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‘Drift into failure’: how complacency kills miners

February 12, 2020

An independent review of Queensland mining deaths has concluded that the recent tragic death toll will continue unless companies overhaul their safety culture. Here are some of the takeouts of Dr Sean Brady’s review of fatal accidents since 2000.

  1. Without change, the rate of fatalities will continue

The mining industry has a fatality cycle characterised by periods where a significant number of fatalities occur, followed by periods with few to no fatalities. If thinking and processes around safety remain the same, this will continue. Disturbingly, the report says that the shocking increase in fatalities over the past 18 months is not an aberration but a continuation of the industry’s usual cycle.

  1. Deaths are caused by ‘everyday’ failures, not freak accidents

The majority of the 47 deaths in Queensland mining and quarrying since 2000 were caused by preventable factors involving system failures. While they may superficially look like ‘freak’ accidents that could not have been anticipated, the causes are usually much more banal. A large number of the fatalities involved inadequate training, inadequate supervision and ineffective or absent control measures.

  1. Poor training a major factor

Of the 47 fatalities, 17 involved a lack of task-specific training or competency for the tasks being undertaken. A further nine involved inadequate training – that’s over half of fatalities involving a deficiency in training. Tasks were often undertaken at the direction of supervisors who were aware of the deficiency in training. Lack of training in many cases resulted in workers being unaware of hazards.

  1. Stop blaming the victim

When an incident or fatality occurs, there is an inclination among organisations to blame human error on behalf of the worker. Of the 47 fatalities examined, human error in and of itself was not a major factor. “While it is often involved, typically many other factors are required to cause fatalities. While it is important to hold people accountable for their actions, it is also important to ensure that the drive for accountability does not overshadow the importance of learning the lessons from the incident… Asking why operators made mistakes helps to expose the system errors that led to, or allowed, the human error… If internal mining company investigations are largely identifying human error as the cause, they are likely missing valuable learning opportunities.”

  1. Industry’s ‘drift into failure’

Dr Brady concludes that the Queensland mining industry exhibits a ‘drift into failure’, with a greater acceptance of risk over time. He argues that periods where there are few to no fatalities are typically periods where a ‘drift into failure’ occurs. “Safety is compromised for a variety of reason, often benign, over time. These compromises typically result in a series of minor near-miss incidents.” He argues that the mining industry must actively seek out the near-miss signals which provide an opportunity to identify and remove hazards.

  1. Lost Time Injury (LTI) rate not a good safety indicator

Lost Time Injuries (LTIs) are not a reliable indicator of safety as they are prone to manipulation and are measure of how the industry manages injuries after they occur, rather than industry safety. “At best the LTI Frequency Rate is a distraction that focuses industry on the wrong safety measure, at worst it results in early warning signs being missed.” The report instead recommends that the Serious Accident Frequency Rate be selected as it is a genuine reflection of how many people are getting seriously injured and is less likely to be susceptible to manipulation.

The Union has welcomed Dr Brady’s report, which was commissioned by the Queensland Government and has been tabled in parliament. You can read the full report here.


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