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Abstract
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Introduction
Considerable research has been undertaken to identify key causes of major incidents and disasters. Single fatalities and incidents resulting in serious injury have received less attention. These incidents, often referred to as occupational incidents, are investigated and prevented by identifying and managing risks related to proximate causes. The plateau in rates of fatalities and serious injuries suggests this approach is not working.
Aim
To examine if recurrent failures identified in major incidents are also present in other serious incidents and if regulatory failure and economic pressures are contributing factors.
Methods
The Ten pathways model was used to analyse 51 serious incidents investigated by the mining regulator in New South Wales (NSW), a major mining jurisdiction in Australia. The sample included incidents at 16 underground and nine surface coal mines, and four underground metalliferous mines. The primary data source was official regulatory investigation and prosecution summary reports published on the NSW mining regulator's website. To understand the socio-economic context, the study used other sources.
Results
The study confirmed the Ten pathways model identified the recurrent failure points for serious incidents. Seventy five percent of incidents exhibited at least five pattern-failures and 25% exhibited eight or more. The most common pattern-failures were engineering (98%); risk assessment failures (98%); and safety management system flaws such as inadequate statutory inspection, information transfer between shifts and levels, and an overreliance on personal safety routines to control risks (96%). Economic pressures and regulatory failure were identified in 71% and 55% of incidents respectively.
Conclusions
When investigating incidents and designing injury prevention strategies regulators and mine operators should consider economic pressures arising from the broader socio-economic environment.
Language: en |