing and utilities, but take no comfort. There are obvious reasons, why mining should be better. There is well known risks and controls, more research, enhanced technologies, more stringent regulations, bigger profits, more structure than in most other industries. We need to be better. Australian mining appears to believe it has “good safety” or “better safety than most”, then we are shocked, when a peak in the death toll occurs, every few years. If you think safety is “good” in Australian mining, consider that in 2014, Australia had more mine fatalities than Iran, a country with more than 10 times as many mines and 20 times as many mine workers. I met with regulator, worker and employer delegates from Iran, whilst at the ILO’s tripartite meeting of experts on safety in open cast mines (Geneva, 2017). Let’s just say, I got the strong impression that “safety is pretty bad” on the mines of Iran.   You can't say there is anything different happening on QLD mines to anywhere else in this country, or any other developed country for that matter.

Then, what's the problem?

This is simply the “Parteto Principle” or “80-20” rule (can be any ratio, but not 50-50). It holds true on mines as in all built and natural systems. I’m not talking about that injury triangle, meant to be descriptive not inferential, showing the 80-20 rule anyway. Nor do I mean the ridiculous iteration of it that added “unsafe behaviours”. I don't mean the swiss cheese, leading the blind down the wrong track for years, making them obsessed with cause and effect or blaming the worker. What I’m talking about is that only a few hazardous energies i.e. gravity; vehicular; and mechanical are represented in these 6 incidents. If we were to look closely at the last 100 single-fatality incidents on mines across developed countries and break them down, we would see the same energies over-represented. Breaking it down further, we would find a similar set of interactions, will be over represented. Fall from height; fall of ground (above or below); single-vehicle loss of control; vehicle over edge; vehicle collision (mobile plant); and caught or crushed in components that move unexpectedly is killing people almost daily in mining across the world. If you dug a little deeper still, you would find that these interactions are killing people at a steady rate, everywhere. 

Hope that did not shock leaders or safety professionals in mining. It also, shouldn’t shock most people in the industry to say that the controls for these risks are simple and well known to the industry, but unfortunately, all too often, they are not implemented, not implemented effectively or not managed properly, in my experience a combination of these. Why is it so? In my experience, leadership either does not know or are not strong enough and motivated enough to spend some money. It could be laziness, labelling things as poor safety culture, spending money on magic behavioural or cultural programs to fix the worker. If you are doing that, you are part of the problem, look inwardly people please, this is a cycle that has to stop.

A history of the same - Solving the wrong problems

When spikes in the death toll come along every few years, within an industry or jurisdiction, there is media attention, responded to by a big huff and puff, by regulators, unions, and employers (tripartite stakeholders). Then, they blow out the same broad-brush solutions. The solutions rolled out continuously, since 2006, can generally be categorised as: tougher penalties (e.g. industrial manslaughter); administrative regulation (e.g. non-specific, soft or risk based self-controls); increased inspections by the regulator; more access for unions; and prescribed industry training (not on-the job). Of course, there have been numerous independent / academic studies to inform all of the above, none of which get to the real problem or changes needed. Do any of these researchers, know how to do a basic Taxonomy?

Perhaps too many psychologists are doing desktop studies, without first-hand knowledge of the risks. Academics doing these studies, love to make complex correlations / cross-tabulations on numerous variables, mostly to suit their agenda i.e. age, sex, shift arrangements, work arrangements, employment basis, socio-economic blah blah; all very clever, but missing the specific energy interactions completely and so of little practical use. Mechanism and agency descriptors first developed in 1981, won’t get them there either, these are too broad. They usually find more problems that require more paid research of course. Not enough real scientists or engineers in safety, just saying.

Critical control management (ICMM), is a body of work that brought us closer to what’s needed. But as with all things that just require good old fashioned thinking and hard work in safety, it has been mis-interpreted, watered down or applied in a box ticking fashion by the regulators and mining companies. Clearly, we are solving the wrong problems, because the measures being applied or applied poorly, have done very little about the tangible risks at the work front. We still have not been able to get the specific energy interactions, over represented in single fatal incidents under control.

Is this spike and 5 / 10 terrible years in Australian mining compelling enough?

Let’s look at what we are doing, in the wake of these incidents in QLD.

“Crisis talks”

After the 6th fatality, the media started. The headline…“an emergency meeting, to identify immediate and long-term safety measures to address this crisis”. The meeting was held in a city, hundreds of miles from the scene, with no input from people or communities facing the risks. It’s like Monty Python’s life of Brian, “this calls for serious discussion”, but to what end?

Firstly, the people who attended were all same people responsible for, or influencing mine safety in QLD, over the period of a high death toll in Australian mining and an escalating death toll in QLD. They have presided over failure, now, they are the solution? They did not know there was a problem, what value can they add now. If they did know about the problem, why didn’t they say? Perhaps it’s time to bring fresh eyes, clear minds and more diverse practical experience to the problem.

Secondly, how do you “discuss measures to solve a problem” you have made no attempt to define or understand. To solve a problem, you must first define it, then understand it (Einstein), not just label it? Thirdly, there has been no sudden change or new threat that makes this an emergency, the same handful of interactions that have been killing people for a very long time have struck again. Labelling it an emergency, makes people prone to emotion, jumping to solutions and hindsight bias, not conducive to solving a complex problem. Are they just going to be solving the wrong problems again?

Lastly, with only officials or representatives of governments, employers and unions in attendance, it was 3 tribes, each with its own agenda, each advocating solution that best suit that agenda. Monty Python again, the Judean people’s front vs the people’s front of Judea, they want the same things, but are not focussed on the common enemy (no not the romans), but the hazards. I doubt whether such a meeting could produce real insights or a common understanding of the underlying problems, nor could it produce a well thought out plan of attack, they are just guessing really.  

“Safety reset”

Called for by the union and being implemented industry wide. With no real plan as to how it will work, its hardly surprising that people are already saying it was done poorly so far. The regulator’s website says: “every mine and quarry worker across QLD will be invited by their employer to participate in an industry-wide safety reset, a crucial first step in refocusing the industry’s attention to what should be everyone’s number one priority – the health and safety of workers”. Safety is an outcome, not something you can do or add, let alone focus on! An intervention to get people to focus on the critical controls that are continually failing might be a better idea. The regulator is running an online survey for anonymous feedback about the safety reset and workers feelings about the safety culture at their site (there is that label again, safety culture). Perhaps this will have a jolt effect, but it has been done before in Australia and overseas with no sustained effect. If it is just lecturing workers about safety, going home safe, reporting or speaking out on safety, to get them “safety aware” (another label), then I’m afraid, not much will come of it. If they took the time to plan it out as an opportunity for each mine to make scientifically principled observations, ask focussing questions and work through co-designing solutions with the workers at their mine, it could have been more valuable.

Desktop review of legal framework”

Another university led desktop review of QLD’s regulatory framework, has been announced, to be done in consultation with regulators, industry and the union appointed industry safety and health representatives. Yes, the same people who brought you the existing mine regulatory framework, smart. What are they looking for in the regulatory framework anyway?   Look at the incidents, similar ones happen in Australia and all over the world with regularity and little variation. We understand how the damaging energy was imparted and why the controls fail to prevent initiation and escalation of the event or reduce the damage. We also know, or at least could design, best practices to reduce these incidents. Legislate that, then enforce it! 

Risk based or Roben’s style legislation is fine, but let’s face it, risk assessment on mines has devolved (perhaps never evolved) into a broad brush, perfunctory process. Risk assessment has been kicked further and further down to the leading hands and workers, where there is not the information, skills, knowledge and resources to do it well. Look at JHA’s, that process or lack thereof is rarely done with any quality. And will the sky fall in if we actually write a standard operating procedure about standard operations i.e. the bloody work. Not safety or not just copying and pasting legislation, but your best available knowledge to do the job well.

It is evident that the mine safety legislation in QLD, is not focussed enough and not specific enough about the controls for these over-represented interactions. I understand you cannot legislate everything or prescribe controls down to every specific detail. But they are just using up words to describe the relevant content of a safety management system or considerations for a risk assessment, without making any specification about the critical controls. For most of the risks associated with these incidents, the regulator is relying on the mines to make management plans, based on a long list of required content, which eventually turns into a fairly useless document on a mine, hardly looked at.

Perhaps the regulator should be looking back at what happened with confined spaces and electrical safety after a string of fatalities. It got very prescriptive on a few critical controls and also brought in a higher standard for the management aspects by prescribing clauses of an Australian Standard. I would urge the regulator to get specific about: road design, construction and maintenance; mobile plant operations and operating areas; operations near walls / edges, on dumps; and the interactions of vehicles in certain areas like loading areas, at ROMS etc. With so many fixed items of plant getting more complicated, in terms of automated operations, perhaps they also need to get hard on equipment isolations as well, the law is virtually silent on critical controls in all these areas.      

Review of QLD mine fatalities over last 20 years

Finally, they announced something that is actually trying to understand the problem. I’m also happy they are getting a forensic engineer to do it. If it is done using a scientifically principled approach, not just desktop, but crawls over and into mines themselves it should find the problem, or will it. Firstly, has it not been done before, if not why? Secondly, whilst a good thing, my problem is with a regulator / industry who actually thinks they need a forensic review of past incidents. The absenteeism’s and failures of the controls meant to prevent these incidents is active, not latent, no need to look at it forensically. They occur every day, just go out and see.

Please no more of the same – Fix what we already know is wrong

I never wish to be so sceptical and scathing, but my fear is, and this is supported by history, that after the huff and puff, work-related death rates will continue to flatline in Australian mining. We have got to do things differently and go back to basics. Is that not what a football team does, when having a bad run. Please, lets fix these hazards first and foremost, now, before all this huff and puff and blowing out the same old people with the same old solutions.