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APPLICATION APPLICATION OF OF A A LOSS LOSS CAUSATION CAUSATION MODEL MODEL TO TO THE

APPLICATIONAPPLICATION OFOF AA LOSSLOSS CAUSATIONCAUSATION MODELMODEL TOTO THETHE WESTRAYWESTRAY MINEMINE EXPLOSIONEXPLOSION

PaulPaul AmyotteAmyotte 11 andand AdrianAdrian OehmenOehmen 22 DepartmentDepartment ofof ChemicalChemical EngineeringEngineering 11 DalhousieDalhousie UniversityUniversity 22 UniversityUniversity ofof QueenslandQueensland

Lacking Lacking t t h h e e simplest simplest protect protect i i ve

LackingLacking tthhee simplestsimplest protectprotectiiveve geagearr,, minersminers strstruggleuggle tthhroughrough ttooxicxic fumesfumes ttoo carcarryry hundrhundreded--plusplus--poundpound loadsloads ofof sulfursulfur outout ofof anan actactiiveve volcanovolcano inin JavaJava (Indonesia).(Indonesia). GrGreeeedydy forfor economiceconomic growth,growth, tthhee nownow

defunctdefunct 3232--yearyear SuharSuharttoo regimeregime paidpaid scantscant attentionattention toto

workerworker safetysafety

NatNatiionalonal Geographic,Geographic, MarchMarch 20012001

i o n t o t o worker worker safety safety Nat Nat i i onal
This This could could never never happen happen in in Canada Canada – – or

ThisThis couldcould nevernever happenhappen inin CanadaCanada oror couldcould it?it? (i.e.(i.e. payingpaying scantscant attentionattention toto workerworker safety)safety)

could could it? it? (i.e. (i.e. paying paying scant scant attention attention to to worker worker
OUTLINE OUTLINE •• ScopeScope && ObjectivesObjectives •• IntroductionIntroduction –– WestrayWestray

OUTLINEOUTLINE

•• ScopeScope && ObjectivesObjectives •• IntroductionIntroduction –– WestrayWestray –– LossLoss CausationCausation ModelModel •• ModelModel ComponentsComponents •• LessonsLessons LearnedLearned •• ConcludingConcluding RemarksRemarks

SCOPE SCOPE & & OBJECTIVES OBJECTIVES •• ScopeScope –– CaseCase studystudy developeddeveloped usingusing

SCOPESCOPE && OBJECTIVESOBJECTIVES

•• ScopeScope –– CaseCase studystudy developeddeveloped usingusing publicpublic domaindomain resourcesresources (particularly(particularly ReportReport ofof thethe WestrayWestray MineMine PublicPublic Inquiry)Inquiry) •• ObjectivesObjectives –– SystematicallySystematically analyzeanalyze accidentaccident causescauses –– IdentifyIdentify lessonslessons toto bebe learnedlearned –– Ultimately,Ultimately, preventprevent similarsimilar accidentsaccidents inin futurefuture

INTRODUCTION INTRODUCTION Westray Westray •• CoalCoal miningmining hashas beenbeen anan integralintegral partpart

INTRODUCTIONINTRODUCTION

WestrayWestray

•• CoalCoal miningmining hashas beenbeen anan integralintegral partpart ofof PictouPictou CountyCounty (Nova(Nova Scotia)Scotia) historyhistory sincesince thethe firstfirst commercialcommercial minemine openedopened inin StellartonStellarton inin 1807,1807, toto thethe closingclosing ofof thethe DrummondDrummond minemine inin WestvilleWestville inin 1974.1974. OnOn SeptemberSeptember 11,11, 19911991 WestrayWestray openedopened aa newnew mmiinene inin Plymouth.Plymouth. •• AtAt 5:205:20 amam onon MayMay 9,9, 19921992 afterafter onlyonly eighteight monthsmonths ofof operation,operation, anan explosionexplosion rippedripped throughthrough thethe minemine killingkilling 2626 menmen whowho werewere undergroundunderground atat thethe time.time.

Nova Nova Scotia Scotia – – East East Coast Coast of of Canada Canada

NovaNova ScotiaScotia EastEast CoastCoast ofof CanadaCanada

Nova Nova Scotia Scotia – – East East Coast Coast of of Canada Canada
Pictou Pictou County County – – Northeastern Northeastern Nova Nova Scotia Scotia

PictouPictou CountyCounty NortheasternNortheastern NovaNova ScotiaScotia

Westray Westray – – Plymouth, Plymouth, NS NS

WestrayWestray Plymouth,Plymouth, NSNS

Westray Westray – – Plymouth, Plymouth, NS NS
INTRODUCTION INTRODUCTION Loss Loss Causation Causation Model Model •• ToolTool usedused inin accidentaccident

INTRODUCTIONINTRODUCTION LossLoss CausationCausation ModelModel

•• ToolTool usedused inin accidentaccident investigationinvestigation toto determinedetermine rootroot causescauses •• ManyMany variationsvariations ofof suchsuch modelsmodels •• DominoDomino modelmodel usedused herehere •• StructuredStructured methodmethod ofof identifyingidentifying andand categorizingcategorizing multiplemultiple causescauses •• ManagementManagement issuesissues (inspectorate(inspectorate andand otherother governmentgovernment officialsofficials outsideoutside scope)scope)

MODEL MODEL COMPONENTS COMPONENTS

MODELMODEL COMPONENTSCOMPONENTS

MODEL MODEL COMPONENTS COMPONENTS
LOSS LOSS People People

LOSSLOSS

PeoplePeople

LOSS LOSS People People
LOSS LOSS Property Property

LOSSLOSS

PropertyProperty

LOSS LOSS Property Property
LOSS LOSS Property Property

LOSSLOSS

PropertyProperty

LOSS LOSS Property Property
LOSS LOSS Property Property

LOSSLOSS

PropertyProperty

LOSS LOSS Property Property
LOSS LOSS Property Property

LOSSLOSS

PropertyProperty

LOSS LOSS Property Property
LOSS LOSS Process Process

LOSSLOSS

ProcessProcess

LOSS LOSS Process Process
LOSS LOSS Process Process •• CurraghCurragh ResourcesResources bankruptbankrupt •• LoanLoan defaultsdefaults

LOSSLOSS

ProcessProcess

•• CurraghCurragh ResourcesResources bankruptbankrupt •• LoanLoan defaultsdefaults (provincial(provincial andand federalfederal governments)governments) •• Severance,Severance, worker’sworker’s compensation,compensation, pensionpension plan,plan, andand UIUI paymentspayments •• CostCost ofof criminalcriminal investigationinvestigation andand trialtrial •• NSNS PowerPower lossloss ofof coalcoal •• FutureFuture wages/income/personalwages/income/personal losseslosses

INCIDENT INCIDENT

INCIDENTINCIDENT

INCIDENT INCIDENT
Mine Mine Layout Layout

MineMine LayoutLayout

Coal Coal Dust Dust Explosibility Explosibility

CoalCoal DustDust ExplosibilityExplosibility

IMMEDIATE IMMEDIATE CAUSES CAUSES Substandard Substandard Practices Practices •• ImproperImproper useuse ofof

IMMEDIATEIMMEDIATE CAUSESCAUSES SubstandardSubstandard PracticesPractices

•• ImproperImproper useuse ofof ventilationventilation •• PoorPoor housekeepinghousekeeping withwith respectrespect toto coalcoal dustdust •• ContinuationContinuation ofof miningmining inin spitespite ofof inoperableinoperable methanometersmethanometers •• StorageStorage ofof fuelfuel andand rere--fuelingfueling ofof vehiclesvehicles undergroundunderground •• InadequateInadequate rockrock dustingdusting

Rock Rock Dust Dust Requirements Requirements

RockRock DustDust RequirementsRequirements

IMMEDIATE IMMEDIATE CAUSES CAUSES Substandard Substandard Conditions Conditions •• InadequateInadequate

IMMEDIATEIMMEDIATE CAUSESCAUSES SubstandardSubstandard ConditionsConditions

•• InadequateInadequate ventilationventilation systemsystem designdesign andand capabilitycapability •• PoorPoor statestate ofof minemine roofroof –– FrequentFrequent roofroof--fallsfalls •• ThickThick layerslayers ofof coalcoal dustdust –– UnacceptablyUnacceptably highhigh levellevel ofof combustiblecombustible mattermatter •• InadequateInadequate systemsystem toto warnwarn ofof highhigh methanemethane levelslevels

BASIC BASIC CAUSES CAUSES Personal Personal Factors Factors •• LackLack ofof miningmining experienceexperience ofof

BASICBASIC CAUSESCAUSES PersonalPersonal FactorsFactors

•• LackLack ofof miningmining experienceexperience ofof personnelpersonnel workingworking inin minemine •• LackLack ofof knowledgeknowledge ofof safesafe undergroundunderground workwork practicespractices •• PhysiologicalPhysiological stressstress –– MethaneMethane overexposureoverexposure –– FatigueFatigue duedue toto 1212--hourhour shiftsshifts •• PsychologicalPsychological stressstress -- fearfear ofof reprisalreprisal •• ImproperImproper motivationmotivation –– ProductionProduction atat expenseexpense ofof safetysafety

BASIC BASIC CAUSES CAUSES Job Job Factors Factors •• LackLack ofof properproper orientationorientation andand

BASICBASIC CAUSESCAUSES JobJob FactorsFactors

•• LackLack ofof properproper orientationorientation andand trainingtraining •• InadequateInadequate followfollow--throughthrough fromfrom inspectionsinspections •• PoorPoor communicationcommunication ofof standardsstandards (e.g.(e.g. JOSHJOSH Co.)Co.) •• InadequateInadequate purchasingpurchasing ofof rockrock dustdust •• InadequateInadequate leadershipleadership inin termsterms ofof assignmentassignment ofof responsibilityresponsibility •• LackLack ofof safesafe workwork practicespractices andand proceduresprocedures •• InadequateInadequate engineeringengineering duringduring minemine designdesign andand planningplanning

LACK LACK OF OF MANAGEMENT MANAGEMENT CONTROL CONTROL Inadequate Inadequate Program Program Elements Elements ••

LACKLACK OFOF MANAGEMENTMANAGEMENT CONTROLCONTROL InadequateInadequate ProgramProgram ElementsElements

•• ManagementManagement commitmentcommitment andand accountabilityaccountability toto safetysafety mattersmatters •• ManagementManagement ofof changechange proceduresprocedures •• IncidentIncident investigationinvestigation •• TrainingTraining •• TaskTask definitiondefinition andand safesafe workwork practicespractices andand proceduresprocedures •• WorkplaceWorkplace inspectionsinspections andand hazardhazard IDID •• ProgramProgram evaluationevaluation andand auditaudit

LACK LACK OF OF MANAGEMENT MANAGEMENT CONTROL CONTROL Inadequate Inadequate Program Program Standards Standards

LACKLACK OFOF MANAGEMENTMANAGEMENT CONTROLCONTROL InadequateInadequate ProgramProgram StandardsStandards

•• ConcernConcern expressedexpressed byby managementmanagement towardtoward safetysafety mattersmatters •• FollowFollow--throughthrough onon inspectionsinspections forfor substandardsubstandard practicespractices andand conditionsconditions •• ActionAction onon hazardhazard reportsreports submittedsubmitted byby employeesemployees •• JobJob instructionsinstructions forfor employeesemployees •• EquipmentEquipment maintenancemaintenance •• SchedulingScheduling ofof management/employeemanagement/employee meetingsmeetings toto discussdiscuss safetysafety concernsconcerns

LACK LACK OF OF MANAGEMENT MANAGEMENT CONTROL CONTROL Inadequate Inadequate Compliance Compliance Factors Factors

LACKLACK OFOF MANAGEMENTMANAGEMENT CONTROLCONTROL InadequateInadequate ComplianceCompliance FactorsFactors

•• PoorPoor correlationcorrelation betweenbetween managementmanagement actionsactions andand officialofficial companycompany policypolicy concerningconcerning relationshiprelationship betweenbetween safetysafety andand productionproduction •• ComplianceCompliance toto industryindustry practicepractice andand legislatedlegislated standardsstandards –– MethaneMethane concentrations,concentrations, rockrock dusting,dusting, controlcontrol ofof ignitionignition sourcessources underground,underground, etc.etc.

LESSONS LESSONS LEARNED LEARNED •• Don’tDon’t dodo thingsthings thethe WestrayWestray way!way!

LESSONSLESSONS LEARNEDLEARNED

•• Don’tDon’t dodo thingsthings thethe WestrayWestray way!way!

LESSONS LESSONS LEARNED LEARNED •• Don’tDon’t dodo thingsthings thethe WestrayWestray way!way!
Pre Pre - - Contact Contact Control Control •• SYSTEMSYSTEM •• LossLoss ManagementManagement System:System:

PrePre--ContactContact ControlControl

•• SYSTEMSYSTEM

•• LossLoss ManagementManagement System:System: PSMPSM

•• ATTITUDEATTITUDE

•• InternalInternal ResponsibilityResponsibility System:System: IRSIRS •• EveryoneEveryone responsibleresponsible forfor healthhealth andand

safetysafety toto extentextent ofof authorityauthority andand

ability ability

CONCLUDING CONCLUDING REMARKS REMARKS •• LossLoss causationcausation modelmodel isis aa usefuluseful tooltool forfor

CONCLUDINGCONCLUDING REMARKSREMARKS

•• LossLoss causationcausation modelmodel isis aa usefuluseful tooltool forfor identificationidentification ofof rootroot causescauses ofof accidentsaccidents •• AccidentAccident preventionprevention requiresrequires leadershipleadership byby managementmanagement onon safetysafety issuesissues •• PrePre--contactcontact stagesstages affordafford greatestgreatest opportunitiesopportunities forfor lossloss preventionprevention •• LossLoss managementmanagement systemsystem andand attitudeattitude towardstowards safetysafety gogo handhand--inin-- handhand