International Journal of Industrial Ergonomics 68 (2018) 270–279

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International Journal of Industrial Ergonomics

journal homepage: www.elsevier.com/locate/ergon

Human factors analysis of major coal mine accidents in China based on the T
HFACS-CM model and AHP method
Rulin Liua,c, Weimin Chenga,c, Yanbin Yua,b,c,∗, Qingfeng Xua,c
a
State Key Laboratory of Mining Disaster Prevention and Control Co-founded by Shandong Province and the Ministry of Science and Technology, Shandong University of
Science and Technology, Qingdao 266590, China
b
Key Laboratory of Safety and High-efficiency Coal Mining, Ministry of Education (Anhui University of Science and Technology), Huainan, 232001, China
c
College of Mining & Safety Engineering, Shandong University of Science and Technology, Qingdao, Shandong, 266590, China

A R T I C LE I N FO A B S T R A C T

Keywords: The safety of coal production in China's mines has been greatly improved in the past few years; however, major
Coal mine human factors analysis and accidents still occur frequently, causing large numbers of casualties and a loss of property. Therefore, this study
classification system first collected the statistics of 362 major coal mine accidents in China during the period from 2000 to 2016, and
Analytic hierarchy process established a human factor analysis and classification system for China's mines (HFACS-CM) based on the sta-
Chi square test
tistical results. Then, in combination with the analytic hierarchy process (AHP) method, the poor safety practices
Weight calculation
Human factor analysis
of coal miners and their related influencing factors, namely, the external environment, organizational influences,
leadership behaviors and preconditions, were investigated systematically. On that basis, by combining expert
grading, weight calculation and a consistency test, the weights of the accident-causing factors were determined,
and the internal relationships among various levels in the HFACS-CM model were analyzed using the chi-square
test and odds ratios. Accordingly, the accident-causing factors were analyzed qualitatively and quantitatively.
Such a qualitative and quantitative evaluation of major coal mine accidents based on the AHP method and
HFACS-CM model could lead to a better management of human factors, provide the basis for accident in-
vestigations and be of great significance with regard to safe production practices in coal mines.

1. Introduction causes. Therefore, gaining an in-depth knowledge of the various unsafe

As an important basic energy source and industrial material, coal
has made a prominent contribution to China's economic development
(Wang et al., 2018). However, various safety-related accidents occur
frequently in coal mines (Cheng et al., 2017; Hu et al., 2018), which not
only have a negative impact on economic development but also cause
significant economic losses. During the period from 2000 to 2016, there
were a total of 8226 accidents in China's coal mines, which caused
22,760 deaths. In particular, 362 major accidents occurred, which al-
though only accounting for 4.40% of the total number of accidents,
caused 7612 deaths, or 33.45% of the total. Accordingly, a compre-
hensive analysis of the causes of major accidents could control and
reduce effectively the occurrence of accidents and make a significant
contribution to improving safety in the coal production process. Chen
et al. (2005) conducted an in-depth analysis of the causes of China's
major coal mining accidents in the two decades from 1980 to 2000 and
concluded that human factors accounted for 97.67% of the various
practices that led to the major coal mining accidents, as well as their
influencing factors, will provide important guidance and a significant
reference for exploring the main reasons for major accidents, and
should lead to more effective precautions being taken.
For a number of years, many researchers have promoted the theory
and model of human factor analysis. For example, Edwards introduced
the famous SHEL model for the first time in 1972 to describe the human
factors in flying. Hawkins and Orlady, 1993 charted this model and by
placing the human being at its center, considered the relationship be-
tween researchers, hardware, software and the environment; i.e., the
four interfaces of the model: human software, human hardware, the
human environment, and humans themselves. It was found that if the
interface can be properly matched, the security system can operate
smoothly; however, if there is a mismatch between the interfaces, a
human error will occur. Rasmussen (1983) considered human behavior
in accordance with the level of cognitive behavior, and suggested a
cognitive behavior model where such behavior was divided into three

∗
Corresponding author. State Key Laboratory of Mining Disaster Prevention and Control Co-founded by Shandong Province and the Ministry of Science and
Technology, Shandong University of Science and Technology, Qingdao 266590, China.
E-mail address: he_yyb@163.com (Y. Yu).

https://doi.org/10.1016/j.ergon.2018.08.009
Received 23 February 2018; Received in revised form 4 July 2018; Accepted 27 August 2018
0169-8141/ © 2018 Elsevier B.V. All rights reserved.
R. Liu et al.
types (skills, rules and knowledge); he also proposed a Skill-Rule-
Knowledge model to describe the process of human cognitive behavior
and the three kinds of cognitive behavioral characteristics, and in
which the reasons for failure were analyzed in detail. Reason (1990),
through the analysis of a nuclear power plant accident, found that ac-
cidents caused by human error usually occur due to interaction pro-
blems in the process of manufacturing elements. These invisible or
dominant errors that compromise the integrity of an organizational
system make it vulnerable to operational risk factors, and therefore
more likely to lead to the failure of the disaster; this is a type of failure
for which one can use different levels of the system in the “hole” to
describe. Each level has its own defects, and when unsafe factors pass
through the defensive layers, the production process will gradually fail
or collapse, eventually leading to accidents. Because Reason's theore-
tical structure looks like a piece of Swiss cheese, it is often called the
“Swiss cheese” model. The biggest advantage of this model, compared
with other models, is that the safety system is placed under the um-
brella of organizational behavior. Furthermore, it not only considers the
explicit cause of the accident, but also the recessive causes of human
errors in organizational management. However, the “Swiss cheese”
model does not show what the defects at each level are; therefore it is
impossible to use it before accident and correct any defects. Thus,
analysts, investigators and other security experts have encountered
obstacles in the application of the “Swiss cheese” model when analyzing
accidents.
Shappell and Wiegmann (2000, 2001) designed and reconstructed a
model, which was based on the Swiss cheese model, through analyzing
a large amount of aviation accident data, and developed a more com-
prehensive human factor analysis and classification system (HFACS).
This system can analyze the human factors in accidents in detail at four
levels, namely, organizational influence, unsafe leadership behaviors,
the preconditions of unsafe behaviors and unsafe behaviors. Therefore,
the HFACS model can not only distinguish the human errors that cause
accidents, but also find potential risk factors from the organizational
execution process and the organizational environment. This theoretical
framework has been tested in a large number of cases, and has been
widely adopted by the US Navy and Air Force and other civil aviation
organizations. It is therefore seen as one of the best models for in-
vestigating the human faults that lead to flight accidents. As the related
research has become more in-depth and advanced, the HFACS model
has been applied gradually to other fields. For example, in the railway
field, Reinach and Viale, 2006 investigated 6 railway accidents, mod-
ified the HFACS model for the first time and established an HFACS
model for this industry (abbreviated to the HFACS-RR model), in which
three external factors, namely, oversight in supervision, economy,
politics and society and the legal environment, were added. In the field
of navigation, Celika and Cebib, 2009 combined the fuzzy analytic
hierarchy process with HFACS to analyze the human factors in marine
accidents. Moreover, by combining the SHEL model (proposed by Ed-
wards and improved by Hawkins) and the precondition levels of unsafe
behaviors in the HFACS model, Shih-Tzung Chen et al. (2013) proposed
an HFACS model for maritime accidents and validated this model
through a case study. Chauvin et al. (2013) proposed a HFACS-Cloo
model for maritime collision accidents and analyzed 27 maritime col-
lisions from 1998 to 2012. In the medical field, Milligan, 2007 used the
HFACS framework to analyze medical accidents. Furthermore,
EIBardissi et al., 2007, through interviews aimed at ascertaining the
causes of surgical accidents in cardiovascular surgery, and the use of
HFACS framework analysis, discovered a mutual influence between
various factors in the framework. Spiess et al. (2015) applied the
HFACS model to medical accident analysis through studying a heart
bypass supply fault case and the specific human factors in the accident;
their results show that health education plays a positive role in patient
safety. In the field of coal mines, by taking account of the actual con-
ditions in coal mines, Patterson et al. (2013) established an HFACS
model for mines (abbreviated to the HFCAS-MI model); they then used
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International Journal of Industrial Ergonomics 68 (2018) 270–279
this model to examine 508 accidents in Austria's coal mines and con-
cluded that technical mistakes were the most common unsafe behavior,
while errors in decision-making played different roles in different
mines. Lenné et al. (2012) analyzed 263 coal mine accidents in Austria,
based the related statistics on the HFACS model and analyzed the odds
ratios (ORs) of the accident causes and their confidence intervals.
In summary, the HFACS model is a relatively mature and convenient
classification method, and is the most powerful tool for the human
factor analysis of various accidents (Dekker,2002). However, when
applying HFACS models in different fields, researchers need to improve
their original models according to the characteristics of accident data in
specific areas and apply them to these other fields, such as railways, and
navigation. In the field of coal mines, the application of HFACS is
limited, although Lenné et al., 2012used the original HFACS framework
directly, and Patterson and Shappell, 2010 proposed an improved
model (HFACS-MI). However, the external factors of this model (such as
regulatory and other factors) could lead to an increase in unsafe be-
havior, and whilst a clear definition is provided, these external factors
are not discussed in detail. Additionally, because HFACS is only a
qualitative analysis tool and there are many human and organizational
factors involved, the main cause of an accident cannot always be de-
termined.
Therefore, based on the current coal mine accident reports, surveys
and interview records, this study considers the background to the
Chinese coal mine industry and adds the external environment (in-
cluding management factors, political factors, economic factors and
historical factors) to the previous HFACS model. Furthermore, by
modifying the second and third levels and adding links relating to
emergency errors and inadequate planning, a feasible HFACS model for
China's mines (HFACS-CM) is proposed. Furthermore, this model is
subsequently used to analyze and discuss 362 major accidents in China
during the period from 2000 to 2016. Additionally, the unsafe practices
(acts) of human beings during coal production, as well as their influ-
encing factors, are investigated to determine in depth the weight of the
cause of the accident in combination with the AHP method (Saaty and
Hu, 1998). The results from this research could provide valuable gui-
dance for the prevention and enhanced supervision of major coal mine
accidents in China.
2. Method
2.1. The establishment of the HFACS-CM model
Having taken into account the actual conditions and characteristics
of China's coal mines, external environment, which is a new level, in-
adequate planning, which was placed in the preconditions for unsafe
acts level, and emergency errors, which was placed in the unsafe acts
level, were added to the HFACS framework; subsequently, an HFACS
model for China's mines (hereinafter referred to as the HFACS-CM
model) was established. As shown in Fig. 1, in the HFCAS-CM model the
reasons for coal accidents are divided into five levels.
As the accident-causing factors in the HFACS model have been
widely accepted by applications in many fields, such as aviation, rail-
ways, and maritime affairs, this study outlines in detail mainly the
newly-added external environment, inadequate planning and emer-
gency errors (as displayed in Fig. 1).
2.1.1. The external environment
The external environment includes management factors, political
factors, economic factors and historical factors. In terms of manage-
ment factors, the entire coal industry is poorly managed, therefore,
safety supervision and inspections in the coal mine industry lack strong
regulation and effective control methods. Through an analysis of nearly
20 years of major coal mine accidents, the total number of adminis-
trative officials who were in charge of a security area that were pun-
ished add up to more than 500 people. The bad practices of coal mine
R. Liu et al.
Fig. 1. The general framework of the established HFACS-CM model.
supervision departments are some of the main reasons for coal mining
accidents (coal mine safety state, 2014). If coal mine supervision de-
partments do not perform their duties properly, this can often lead to
safety-related accidents in coal mines; indeed the probability of major
accidents occurring in the production process is greatly increased.
Eventually mining companies will suffer serious losses if staff safety
cannot be guaranteed, resulting in a bad reputation for the industry
(Zhou, 2014).
In terms of political factors, the imperfect legal guarantee system in
the coal production process is one of the main causes for frequent
safety-related coal mine accidents (Chen, 2012). The lack of laws and
regulations of coal mines, with some coal mine operators allowing
practices that do not take the safety of their employees into account,
and the miner's life and property not being protected effectively, means
that illegal acts in the coal production process cannot be fundamentally
deterred and punished (Chen, 2006); therefore the probability of safety-
related coal production accidents occurring is increased indirectly.
In terms of economic factors, due to the Chinese economy doing
well and the country's rapid economic development, there has been a
high demand for the output of heavy industry. Consequently, both the
price of, and demand for, coal in China has risen constantly, which has
led to an over production problem in many mines and caused a con-
siderable number of accidents. However, as the economy has slowed
down, market demand has fallen and the coal market has begun to
decline; therefore the capacity problem has become increasingly ser-
ious, with coal enterprises experiencing production and operation dif-
ficulties. Within this context, coal enterprises gradually reduced their
investment in production and safety methods in order to reduce costs,
which resulted in the loss of professional and special operational staff
and the weakening of technical expertise.
In terms of historical factors, after coal exploitation for over half a
century, some old mining areas have experienced gradually shrinking
and exhausted coal resources; additionally, complex geological struc-
tures have also increased the difficulties with regard to resource
mining. Some old mines were extended too deeply for exploitation, and
the once hidden factors that could have led to a disaster became
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International Journal of Industrial Ergonomics 68 (2018) 270–279
increasingly obvious, which gradually increased the safety risks.
2.1.2. Emergency errors (Horberry et al., 2013) and inadequate planning
In the case of unavoidable major accidents, if the mine workers can
master the rescue methods and procedures systematically, compre-
hensively and expertly, and deal with any accidents quickly, any losses
due to accidents can be minimized; otherwise, the accidents become
exacerbated and spread, causing greater losses, and even more ser-
iously, new causalities. Errors in accident handling may affect coal
mine accidents in the following two ways: delayed emergency response
and improper emergency response. If the emergency cannot be resolved
in time, the rescue time will increase, thereby causing more injuries and
deaths as well as property losses. For instance, on September 22nd,
2012, after a fire in the Longshan Coal Mine, Heilongjiang, China, the
owners tried to cover up the accident, and the supervisors concealed it
and did not report it; therefore, the fire was not controlled effectively
and quickly, and the optimal rescue time was increased, which led to 12
deaths in total and a direct economic loss of 25.16 million yuan. If
improper decisions are made in the emergency response or rescue
measures are not implemented optimally, accidents can become ex-
acerbated quickly. For instance, on November 24th, 2004, a gas de-
flagration accident occurred in the No. 415 working face of the
Chengjianshan Coal Mine, Shaanxi, China; unfortunately, because of
poor organization and leadership, the hidden dangers were not elimi-
nated thoroughly, which triggered a secondary explosion and caused
166 deaths, 45 injuries and a direct economic loss of 41.659 million
yuan.
Inadequate planning refers to situations where underground
workers do not make adequate plans and precautions in advance. For
example, underground workers do not take effective water detection
and drainage, outburst and fire prevention and extinguishing measures,
do not undertake any rescue themselves, or the adopted measures are
far from ideal; all of which can exacerbate the risks of major accidents.
Taking the gas explosion accident in Baijiagou Coal mine, Liaoning,
China, on August 18th, 2008 as an example, the gas inspectors were not
carrying a portable methane detector and no effective preventive
R. Liu et al.
measures were taken for preventing the periodic weighting in the
working face.
Conclusively, the external environment, emergency errors and in-
adequate planning all have a significant impact on the occurrence of
major accidents in coal mines, and thus were added to the established
HFACS-CM model.
2.2. The analytic hierarchy process method (AHP)
The AHP method is an effective means of determining the weight
coefficient based on the network system theory and multi-objective
comprehensive evaluation (Beynon, 2007). The AHP method divides
various factors in a complex problem into several ordered layers that
are correlated with each other, therefore organizing these factors. Then,
according to the fuzzy judgment of the objective reality, the relative
importance of each layer is expressed quantitatively, and the weight
coefficients of various factors that represent their relative importance
degrees are determined using mathematical methods (Qiao et al.,
2016).
In this study, the established HFACS-CM model was regarded as an
AHP structure, and from top to bottom consists of the target layer, the
standard layer and the index layer. As shown in Fig. 2, there are 5
criteria and 24 evaluation indexes. Firstly, the importance degrees of
various factors in each layer were determined by experts; then, ac-
cording to these experts' opinions, 5 judgment matrices, S = (uij )n × n ,
were established, where U is the evaluation index, u = {u1, u2, ⋯⋯,un} ,
and n is the order of the judgement matrix. In these matrices, each
factor was assigned different scales between 1 and 9. Table 1 lists the
implications of the different scales in the judgment matrix.
Next, the maximum eigenvalue λ max and corresponding eigenvector
W of the judgment matrix S were calculated using MATLAB. The ei-
genvector is the order of importance of each evaluation index in the
criterion layer; i.e., the allocation of the weight coefficient.
Finally, the consistency index (CI) was calculated for checking the
judgement matrix's consistency. CI can be calculated by:
λ max − n
CI =
n−1
CI
When the random consistency ratio is CR = RI < 0.10 , the AHP-
based ranking results display a favorable consistency, i.e., the weight
coefficients are assigned in a feasible manner. Otherwise, the element
values in the matrix need to be adjusted and the weight coefficient
should be reassigned. Table 2 shows the assignment of average random
RI values.
3. Results
3.1. A statistical analysis of major accidents in China's coal mines from
2000 to 2016
This study first investigated and analyzed the data of major coal
mine accidents in China from 2000 to 2016, and compiled statistics of
accident occurrence regions and times, as well as accident types, using
two absolute indexes (namely, number of accidents and deaths caused
by an accident) and probed the occurrence rules and characteristics of
major coal mine accidents in China. This was done in order to provide
fundamental bases for analyzing the major reasons for the frequency
occurrence of major accidents.
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International Journal of Industrial Ergonomics 68 (2018) 270–279
Table 1
The scales in the judgment matrix and their implications.
Scale Implications and explanations
1 Two factors are equal in importance.
3 Between these two factors, a factor is slightly more important
than the other.
5 Between these two factors, a factor is significantly more
important than the other.
7 Between these two factors, a factor is far more important than
the other.
9 Between these two factors, a factor is extremely more important
than the other
2, 4, 6, 8 The factor is between the above-described two factors in terms
of its importance degree.
1, 1/2, …, 1/9 The importance degrees of two factors are contrary to the above
results.
3.1.1. The regional distribution of major coal mine accidents in China from
2000 to 2016
During the period between 2000 and 2016, 363 major accidents
occurred in China, causing 7612 deaths in total. Fig. 3 shows the
classification statistics of the accidents in different regions, from which
it can be observed that major accidents occurred mainly in southwest,
north, northeast and central China. Specifically: major coal mine acci-
dents occurred mainly in Shanxi, with 62 accidents and 1572 deaths in
total, with deaths from Shanxi's major accidents accounting for 20.65%
of the total death toll in China; and 56, 32 and 34 major accidents
occurred in Guizhou, Heilongjiang and Hunan, respectively, causing
882, 937 and 577 deaths (which accounted for 11.59%, 12.31% and
7.58% of the total death toll respectively). The unbalanced regional
distribution of accidents outlined above is related to the differences in
coal seam conditions, mining difficulties and the level of management
in different regions.
3.1.2. The temporal distribution of major coal mine accidents in China from
2000 to 2016
Fig. 4 shows the trend of major coal mine accidents in China over
the past 17 years. It can be seen that the occurrence of major coal mine
accidents in China decreased overall in a fluctuating pattern; however,
accidents occurred quite frequently from 2002 to 2006, during which
approximately 31–45 accidents occurred and 644–1271 workers died
every year. In particular, the occurrence of major accidents, as well as
the associated deaths, experienced two peaks in 2002 and 2005. The
reason for this is that since 2002, China's coal industry has entered a
“golden age”. Under the macro-economic growth environment, China's
industrialization process has accelerated, and the demand for coal has
increased significantly, bringing rapid growth in production, prices,
and profits. As a result, mining took place in a large number of private
small coal mines, and the investment in safety was relatively in-
sufficient, resulting in the frequent occurrences of serious accidents. In
2005, the State Council issued a document stating explicitly that it is
necessary to speed up the rectification, transformation and improve-
ment of small and medium-sized coal mines, integrate coal resources,
cultivate large-scale coal mining enterprises and enterprise groups, and
complete the mine closure program in 2008. Subsequently, as can be
seen in Fig. 4, the number of accidents and deaths has fallen sharply
since 2006; in particular, major accidents decreased steadily during the
period from 2009 to 2016, with a small fluctuation. From the external
Fig. 2. The AHP architecture in the HFACS-
CM model.
R. Liu et al. International Journal of Industrial Ergonomics 68 (2018) 270–279

Table 2
The assignment of average random RI values.
n 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

RI 0 0 0.58 0.90 1.12 1.24 1.32 1.41 1.45 1.49 1.51 1.54 1.56 1.58 1.59

Fig. 3. The distribution of major coal mine accidents in China from 2000 to 2016.

environment perspective, both the robustness of policies and the related
safety laws and regulations in the coal industry and the reinforcement
of safety supervision reduced the occurrence of major coal mine acci-
dents effectively.
3.1.3. The type distribution of major coal mine accidents in China from
2000 to 2016
We then compiled a classification system using the statistics of
major coal mine accidents in China from 2000 to 2015 in terms of
accident types, with the results shown in Fig. 5. It can be observed that
gas accidents far exceeded the other types of accidents both in fre-
quency and death toll. 233 gas accidents occurred in this period,

Fig. 4. The temporal trend of major coal mine accidents in China from 2000 to 2016.

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R. Liu et al. International Journal of Industrial Ergonomics 68 (2018) 270–279

3.2. The weights of accident-causing factors based on the AHP method

3.2.1. The construction of the judgment matrix and consistency check

The judgment matrices in the HFACS-CM model at the five levels,
namely, external environment, organizational influence, unsafe lea-
dership behaviors, the preconditions of unsafe behaviors and unsafe
behaviors, are denoted as S1, S2, S3, S4 and S5 respectively, and can be
expressed as:

⎡1 3 2 4⎤
1 ⎡1 2 1 2⎤
1
⎢1 3 1 1 2 1⎥ ⎡ 1 2 2⎤ ⎢1
S1 = ⎢ 1 ⎢
⎥ S = 1 1 ⎥ S = 1 3 4⎥
1 1
2 1 2⎥ 2 ⎢ 2 1 3⎥ 3 ⎢ 2 ⎥S4
⎢ 2 ⎢1 3 1 1⎥
⎢1 4 1 1 2 1⎥ ⎣2 3 1⎦
⎣ ⎦ ⎣2 4 1 1⎦

1 1 1 1 1
⎡1 3 2 4 1 1 4 4⎤
⎢3 1 2 1 4 2 1 1⎥
3 2
⎢ ⎥ 1 1
⎡1 2 2 5 1⎤
1
⎢2 1 1 1 2 2 1 1 ⎥
2 3 3 2 ⎢2 1 1 1 2⎥
Fig. 5. The statistics of the types of major coal mine accidents in China from ⎢4 3 3 1 5 3 2 2⎥ ⎢ 3
⎥
2000 to 2016. =⎢ 1 1 1 1 1 1
⎥ S5 = ⎢2 1 1 1 2 2⎥
⎢1 3 2 5 1 2 5 5⎥
⎢5 3 2 1 3 ⎥
⎢ 1 1 1 1 1 ⎥ ⎢ ⎥
⎢1 2 2 3 2 1 3 3⎥ 1 1 1
accounting for 64.37% of the total, and causing 5175 deaths, which ⎢4 2 3 1 5 3 1 2⎥ ⎣1 2 2 3 1⎥
⎢ ⎦
2
accounted for 67.99% of the total. Water disaster accidents were ranked ⎢ ⎥
1 1
second and accounted for 17.96% of total mine accidents. 65 water ⎣4
⎢ 1 2 2 5 3 2 1⎥ ⎦
accidents occurred and caused 1210 deaths, which accounted for Next, the maximum eigenvalues of the established judgment matrix
15.90% of total deaths. With regard to natural conditions, the ex- (λ max ), the values of the consistency index (CI) and the consistency
ploitable coal seams in China consist mainly of Permian limestones, ratios (CR) were calculated, with the results listed in Table 3.
with a high gas content and poor air permeability; additionally, the
geological conditions are complex and gas drainage and outburst pre- 3.2.2. The determination of weights
vention performances are poor, thereby triggering the frequent occur- As can be seen in Table 3, the CR values of S1, S2, S3, S4 and S5 are
rence of gas accidents. all smaller than 0.10, suggesting that the AHP-based raking results have
More specifically, the most common cause of a gas accident was gas a favorable consistency. In other words, the weight coefficients were
explosions, followed by coal and gas outbursts (see Fig. 6). During the assigned in a feasible manner. Having taken into account the calculated
period from 2000 to 2007, gas explosions far exceeded coal and gas maximum characteristic eigenvalues (λ max ), the weights of the acci-
outbursts as well as gas combustion accidents with regard to occurrence dent-causing factors in the established HFACS-CM model were calcu-
and death toll. Since 2008, due to an increase in the coal mining depth, lated, with the results listed in Table 4.
gas outburst disasters have become increasingly serious; therefore the As shown in Table 4: the ranking of the external environment
prevention of coal and gas outburst disasters has become the focus of weights is, management factors > economic factors > economic fac-
mine safety programs (Wang et al., 2017). To fully prevent gas outburst tors > historical factors; the ranking of the organizational influences
accidents, the gas monitoring capabilities must be strengthened. This weights is, organizational processes > resource management >
can be done by Intensifying the control of gas in coal mines, increasing organizational climate; the ranking of the unsafe leadership weights is,
gas monitoring and inspections, actively introducing advanced gas supervisory violations > failure to correct problems > inadequate
forecasting and early warning instruments, and using advanced tech- supervision > planned inappropriate operations; the ranking of the
nologies such as acoustic emission technology (Zhang et al., 2016; preconditions for unsafe acts weights is, mental state > physical en-
Becker et al., 2014), electromagnetic radiation technology (Wang et al., vironment > technological environment > team resource manage-
2003; Hu et al., 2014), and infrared radiation technology (Liu and Lu, ment > personal readiness > physical/intellectual limitations >
2008) to strengthen gas monitoring. inadequate planning > physiological state; and the ranking of the
unsafe acts weights is, violations > decision errors > skill-based er-
rors > emergency errors > perceptual errors.

Fig. 6. The occurrence trend of major coal mine accidents in China from 2000 to 2016.

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Table 3 organizational processes can cause planned inappropriate operations

The index of judgment matrices S. and supervisory violations, or the workers cannot find and correct
Judgment Maximum number average consistency consistency problems. 7 groups in the third and fourth levels had significant causal
matrix S eigenvalues of random index CI ratios CR relationships under the HFACS-CM framework; specifically, inadequate
λmax factors n consistency supervision can cause the workers to prepare poorly and operate in a
index RI poor mental state, planned inappropriate operations can cause the
S1 4.0104 4 0.9 0.0035 0.0038
workers to operate in a poor mental state and an inappropriate man-
S2 3.0092 3 0.58 0.0046 0.0079 agement of team resources, failure to correct the problems can lead to a
S3 4.0458 4 0.9 0.0153 0.0170 poor technological environment and inadequate planning, and super-
S4 8.2351 8 1.41 0.0336 0.0238 visory violations can cause the workers to operate in a poor mental
S5 5.0432 5 1.12 0.0108 0.0097
state. 4 groups in the fourth and fifth levels had significant causal re-
lationships under the HFACS-CM framework; specifically, poor personal
Table 4
readiness can cause skill-based errors, poor mental states can lead to
The weights of accident-causing factors in the HFACS-CM model. violations, improper management of team resources can result in
emergency errors, and a poor technological environment can cause
Index system of HFACS-CM weight Index system of HFACS-CM weight
errors in decision-making.
Level 1:External Environment Level 4:Preconditions for Unsafe Acts
management factors 0.4778 inadequate planning 0.0479 3.4. Results and discussion
political factors 0.1380 team resource management 0.1306
economic factors 0.2561 personal readiness 0.0833 3.4.1. The external environment
historical factors 0.1281 mental state 0.2699
Level 2:Organizational Influences physiological state 0.0403
Management factors are the most important external factor leading
resource management 0.2970 physical/intellectual 0.0618 to major coal mine accidents at the external environment level, with a
limitations weight up to 0.4778. Management factors can increase the possibility of
organizational climate 0.1634 physical environment 0.2119 vulnerabilities in organizational processes by approximately 2.2 times
organizational processes 0.5396 technological environment 0.1543
(with an OR value of 2.169). This is due mainly to the fact that a lack of
Level 3:Unsafe Leadership Level 5:Unsafe Acts
inadequate supervision 0.2254 perceptual errors 0.0935 an effective management mechanism in the coal industry, unsound
planned inappropriate 0.1005 skill-based errors 0.1815 management organization and inappropriate implementation of su-
operations pervision in coal mines all led to vulnerabilities in some mines' on-site
failure to correct problems 0.2968 decision errors 0.1955 safety management and supervision systems. The weight of the eco-
supervisory violations 0.3774 violations 0.4247
emergency errors 0.1048
nomic factors is 0.2561. Rapid economic development led to an in-
crease in the demand for, and price of, coal, thereby causing over
production in mines; contrarily, when the economy is in a difficult si-
3.3. An analysis of the human factors in major coal mine accidents based on tuation, both the demand for, and price of, coal drop, and at the same
the HFACS-CM model time, there is an under-investment in safety and the brain drain be-
comes serious. Economic factors can increase the possibilities of in-
The chi-square test and odds ratio (OR) analysis are types of a hy- appropriate resource management and the loss of an organizational
pothesis test method, which is based on chi-square distribution, and climate by approximately 2.9 times and 2.1 times, with OR values of
were employed in this study for analyzing whether the neighboring two 2.848 and 2.045, respectively. The weight of political factors is 0.1380;
layers in the HFACS-CM model had a significant causal relationship. specifically, the standard system of safety laws and regulations in mines
This study assumed that H0 represented a situation where the accident is still imperfect, and some technical standards and specifications re-
causes in the neighboring two layers of the HFACS-CM model had no lated to safety production are in need of improvement. Political factors
significant causal relationship, and H1 represented a situation where the can increase the possibility of inappropriate resource management by
accident causes in the neighboring two layers of the HFACS-CM model approximately 3.2 times, with an OR value of 3.192. The weight of
had a significant causal relationship. historical factors is 0.1281. The specific issues are a large number of
We then conducted a chi-square and OR analysis on 362 major ac- reserved goaves, the gradual exhaustion of coal resources, complex
cidents in China's mines from 2000 to 2016. If the value of P is very geological conditions in coal seams (Zhou et al., 2018), and the ex-
small, H0 should be rejected and H1 accepted; i.e. there is a significant istence of many dangerous mines, consisting mainly of mines where
cause and effect relationship between the HFACS-CM and the upper and coal and gas outbursts occur frequently, highly gassy mines and spon-
lower levels of the accident. If the OR value is greater than 1, it in- taneous-combustion mines.
dicates that the factors at the upper level can increase the possibility of
the factors occurring at the next level. After screening using the cri- 3.4.2. Organizational influences
terion (P < 0.05 and OR > 1), the causal relationships among different The vulnerabilities in organizational processes are an important
levels in the HFACS-CM model were displayed visually, as can be seen factor leading to major coal mine accidents at the organizational in-
in Fig. 7. fluence level, with a weight of 0.5396. The vulnerabilities in organi-
As shown in Fig. 7, after the significance conditions for chi-square zational processes mainly include the lack of detailed management
tests (i.e., P < 0.05 and OR > 1) were satisfied, 4 groups of factors in systems in the coal enterprises, disordered on-site organizational
the first and second levels had significant causal relationships under the management as well as imperfect regulation and pre-arranged plans.
HFACS-CM framework; specifically, economic factors affected the or- These vulnerabilities imposed significant effects on planned in-
ganizational climate and resource management, political factors af- appropriate operations, failure to correct problems and supervisory
fected resource management, while management factors affected the violations at the level of unsafe leadership. In particular, they affected
organizational process. 6 groups in the second and third levels had the failure to correct problems most significantly. Due to the im-
significant causal relationships under the HFACS-CM framework; spe- perfection of safety production and management systems in coal en-
cifically, the loss of organizational climate can cause inadequate su- terprises, the supervisors were frequently unable to correct the pro-
pervision, improper resource management can cause inadequate su- blems having uncovered them. The imperfection of safety production
pervision and improper operational planning and vulnerabilities in the and management systems in coal enterprises can increase the possibility
of the supervisors' failure to correct the problems having uncovered

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R. Liu et al. International Journal of Industrial Ergonomics 68 (2018) 270–279

Fig. 7. The causal relationships among different levels in the established HFACS-CM model.

them by 5.3 times, with an OR value of 5.300. The weight of imperfect 1.571. If the enterprise is focused overly on production but neglects
resource management ranked only second to vulnerabilities in organi- safety, the supervisors may lack responsibility and pay less attention to
zational processes at this level, and has a weight of 0.2970. The im- safety management; therefore they cannot provide professional gui-
perfect resource management was reflected mainly in the sub-optimal dance, training and supervision for the operational workforce.
arrangement of human resources, capital and facilities. It was also
found that, no suitable ventilation systems and facilities in underground
3.4.3. Poor leadership
mines, insufficient operating personnel, improper arrangements, un-
Supervisory violations are the main reason for the occurrence of
suitable equipment or lack of timely inspections of the equipment can
major coal mine accidents at the leadership behaviors' level, with a
all lead to a situation where the prevention and control of the occur-
weight value of 0.3774. Specifically, supervisory violations include
rence of major accidents is ineffective. Improper resource management
mainly failure to implement the existing rules and regulations and au-
can increase the occurrence of both inadequate supervision and
thorizing unqualified teams to work in the mines. These errors in the
planned inappropriate operations by 1.8 times, with OR values of 1.806
supervisors' decision-making resulted from an unfamiliarity with the
and 1.745, respectively. The weight of the loss of an organizational
production environment, incapability of conscientiously implementing
climate is 0.1634. The loss of an organizational climate refers mainly to
safety measures and lack of communication and coordination with the
placing too much emphasis on production, but not enough on safety,
relevant technicians. Among all the supervisory violations, illegal
and the imperfections in the enterprises' management structures and
commands are the most common. Supervisory violations imposed sig-
policies. The loss of an organizational climate can increase the occur-
nificant effects on the workers' mental states, which can increase the
rence of insufficient supervision by 1.6 times, with an OR value of
possibility of poor mental states by 2.8 times, with an OR value of

277
R. Liu et al.
2.761. The weight of failure to correct problems ranks second, with a
value of 0.2968. Specifically, failure to correct problems means that the
supervisors cannot find the problems or did not correct them when they
discovered defects in individuals, equipment, training or other safety-
related fields. Failure to correct problems can affect the technological
environment at the preconditions' level significantly. If the supervisors
discovered problems with the equipment but did not report them and
eliminate the problems in a timely manner, the daily equipment
maintenance would be insufficient and the risk of a poor technical
environment would be increased; meanwhile, if the supervisors do not
find or correct any problems, the operators will not make adequate
plans or take precautionary measures in advance, thereby increasing
the possibility of inadequate planning by 1.88 times (with an OR value
of 1.871). Inadequate supervision has a weight value of 0.2254; spe-
cifically, it means that the supervisors do not provide the operators with
proper guidance, training, supervision and encouragement. If the su-
pervisors do not educate and train their staff adequately, the operators
in some important positions will work without proper training and the
staff will pay insufficient attention to safe production methods.
Inadequate supervision can make the possibility of poor personal
readiness increase by 2.3 times, with an OR value of 2.270. The weight
of planned inappropriate operations is 0.1005. Planned inappropriate
operations include mainly the improper matching of personnel in a
team, insufficient instruction time and opportunity to rest and too
heavy a workload. Planned inappropriate operations can increase the
possibility of inappropriate team resource management by 3.0 times,
with an OR value of 2.957. If the workers in a team are matched in-
appropriately, the communication among different sectors and different
miners would be affected very quickly.
3.4.4. Preconditions of unsafe acts
The operators' poor mental states are the main reason for the oc-
currence of unsafe behaviors at the preconditions' level, with a weight
of 0.2699. This manifests itself in the negative effects of workers' psy-
chosocial or mental states, such as mental fatigue, improper attitude,
poor motivation, low vigilance, and lack of concentration. Although the
weight value of this factor is relatively large, the psychosocial or mental
states of miners are easily overlooked in accident investigation and
analysis. If a coal mine employee is in a state of high pressure and
anxiety, is feeling unlucky or distracted, or has other unhealthy psy-
chosocial or mental feelings during operations, it may lead directly to
employees making erroneous perceptions and judgments, resulting in
unsafe behavior. Taking the 8.14 roof accident in Xinjiang as an ex-
ample, as the miners worked intensively for a long time, they became
mentally exhausted. The workers' poor mental states, weak safety
awareness and lack of vigilance may increase the occurrence of viola-
tions by 12.1 times, with an OR value up to 12.051. The physical en-
vironment ranks only second to poor mental states among all the pre-
conditions of unsafe behaviors, and has a weight of 0.2119. Due to the
extremely harsh environment underground, the operators may suffer
from a number of issues; specifically, the underground operating en-
vironment has a number of problems (Fan et al., 2018; Zhou et al.,
2017), including inadequate lighting, noise, vibration, harmful gases,
dust and flooding. The weight of the technological environment is
0.1543. The technical environment mainly refers to the conditions
where the operating environment lacks protective equipment or the
protective equipment is imperfect and requires a timely overhaul.
Taking the 6.15 gas explosion accident in Shaanxi as an example, due
the lack of a timely repair, a short circuit appeared in the electrical
equipment, thereby generating electric sparks. The lack of the techno-
logical environment can cause mistakes in the operators' decision errors
to increase by 2.1 times (with an OR value of 2.138). The weight of
team resource management is 0.1306. Specifically, a poor team re-
source management is manifested mainly in the following aspects: the
leaders' lack of leadership ability; there is insufficient communications
among the staff or between the departments and the staff; and there is a
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International Journal of Industrial Ergonomics 68 (2018) 270–279
lack of teamwork. After an accident, insufficient teamwork and com-
munication can increase the occurrence of emergency errors by 2.6
times (with an OR value of 2.548). The weight of personal readiness is
0.0833. If the operators are not tested as required, lack training, do not
take medicine or have a poor diet, they will be in a poor individual state
of preparation. Taking the 12.26 fire accident in Hebei as an example,
the miners worked for a long period, did not conform to rest re-
commendations, and therefore became weak physically and lacked
energy. In such cases, the workers' skills can drop significantly, and the
possibility of skill-based errors occurring increase by 2.5 times (with an
OR value of 2.460). The weight of physical and intellectual limitations
is 0.0618. Physical and intellectual limits refer mainly to insufficient
operating skills, a lack of safety knowledge or experience of handling
complex scenarios. Taking the 10.29 flooding accident in Sichuan as an
example, the operators lacked geological and hydrological knowledge
and experience in the incident of a water burst and did not discover the
flood in a timely manner, thereby triggering the accident. Inadequate
planning, with a weight of 0.0479, includes mainly the operators not
making adequate plans and taking preventive measures in advance. If
underground operators do not take effective water detection and drai-
nage, outburst prevention and fire prevention and extinguishing mea-
sures, the possibility of an accident occurring will be increased. Poor
physiological states, with a weight of 0.0403, are manifested mainly in
poor individual physiological states that hinder safe operations and are
induced by illness or hypoxia. Obviously, if the operator persists in
working in spite of an illness, unsafe acts will occur quickly, thereby
triggering an accident.
3.4.5. Unsafe acts
The workers' violations have a maximum weight of up to 0.4247 at
the unsafe behaviors' level, followed by decision errors, skill-based er-
rors, emergency errors, and perceptual errors, with a weight of 0.1995,
0.1815, 0.1048 and 0.0935 respectively. Specifically, violations include
mainly the violation of rules, regulations and standard operating pro-
cedures. For instance: the 2.16 derailing accident in Hunan was caused
by workers travelling in a tramcar and the mixed hanging of the
tramcar, which was against regulations; and with regard to the 3.24 gas
explosion accident in Jilin, the workers did not obey regulations and
repaired a switch in the spotting hoist without switching the power off,
thereby generating electric sparks and triggering the accident. In gen-
eral, decision errors mean that operators do not resolve problems in the
correct way or do not spot any dangers before starting work. For ex-
ample, both the 10.5 roof-fall accident in Xinjiang and 9.20 fire acci-
dent in Heilongjiang were caused by workers' decision errors. Technical
errors refer to the errors related to skills caused by inattention, bad
memory or poor technical quality; specifically, they are manifested in
non-standard operations, blind operations, rash operations and dan-
gerous operations. For example, the 4.7 flooding accident in Yunnan
was caused directly by workers' rash and dangerous operations.
Emergency errors mean that the operators do not take the correct
measures, or don't take them in a timely manner. Taking the 5.11 gas
explosion accident in Guizhou and gas poisoning accident in
Heilongjiang as examples, after the accidents, the people concerned
organized the rescue blindly and therefore exacerbated the number of
casualties. Perceptual errors are those that occur when working un-
derground or under conditions of bad weather and noisy machinery, or
other conditions that reduce human perception (cognition is an in-
consistent understanding of the actual conditions), such as a misjudg-
ment of distance, height, and direction. For example, in underground
mining or mechanized mining, the noise generated by vibrations far
exceeds that which the human body is able to bear, seriously hindering
the human body's ability to adjust and adapt, and thus leading to
mistakes in the judgment of outside information and safety. In addition,
most underground coal mines have small and dark working spaces and
irregular layouts, which also affect the miners' behavior. For example,
the 3.11 water/sand bursting accident in Heilongjiang was caused by an
R. Liu et al.
incorrect knowledge of the overlying strata's destruction height.
4. Conclusions
Based on a summary and analysis of the serious accident in-
vestigation reports of 2000–2016, the HFACS-CM model for the coal
mining industry is established in this paper. The 362 serious accidents
are analyzed and discussed in combination with the AHP method,
which confirms the feasibility and applicability of the model in the field
of coal mining. The HFACS-CM model can not only provide a reference
and basis for the establishment of a coal industry safety risk classifi-
cation management system, standards of reporting and an analysis
framework, but can also be used for coal mine safety accident in-
vestigation and analysis and to avoid prejudice in the investigation and
analysis of accidents due to restricted or missing information.
Acknowledgements
This work was supported by the National Natural Science
Foundation of China [51704184, 51574158]; Research Foundation of
Key Laboratory of Safety and High-efficiency Coal Mining, Ministry of
Education [JYBSYS2017102]; Opening Project Fund of State Key
Laboratory of Mining Disaster Prevention and Control Co-founded by
Shandong Province and the Ministry of Science and Technology
[MDPC2016ZR02]; Talent Introduction Research Start-up Fund Project
of Shandong University of Science and Technology [2016RCJJ024];
Shandong Natural Science Foundation of China [ZR2017QEE017,
2018GSF120013]; and 2018 Graduate Science and Technology
Innovation Funded Project [SDKDYC180306].
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