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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.

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.’

Beaconsfield mine supervisor’s safety comments

It is reported in today’s Australian newspaper that the coronial inquest into the death of Larry Knight has heard from Mr Knight’s supervisor, Gavan Cheesman. Mr Cheesman has said that he was not aware of a report of seismic activity at level 925 (the scene of the fatal rockfall) from the previous shift. If he had

“I would have gone down personally and checked out the area before sending them (Knight, Russell and Webb) in”.

This reinforces the importance of taking time before a job or shift starts to familiarise yourself with the state of the workplace. In many industries this takes the form of a job safety analysis. In hospitals there is a handover process between nursing staff.

Mr Cheesman has also said that he believes that the void at levels 915 and 925 was too large and insufficiently supported. He agreed that the inadequate support contriubuted to the rockfall that caused the death of Larry Knight.

The inquest is continuing.

Inquiry into health impacts of maintaining jet-fighter fuel tanks

Earlier this century the Australian Defence Force established the F-111 Deseal-Reseal Health Care Scheme to compensate workers who may have been affected through exposure to chemicals while cleaning F111 fighter aircraft between 1977 and the late 1990s.

A parliamentary inquiry has been established to further investigate the issue of compensation. In the 29 July 2008 edition of The Australian newspaper details of the work exposures have been restated.

“More than 800 RAAF personnel were forced to do the work on the fuel tanks, removing old sealant using chemicals.

The work was done because of a basic flaw in the design of the aircraft — their fuel tanks did not include a bladder, and the sealant used on rivets to stop leaking had to be replaced at regular intervals.”

Details of the impact of this work on workers and their families have also been restated. Ian Fraser, Queensland president of the F-111 Deseal-Reseal support group has said that

“former workers now suffer temper swings, drug abuse and broken marriages — and some had committed suicide.

A significant number have died from cancer, which Mr Fraser’s organisation says is directly attributable to them being made to work with the chemicals — particularly one known as SR51.”

Those OHS professionals who have read Professor Andrew Hopkins’ book “Safety, Risk and Culture” should be familiar with the case as Hopkins investigated the issue and devoted a chapter to his book on the F111 Deseal/Reseal process. A review of the Hopkins book is available online as is a useful article by Hopkins on safety culture.

It is worth remembering that exposure to chemicals and inadequate protection is not something from the developing nations or from Western industrial history. These workers faced unacceptable risks within the last twenty years.

Would you fire someone who could fire back?

Any gun issue in the United States comes down to the right to bear arms but what happens when that right conflicts with the employers’ obligations to provide a safe working environment and one without risks to health.

On 9 April 2008 Reuters reported on a new law in Florida that allows employees to take their guns to work. The law would “prohibit business owners from banning guns kept locked in motor vehicles on their private property.”

The law has now been tested at Disneyworld and NPR provides an audio report on the issue.

Hole in Qantas aircraft

Qantas Airways has a reputation for safety. It’s aircraft have not fallen from the sky for over 50 years. This fact was brought to wide public attention in the movie RainMan and is a fact that most Australians take pride in.

Airlines do not promote themselves on the basis of their safety record principally because it is a high-risk strategy that can be ruined by just one crash.

In late-July 2008 Qantas Airways had a very lucky escape when, according to current reports, an oxygen cylinder exploded and tore a hole in the fuselage of a plan flying over South East Asia. Ben Sandilands in the Sunday Age rightly points out that lives were saved because the pilot was able to undertake an emergency landing at the nearby Manila airport.

In The Sunday Age 27 July 2008 (not available online), Sandilands pointed out that Qantas often flies on long routes over the sea such as Melbourne to Los Angeles, or over Antarctica on its Argentinean route. Had the fuselage damage occurred on one of these routes:

“The pilots would have been forced to choose between risking a potentially catastrophic mid-air break-up versus a crash landing or ditching.”

Qantas does not advertise on its safety record but its continuing success is partly attributed to that record. The avoidance of disaster from this recent episode is a combination of luck and good management. Qantas executives can do little about luck but it does need to maintain its good management and be seen to do so.

Relocating maintenance tasks to Malaysia may make sound economic sense, perhaps moreso in times of extremely high fuel prices, but national pride in a national airline should not be underestimated.

UPDATE

An exploding oxygen bottle is firming as the cause of the hole in the fuselage. However other issues are being raised as another Qantas plane had problems overnight. An undercarriage door would not close complete and Qantas flight needed to return to Adelaide. Passengers were understandable a little more concerned than usual.

Several of the articles referenced in this blog include complaints by passengers that oxygen masks failed to work or could not be fitted. Qantas has said that inspections of masks are included in maintenance schedules and it may be a significant factor that it seems to be an oxygen bottle that exploded however the Australian Transport Safety Bureau has asked for passengers to contact it if they had such problems.

Editorials are appearing in which the importance of safety to the longevity of an airline (as well as the passengers) is being emphasised. The Age newspaper on 29 July 2008 said that

An airline’s future is its good name. Qantas has for decades thrived on its reputation. Alan Joyce has the challenge before him to continue that tradition.

(Alan Joyce is the incoming chief executive officer.)

Presenteeism in the US

Presenteeism is when a worker attends work when they should not due to illness. Frequently ill workers attend the office or the factory because they feel that they are indispensable. This may be the case but they can then present health risks to others by communicating their flu or other disease to their colleagues. However, the worker is also impaired and may undertake work tasks or make decisions that put themselves at risk, a clear breach of their OHS obligations.

Presenteeism is an obvious overlap between OHS and Human Resources. Sick leave has an important role to play in managing a safe and healthy work environment.

A 28 July 2008 article on NPR reports on a poll about presenteeism. The US context is slightly different from Europe and Australia because paid sick leave is not a workplace entitlement although many workplaces provide health insurance.

I don’t agree with Marc Burgat, vice president of government relations for the California Chamber of Commerce who argues against the imposition of sick leave entitlements on employers.

Good managers have structured their workforces or production deadlines to accommodate levels of absence due to illness. Health absences should be an element considered in a risk management plan. Good employers can cope with sick workers and foster good relationship (a good workplace culture) by accommodating unavoidable human foibles.

Tag: OHS

Crandall Canyon Mine Investigation Report

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Imperial Sugar explosion update

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Beaconsfield mine supervisor’s safety comments

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Inquiry into health impacts of maintaining jet-fighter fuel tanks

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Would you fire someone who could fire back?

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Hole in Qantas aircraft

UPDATE

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Presenteeism in the US

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UPDATE

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