Ten steps from disaster

In an era where we scarcely blink when a probe lands on an asteroid, why do major industries continue to kill in the same old ways? A groundbreaking new study shows a lack of will and not a lack of know-how is behind ‘ten pathways to death and disaster’.

In an era where we scarcely blink when a probe lands on an asteroid, why do major industries continue to kill in the same old ways?

Professor Michael Quinlan has studied the causes of workplace tragedies. He has reached a clear conclusion. A lack of will and not a lack of know-how is behind ‘ten pathways to death and disaster’.

The professor’s research shows that obtaining, processing and using the substances that fill our lives – from food, to fuels to household products – can come at a high human price. “In mining, apart from electrocution and incidents with machinery, the ways miners are killed - fires and explosion, falls of ground, falls from height, inrush/inundations and asphyxiation - have been known for hundreds of years,” notes Quinlan. He says this raises a troubling question.

“With a litany of death and disasters to learn from, why are incidents like the fatal explosions at the Upper Big Branch mine in the US and Pike River mine in New Zealand, which both killed 29 coal miners in 2010, still occurring?”

The safety management expert from the University of New South Wales in Australia says these repeat incidents often arise from strikingly similar causes, or ‘pattern failures’.

So when a chemical factory blows up or a mine caves in, it is not the inevitable consequence of our thirst for ‘stuff’. “Failures or flaws arise from conscious decisions by those in charge of workplaces, by governments or those responsible for enforcing safety legislation,” he notes.

Quinlan has just completed a review of the official investigations into 23 fatal mine incidents in five countries - Australia, Britain, Canada, New Zealand and the United States - between 1992 and 2011. The findings, spelled out in his new book, Ten pathways to death and disaster, reveal 10 recurring pattern causes.

1. Engineering, design and maintenance flaws
2. failure to heed warning signs
3. flaws in risk assessment
4. flaws in management systems
5. flaws in system auditing
6. economic or reward pressures compromising safety
7. failures in regulatory oversight
8. worker or supervisor concerns that were ignored
9. poor worker or management communication and trust, and
10. flaws in emergency and rescue procedures.

The most common pattern flaws include design, engineering and maintenance failures, failures to heed warning signals, flaws in management systems, worker and other concerns that were ignored, poor emergency procedures, and failures in regulatory oversight.

Quinlan found systems that allowed workers – unions – an active role were safer. He cites the example of a law change in the late 1990s that introduced full-time union safety officers in the two major mining states in Australia. Since then, there have been no mine disasters at a time when there has been a substantial expansion in the sector.

His study also examines workplace disasters in other high hazard workplaces including aviation, major hazard facilities, factories, oil rigs and refineries across a wider timescale, 1980 to 2011, and range of countries.

Again, the same pattern failures played “a recurring and conspicuous role” in these incidents, including the fire at BP’s Texas City Refinery in 2005 that killed 15 contract workers and the Deepwater Horizon oil rig disaster in 2010 that killed 11 workers and did monumental environmental damage.

“Almost all these incidents arose from causes that were both predictable and preventable. In most cases there was clear evidence of serious flaws long before the incident that were ignored by management. The flaws were not addressed by regulators due to a lack of resources or effective enforcement measures,” he says.

Cost-cutting and production pressures were evident again and again. Reliance on multi-tiered subcontracting, which encouraged cost cutting and fractured occupational health and safety (OHS) systems, was another recurring failure point. He points to the catastrophic fire at the AZF chemical plant in France in 2001, where 28 workers and one student died, and 30 others were seriously injured.

According to Quinlan: “Changes to work organisation including downsizing and restructuring can rapidly corrode even initially robust safety regimes.”

Some popular explanations of disaster and death at work didn’t stand up to scrutiny. Quinlan found the incidents didn’t arise from complex technology, unknown hazards, poor safety culture or simple human error.

‘Unsafe’ behaviour was at most “the last failure point in a system that was already severely corroded”, with the behaviour anyway commonly condoned and conditioned by management through poor training and supervision, production pressures, pay incentives and bonuses and the use of contractors.

“My findings provide a clear guide for interventions,” says Quinlan. “Unfortunately, the current political economy of safety makes this unlikely to occur in anything other than a sporadic and partial fashion.”

The book points the finger at a system that puts a low value on human life. Quinlan writes: “The political economy perspective argues that safety, including workplace disasters, can only be understood in the context of the distribution of wealth and power within societies, and dominant social policy paradigms that privilege markets and profit, production or economic growth over safety.”

In all five countries examined by Quinlan, there was evidence of a pervasive mantra of the ‘need’ to reduce the regulatory burden or ‘red tape’ on business– “an obscenity in the context of work safety laws whose goal is to stop the spilling of blood at work,” Quinlan notes.

“The failure of governments to hold boards of directors accountable for their decisions affecting safety and their connivance in the weakening of unions and worker input, has also limited any incentive for learning. Prosecution let alone conviction or gaoling of directors whose decisions - including the failure to consider safety consequences - contributed to deaths is exceptionally rare, and then usually limited to smaller companies.”

In the book, Quinlan says directors cherry-pick the issues for which they accept responsibility. “Directors take credit for the financial success of organisations but very few appear to take a corresponding responsibility for failures that result in the death of those that work for them,” he writes. “That this bizarre situation is accepted as normal is telling about what the rhetoric about safety coming first really means.”

While his research focused on five rich countries with longstanding regulatory regimes and some (though corroding) level of accountability, Quinlan identified the same pattern causes in incidents in high hazard workplaces in low to middle income countries like Brazil and China.

“The same point can be made with regard to the 2014 mine disaster in Soma, Turkey where 301 miners died and there was evidence of inadequate rescue and emergency procedures and poor inadequate regulatory oversight to name but two pattern causes,” he says, warning that, if anything, the trend is towards more dangerous practices.

“Global supply chains are increasingly facilitating the erosion of safety standards by moving work to countries with minimal safety standards and no protocols for raising standards as part a free trade agenda. The 2013 Rana Plaza building collapse in Bangladesh which killed over 1,100 - mainly garment factory workers, many producing clothing for the West - exemplifies this,” he says.

“These facts are eloquent testament to the point that irrespective of the rhetoric, workplace safety doesn’t come first, or even second or third when it comes to the priorities of governments or most corporations.”

Ten pathways to death and disaster, Michael Quinlan, The Federation Press, ISBN 9781862879775, December 2014.