SafetyAtWorkBlog has repeatedly called for the release of the report into the Beaconsfield mine disaster that was undertaken by Greg Melick, QC. The Tasmanian Government has today made the report and appendices available online.
The OHS-specific reports by Professor Michael Quinlan have also been released.
Since the 2006 rockfall at Beaconsfield Mine in Tasmania, the public has received limited information. There have been books about the rescue of two workers and the Coroner’s inquest into the death of Larry Knight. Greg Mellick undertook an investigation into the rockfall and found that noone was to blame for the rockfall.
Many workplace disasters have generated royal commissions in Australia. The rockfall did not. However, industry specialists, OHS professionals and others have established an expectation that investigations and reports into industrial disasters are publicly accessible.
The expectation is not unreasonable given that the OHS profession, legal profession, engineers and others operate within a belief that the analysis of disasters can provide ways of avoiding a recurrence. Apparently the Tasmanian Government does not understand the significance of information in improving the safety of workers and the public in its State, even though its OHS and mine safety legislation is structured around prevention.
The Tasmanian Coroner released his findings into the death of Larry Knight. The findings quoted extensively from the 400+ page OHS report from Professor Michael Quinlan that was part of Greg Mellick’s investigation process. But the report itself is yet to be released. Nor has the larger report undertaken by Greg Mellick.
The Director of Public Prosecutions has chosen not to lay charges over the rockfall.
The mine is back at full operation.
The survivors of the rockfall are rebuilding their lives.
Only a couple of weeks ago, the Legislative Council Select Committee on Mining Industry Regulation released its report into the State’s mining legislation. The terms of reference have evolved from the findings of various investigations including Quinlan’s. The committee was required to investigate
On 2 April 2009 at the Safety In Action Conference in Melbourne, Professor Michael Quinlan expressed bewilderment at the decision to not release his investigation report.
SafetyAtWorkBlog contacted the OHS regulator in Tasmania asking for the Quinlan report. We were advised that it was likely that the only way to obtain a copy was through Freedom of Information with the Department of Premier & Cabinet. (DPAC) A representative of DPAC will contact us about the report’s status.
DPAC has a copy of the Mellick report. The Australian Workers Union has a copy of the Mellick report. SafetyAtWorkBlog believes there are leaked copies of the report in existence but for some reason, unknown at this time, the public is not permitted to see the report.
The Queensland government has available four reports into mining disasters in the Moura area with one report going back to 1972!!
In the years after the ESSO-Longford gas explosion, Professor Andrew Hopkins published “Lessons From Longford“. It was for a long time the publisher’s best-selling book. It is quoted extensively in the OHS and management professions. Some of Andrew’s terminologies and concepts of safety culture have become ingrained in the psyche of OHS professionals in Australia.
It is hard to see any reason in April 2009 for the Mellick and Quinlan reports not be be publicly available. Indeed there are many important professional and community reasons for the reports to be seen.
What is the professional legacy of the Tasmanian government’s investigations into the Beaconsfield Mine rockfall in 2004?
What will the government say when the next rockfall occurs in an underground mine? What will the Premier or the Minister say to the next generation of widows or to the carers of the crippled miners? Certainly David Bartlett or David Llewellyn cannot say that they did all they could to make workplaces safe.
Australian Standards can have a major role to play in the management of safety in workplaces. They apply to equipment, documents, decisions and can have legislative credibility if required by specific regulations. Australian Standards are regularly referred to in guidances issued by OHS regulators adding further credibility. The highest selling standard for many years has been Risk Management.
One of SafetyAtWorkBlog’s long-held peeves needs to be stated here. The standards are produced by a private company, Standards Australia. The standards are only available for sale. Small business, in particular, often baulks at OHS improvements because they see OHS management as a large cost for a small return, in a risk management context. But the standards they need to satisfy regulatory compliance can only to be purchased.
If the Australian government is serious about easing the cost of regulatory compliance, make any Australian Standard that is mentioned in legislation available for free.
But government’s are only interested in reducing indirect OHS costs through paperwork and “red tape”, and OHS compliance requires some level of documentation.
Two important OHS documents that discuss risk management were released within weeks of each other. First the Australian government released the second and final report of the Review into National Model OHS Laws (OHS Report). The other report was the findings of the Tasmanian Coroner into the death of Larry Knight.
The Coroner’s report was highly critical of the Beaconsfield mine’s (BGM) risk management process.
“BGM submits that there has been adequate documentation of its risk management…… I do not accept BGM’s submission” (pages 68-69)
The Coroner goes on to say
“…., the evidence is unclear upon the steps taken by BGM, prior to this decision, in its evaluation of those risks identified by its own risk analysis process. To illustrate:
- There is no evidence to explain the decision to resume mining in contradiction of Mr Gill’s memorandum which had stipulated that forward modelling be completed beforehand.
- Mr Gill had, in his memorandum posed the questions, “Are our current ground support standards sufficient for the seismicity being experienced?, and if they aren’t, “What is required?” However, there is not any evidence of BGM having undertaking an assessment of the sufficiency of its ground support standards so that these questions could be answered nor is there any record evidencing why the decision was taken to resume mining without these questions being addressed.
- Dr Sharrock had identified an important depth of failure issue which Mr Gill acknowledged was raised by him at his close-out meeting yet there is no evidence to explain the evaluation of this concern by BGM and the basis for its rejection.
- There does not appear to be any evidence of BMG having considered the reevaluation of its ground support after Mr Basson’s modelling results became available although this had been advised by Mr Turner.” (pages 66-67, my emphasis)
The coroner’s report is full of this type of comment of an inadequate risk management and assessment process.
Reading the report in full generates a big question of how can a company be so deficient in its safety management system and still not be held responsible for the consequences of its actions?
The company remains belligerent in its defence of the very risk assessment process that the Coroner slammed. In a media statement, CEO Bill Colvin states
“…the company is disappointed at the lack of acknowledgement of the extensive risk assessment process undertaken by the Beaconsfield Gold mine following the October 2005 rock fall.
“Contrary to comments made by the Coroner, there was rigorous risk assessment, the mine did vary its ground support system and it changed its mining method. Nevertheless, the Coroner did find that no person contributed to the death of Larry Knight.”
Which report was he reading?
Outside of the coronial process, there seems to be sufficient evidence in the coroner’s report for Workplace Standards Tasmania to have another look at prosecuting BGM for failing to ensure that Larry Knight had a healthy and safe work environment.
The Review Panel decided not to include risk management as an enforceable element of national OHS legislation, even though it is a legislative requirement in Queensland. The panel has reduced the emphasis on risk management by including it only “as part of an object of the model Act.” (page xviii)
Placing it as an object of the Act puts risk management out of the public’s eye. If risk management is not part of the obligations of an employer in law, we should not expect business operators to embrace them. The BGM risk management process was found to be deficient by the Coroner and may have contributed to the death of Larry Knight but the Review Panel sets risk management as an aim and not an enforceable part of model OHS legislation. It advocated the concept but would not committed
The panel heard, in a submission by Johnstone, Bluff and Quinlan, that
“The Model OHS Act should explicitly require duty holders to undertake systematic OHS management in order to comply with their general duty obligations, and the Act should outline the approach to be taken in a way that integrates the concept of ‘reasonably practicable’ into the process, and also shows how duty holders should use the provisions in regulations and codes of relevance to the issue being addressed in order to comply with the general duty.”
The Review Panel followed the recommendation of the Law Council of Australia that risk management be included in Regulations and not the Act itself.
But then, the review was not a review of occupational health and safety but of occupational health and safety law. The management of safety was never its focus.
If it had been such a review, or if the government decides that a “safety management review” is warranted in the next few years, there would have been the opportunity to analyse the cost of managing safety and to show how the legal fraternity and the standards setting processes unnecessarily contribute to high compliance costs and red tape.
Risk management was clearly an important business process at Beaconsfield Gold even if the application of the process was poor. The Coroner said
“one obvious line of defence is to have in place a systematic, comprehensive, rigorous and properly documented risk assessment process. It is my opinion that BGM did not abide by such a process in the period between the October ’05 rockfalls and Anzac Day 2006.” (page 71)
Larry Knight died on Anzac day 2006.
The Review Panel believes risk management can sit in Regulations and in legislative aims. Standards Australia continues to charge for its OHS and risk management standards. The Australian government remains silent on providing free business management information that has the real possibility of saving lives. Bring on the safety management review!
Safety advocates often say that safety begins at the top. Yet few CEO’s will talk overtly and publicly about safety to the extent that Janet Holmes a Court has in Australia. Janet is a rarity but John Bresland of the United States Chemical Safety Board is making a good attempt through YouTube technology.
In January 2009, Bresland has produced on of CSB’s “safety messages” and, he is not afraid to criticise his political colleagues.
In the latest safety message he criticises those American states who do not allow state employees to be covered by federal OHS legislation and he uses an actual fatality incident to make the point very clear.
For those outside of the US, the video is a good example of a safety advocate putting his face out there and broadcasting about safety to his constituents and interested parties. Political criticism is seen as valid in this case due to Bresland pointing out an anomaly and showing how an anomaly can kill, injure and maim.
Too many senior executives and professional associations are scared of making political statements even though they support the mission statement of their organisation. This is an immature position based on insecurity – a quality that should have no place in the coordination of corporations and professional bodies.
Branding is a worthwhile process but it will only succeed if what is being promoted has substance. The Chemical Safety Bureau has been a solid platform for education and safety improvement for years and deserves support by OHS professionals learning the lessons being shared and displayed.
It is relatively easy to manage a workplace in an urban environment. The buildings stay in one place, the neighbours are almost always the same and the weather bureau provides plenty of warnings. But in isolated areas, particularly in Australia, it seems the work environment is often more exposed. Certainly this was the case in mid-March 2007 when Cyclone George hit a railway construction camp killing several workers and injuring twenty.
The camp accommodation of demountable units, called dongas, were supposedly cyclone-proof. At the time, the Construction Forestry Mining and Energy Union said that administrative staff were evacuated but construction workers were directed to the dongas.
The owner of the worksite, Fortescue Metals Groups said on 11 December 2008 that it will fight 40 charges brought by Worksafe WA under the West Australian Occupational Health and Safety Act.
According to one media report:
“The charges include the failure to provide a safe work environment, failure to design and construct temporary accommodation and other buildings capable of withstanding a cyclone and failure to properly instruct and train workers.”
The installer of the demountable buildings, Sunbrood, had all charges dismissed.
The court case will continue in Western Australia in February and March next year.
Last year, Sydney Australia hosted World Youth Day (WYD). In some ways Australia had not seen such a large influx of people from so many countries for a single event before. The Sydney Olympics had a high proportion of locals attending and the 1956 Melbourne Olympics never had the infrastructure to provide so many overseas visitors.
For several months after the 2008 World Youth Day, it was rumoured that the level of absenteeism in workplaces was very high. At the time of WYD there were several reports of quarantined pilgrims and the risk to public health of the Sydney population was assessed. (Peter Curson, professor of population and security in the Centre for International Security Studies at the University of Sydney wrote a discussion piece on this)
There were reports of influenza and viral gastroenteritis amongst pilgrims who were required to be quarantined.
The Medical Journal of Australia has released a report into the impact of World Youth Day on the emergency departments of hospitals (MJA 2008; 189 (11/12): 630-632). This study found minimal impact in this sector of the hospital care.
However, SafetyAtWorkBlog is not aware of any research having been done on the impact of World Youth Day on workplace absenteeism. The EMJA study correlates World Youth Day with hospital admissions but it would be useful to see a comparative study of workplace absenteeism in the weeks after WYD, during the incubation period of influenza in particular.
World Youth Day did seem to overlap with the existing flu season in Australia’s winter but those statistical peaks are well-established and it would be interesting to see if those peaks had increased just after World Youth Day.
If there were a correlation, cost estimates for hosting the event may need adjusting to include the reduced productivity due to the “pilgrim’s plague”.
The 11 November 2008 edition of The Australian includes a page 2 story where the previous manager of the Beaconsfield Mine has been called on to be held responsible for the management failures that led to the death of Larry Knight in 2006. The call was made by counsel for Larry Knight’s family and the Australian Workers’ Union in a submission to the Tasmanian inquest into the fatality.
According to the media report, the wrong decision was made in trying to stabilise the working area of the mine and that the risk assessment process was inadequate. The latter comment should be of considerable interest to OHS regulators and safety professionals.
The importance of the Tasmanian Coroner’s findings are illustrated by comments in the submission by the counsel for the mine. The media report says that
“…Dr Neal tells the Coroner the mine had done all it reasonably could to guard against the risk of rockfall and to manage the mine’s notorious seismicity.” [emphasis added]
This is particularly important when considering the introduction of “reasonably practicable” into the OHS legislation throughout the Australian States being considered by the National OHS Law Review.
It is regrettable that the to-ing and fro-ing in the inquest is not getting as much media attention in the non-mining states, as there have been many risk management and accountability issues raised. The media is likely to wait until the findings of the Coroner, Rod Chandler, and focus on the result rather than the journey.
There was a similar experience in New South Wales with the inquiry that followed the drowning of four mine workers at the Gretley mine in November 1996. The information did not resonate to the rest of Australia except through the mining sector, yet there were important lessons from the inquiry. Most OHS professionals, if at all, would recollect the prosecution of Gretley mine managers on matters of culpability, rather than the death of the four workers.
When the Tasmanian Coroner hands down his findings in the near future, it will be very useful to consider them in the light of the earlier reports, assessments and papers, among many others, listed below.
SafetyAtWorkBlog is a strong advocate of learning new OHS management practices by looking beyond one’s field of expertise. OHS professionals, safety managers and risk managers need to watch the action in Tasmania and other jurisdictions for themselves and not rely on a small group of OHS lawyers to bring matters to their attention and advise them how to avoid their responsibilities. Accountability is a moral and legal responsibility.
Holding Corporate Leaders Responsible by Andrew Hopkins
The Impact of the Gretley Prosecutions by Andrew Hopkins
Mine Safety – Law, Regulation, Policy by Neil Gunningham
A submission by the Tasmanian Minerals Council on CRIMINAL LIABILITY OF ORGANISATIONS – ISSUES PAPER NO 9, JUNE 2005 to the Tasmanian Law Reform Institute
N Gunningham, ‘Prosecution for OHS offences: deterrent or disincentive?’ (2007) Sydney Law Review, 29 (3), pp 359-390.
R Guthrie and E Waldeck, ‘The liability of corporations, company directors and officers for OSH breaches: a review of the Australian landscape’ (2008) Policy and Practice in Health and Safety 6(1),
pp 31-54.
N Foster, ‘Mining, maps and mindfulness: the Gretley appeal to the Full Bench of the Industrial Court of NSW’ (2008) Journal of Occupational Health and Safety – Australia and New Zealand 24(2),
pp 113-129.