Mining fatalities and accountability

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.

Maintaining professional standards by looking outside the discipline

I am a great believer that solutions to hazards in one industry can be applied or adapted to other industry sectors.  Regular readers of SafetyAtWorkBlog are aware of the cross-referencing between general workplace hazards and some solutions from the sex industry.

However, solutions can come from other countries as well, and not just from the United States.  Last week, a car bomb set off by Basque separatists in the University of Navarra in the northern city of Pamplona resulted in 248 people being treated for respiratory trouble, coughing and nausea from inhaling unidentified gases.  A university spokesperson, Javier Diaz, reportedly said that the fumes were generated by repair works that “are related to the terrorist attack.”

This occurred seven years after the 9/11 attacks in New York and after the resultant and widespread reporting of persistent health issues suffered by relief workers and emergency services personnel.  Yes, fumes are different from airborne particles of asbestos but the hazard, and the control mechanisms, are similar.  The lessons of exposure by emergency workers in disasters are obviously still to be learnt.

This morning, 10 November 2008, we wake up to a Russian submarine disaster that immediately reminds us of the tragedy of the Kursk in 2000.  Overnight 200 submariners and shipyard workers were affected in  the K-152 Nerpa submarine from exposure to freon gas.  Three servicemen and seventeen civilians have died.  Initial reports say that the gas was released when the fire extinguisher system was activated.

Russian submarines off the east coast of Russia can easily be dismissed by newspaper readers and business professionals as largely irrelevant but the media has said that 

“A Russian expert has reportedly said that a lack of gas masks among too many untrained civilians may have elevated the death toll in the submarine.”

Does insufficient PPE and training sound familiar? The release of gas in a restricted area?

For OHS professionals everything is relevant to making the best decisions possible for clients and employers.  The trick is to allocate the appropriate level of relevance to the information.  Risk managers and OHS professionals need to filter information from the widest possible pool of knowledge in order to provide the best advice.

We are not all Russian shipyard workers in a just-built submarine but, increasingly, we could be helping people from the rubble of a collapsed building, or helping in the aftermath of a natural disaster or a terrorist attack, or advising on a fire safety procedure and safe design of buildings.  We need to read, listen and digest so as to maintain and improve our personal core body of knowledge.

Dust explosion update – podcast

Several months ago SafetyAtWorkBlog reported on the outcomes of a dust exploion in a sugar factory in the United States.  The ICIS Radio podcast for 6 October 2008 provides the latest information on dust explosions as well as a good update on OHS issues in the chemical industry.

It is clearly a promotion for ICIS Magazine but it is a good short news podcast.

Longford explosion anniversary, Andrew Hopkins and a new book

October 2008 was the tenth anniversary of the explosion at Longford gas plant in Australia that resulted in many injuries, two fatalities and almost two weeks of severely interrupted gas supply to the State of Victoria.

The Longford explosion at an Exxon-Mobil site resulted in a Royal Commission, an OHS prosecution and a record fine.  Recently it was often invoked in comparison to the Varanus Island pipeline explosion in Western Australia.

Professor Andrew Hopkins, sociologist with the Australian National University, was studying safety management systems well before the Esso Longford explosion but it was that major disaster that added international prominence, and a substantial extra workload, to Andrew.  Other than domestic acclaim, in July 2008, the European Process Safety Centre declared Andrew winner of the EPSC Award for 2008.  He is the first person outside of Europe to win this award.  It is believed that Andrew was formally presented with the award at the EPSC conference earlier this month.

Andrew has a refreshing perspective on safety management systems, partly because he has brought a sociologist’s eye to management decisions; his vision is not clouded by the OHS baggage through which many other analysts struggle.

Andrew’s next book due out this month through CCH Australia is Failure to Learn The BP Texas City refinery disaster and could have him travelling frequently the United States to offer his wisdom.

SafetyAtWorkBlog is working on a new interview with Andrew when he returns to Australia but in the meantime, a 2000 interview with Andrew is available as a page on this blog.  The interview was conducted at a book launch in September 2000 for Lessons From Longford.

Professor Andrew Hopkins (right) receiving the award from Christian Jochum, Director of the European Process Safety Centre
Professor Andrew Hopkins (right) receiving the award from Christian Jochum, Director of the European Process Safety Centre

Varanus Island Report released

On 10 October 2008, the Western Australian Mines and Petroleum Minister, Norman Moore, released the final report into the Varanus Island pipeline explosion.  Sadly due to legislative restrictions the report is not being made available in an electronic edition accessible through the internet.  However, hard copies can be requested from the government.

Recent media statements indicate that “the immediate physical cause of the gas explosion at the island’s gas production facility operated by Apache Energy Ltd was the rupture of the 12-inch gas sales pipeline.”

Some media reports mention the dreaded n-word – negligence.  Apache Energy has stated that investigations into the 

Varanus Island explosion were premature and based on an incomplete investigation 

Contrary to most incident investigation techniques known to SafetyAtWorkBlog, Apache Energy says that it will continue to investigate in order to determine the “root cause”.  

Since the incident, there has been a change to a conservative State government so the statements contain a political edge.  The current Minister says that the terms of reference were too narrow and did not allow for investigation into “regulatory oversight” however deficiencies in this area were illustrated through media reports in the weeks following the incident.

The Minister has not ruled out ordering a  “a full and independent investigation into this issue… at a later date” but I suspect only if there were political benefits rather than safety benefits.  There are a considerable number of voices supporting a broader inquiry from unions and industry groups

The report is said to identify the following three contributing factors:

  • ineffective anti-corrosion coating at the beach crossing section of a 12-inch sales gas pipeline, due to damage and/or dis-bondment from the pipeline;
  • ineffective cathodic protection of the wet-dry transition zone of the beach crossing section of  a 12-inch sales gas pipeline on Varanus Island; and
  • ineffective inspection and monitoring by Apache Energy of the beach crossing and shallow water section of the pipeline.

Mr Moore stated that

“Under the safety case regime, the operator is required to identify hazards and assess risks to health and safety and to implement control measures to reduce those risks. The ongoing inspection, monitoring and maintenance of control measures are associated with those risks and the management regime. The report has indicated that Apache and its co-licensees may have committed offences under two pipeline Acts.”

A Senate inquiry is looking into the economic impact of the Western Australian gas crisis and the State Government’s response to the incident.

Crandall Canyon Mine Investigation Report

On 24 July 2008 the U.S. Department of Labor’s Mine Safety and Health Administration (MSHA) announced that it has fined the operator of the Crandall Canyon Mine in Emery County, Utah, $1,340,000 for violations that directly contributed to the deaths of six miners in 2007.

According to MSHA’s media release, Agapito Associates Inc., a mining engineering consultant, was fined $220,000 for faulty analysis of the mine’s design. MSHA cited the mine operator for 11 additional, non-contributory violations issued as the result of the investigation. The proposed penalty for these violations is $296,664, bringing the total proposed penalties against the mine operator to $1,636,664. Crandall Canyon Mine is operated by Genwal Resources Inc., whose parent company is Murray Energy Corp.

Safety At Work magazine covered the incident extensively as it provided a stained mirror to the lucky rescue of the miners from Tasmania’s Beaconsfield mine. I reported elsewhere on the fresh seismology findings.

Safety at Work magazine - August 2007
Safety at Work magazine - August 2007

The MSHA report states that

“Three separate methods of analysis employed as part of MSHA’s investigation confirmed that the mining plan was destined to fail.” (my emphasis)

To a non-US observer the fine seems remarkably light given that the mining plan was critically deficient, 6 people died in the first incident and 3 died ten days later.

Not everyone is happy with how the investigation has been conducted.

MSHA accident investigators have cited Genwal Resources Inc. and Agapito Associates Inc. for the following violations:

  • The mine operator did not immediately contact MSHA after coal outbursts threw coal into the mine openings and disrupted regular mining activities for more than one hour on three separate occasions prior to the August 6 outburst.
  • The mine operator failed to propose revisions to the roof control plan when conditions (coal outbursts) clearly indicated that the plan was inadequate and miners were being exposed to dangerous conditions.
  • The operator violated the approved roof control plan by removing coal that was required to support the roof.
  • The operator’s outside engineering firm failed to recommend safe mining methods and pillar/barrier dimensions, and the operator failed to maintain pillar dimensions that would effectively control coal outbursts.

The complete accident investigation report (16 megabyte) is available at as is MSHA’s response and additional content.

The earlier investigation report by the Utah Mine Safety Commission is available HERE

Imperial Sugar explosion update

Last month America’s 60 Minutes broadcast an article on the explosion at the Imperial Sugar plant (pictured below) in Port Wentworth which killed 13 workers and hospitalised 40.  On 25 July 2008, the Occupational Safety and Health Administration (OSHA) issued citations proposing penalties totalling $8,777,500 against the Imperial Sugar Co. and its two affiliates alleging violations at their plants in Port Wentworth and Gramercy. 

The US Chemical Safety Board (CSB) has released some details about its appearance at the US Subcommittee on Employment and Workplace Safety, Senate Committee on Health, Education, Labor, and Pensions, on 29 July 2008. (Transcripts and video are available HERE)

CSB Chairman John Bresland said the tragedy demonstrates the need for a new OSHA standard that would cover a range of industries exposed to this hazard, such as food, chemicals, plastics, automotive parts, pharmaceuticals, electrical power (where generated by coal) and others.
According to the CSB, Chairman Bresland told the subcommittee, chaired by Sen. Patty Murray of Washington,

‘After witnessing the terrible human and physical toll from the Imperial explosion, I believe the urgency of a new combustible dust standard is greater than ever. A new standard, combined with enforcement and education, will save workers’ lives.’
‘We obtained documents indicating that certain parts of Imperial’s milling process were releasing tens of thousands of pounds of sugar per month into the work area. Based on our evidence, Imperial did not have a written dust control program or a program for using safe dust removal methods. And the company lacked a formal training program to educate its workers about combustible dust hazards.’

Bresland emphasised the need for a uniform Federal standard:

‘Instead of the present patchwork of miscellaneous federal, state, and local requirements, the Chemical Safety Board has recommended that OSHA develop a single, comprehensive, uniform standard – based on the sound, consensus-based technical principles and practices that are embodied in NFPA standards,’ Chairman Bresland said.  ‘Ambiguities in the NFPA standards need to be resolved in clear, enforceable regulations developed by a thorough, public rulemaking process.’

 

 

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