Learning from the past – the lessons of recent investigations and inquiries in Queensland’s mining industry

In recent times, Queensland’s mining industry has experienced a number of systemic failures that have had significant adverse effects on the safety and health of workers.

In 2015, Queensland’s mining industry was impacted by the re-identification of coal workers’ pneumoconiosis, or black lung. For the preceding 30 years, no cases of black lung had been diagnosed and the industry had worked under the mistaken belief that the disease had been eradicated. Sadly, it had never been eradicated and continued to afflict workers throughout that period.

When black lung was first re-identified, investigations primarily focused on protecting underground coal mine workers from the harmful effects of coal dust. However, it was soon apparent that the issue was far more complex and involved a number of other mine dust lung diseases, including silicosis, chronic obstructive pulmonary disease, and asbestosis. The monitoring of hazardous dusts was expanded to include respirable crystalline silica and other airborne contaminants in both underground and surface coal mines, and programs were expanded to include mineral mines and quarries.

A number of investigations and inquiries were initiated and they revealed a complex failure at many levels including among the industry, the regulator and the health system. Many of the findings related to a lack of effective controls being in place to minimise risk and to protect workers from harm. However, on closer examination, it was also apparent there was a lack of appropriate data to measure performance and risk. Put simply, the industry was not accurately measuring exposure and was unable to identify the precursors and early warnings that would have allowed corrective action to take place.

Fast forward a few years and Queensland’s mining industry was again at a crossroads as it experienced eight fatalities and two significant underground events in a two-year period. These incidents prompted a new round of reviews and inquiries including the Review of all fatal accidents in Queensland mines and quarries from 2000 to 2019 by Dr Sean Brady and the recently completed Queensland Coal Mining Board of Inquiry.

One of the significant findings of the Brady review was that the industry had a lack of effective controls in place to minimise risk and protect workers from harm. Dr Brady observed that this was borne out of a lack of appropriate data and identification of the hazards and an inadequate reporting culture in the industry.

In his report, Dr Brady said that an examination of the investigations into the 47 fatalities between 2000 and 2019 gave the impression that many were freak accidents or human error – that events transpired in such a way that could never have been anticipated. However, he noted that the majority of fatalities were not freak accidents at all – many were preventable, and there was rarely a single cause. He found that many of these incidents occurred because of a failure of the fundamentals of safety – ineffective or non-existent controls – a failure to identify the hazards and control them effectively. Like mine dust lung disease, these fatalities were the result of systemic and organisational failures.

Concerningly, another of Dr Brady’s findings was that the most common type of controls put in place in the aftermath of an incident were administrative controls—one of the least effective available. The industry’s main response to fatal incidents was to rely on more paperwork and more checklists to try to control hazards, rather than using effective elimination, substitution or engineering controls to remove people from harm’s way.

The Queensland Coal Mining Board of Inquiry too has made findings that are consistent with those of the coal workers’ pneumoconiosis investigations and Brady review – complex failures relating to the measuring and monitoring of hazards, resulting in ineffective controls and ultimately leading to catastrophic outcomes. The board also highlighted the importance of ensuring workers have the confidence to raise safety concerns and report incidents as soon as possible, without fear of reprisal or adverse consequences.

Even though the Board of Inquiry, Coal Workers’ Pneumoconiosis Select Committee and Brady reviews were all looking at very different incidents, there are consistencies in the findings of their investigations:

• the failures were complex but the explanations were often simplified – blaming human error
• a failure to learn from past incidents – there are always precursors or early warnings that should have been noticed and acted upon
• a failure to identify hazards correctly – resulting in an inability to measure the risk posed to workers
• ineffective or non-existent controls
• a preference for administrative controls over engineering controls
• an inadequate reporting culture – resulting in the normalisation of hazards.

These common findings are equally applicable to coal mining, mineral mining and quarrying operations of all sizes and levels of sophistication.

Most concerning of all is that none of the failures identified by the Coal Workers’ Pneumoconiosis Select Committee, Brady review or Coal Mining Board of Inquiry are new—and the recommendations made for industry or the regulator share many themes in common. All of them build on recommendations made in the aftermath of many previous incidents, which have been explored and discussed at industry conferences, seminars and workshops for decades.

In his report, Dr Brady recommended that the industry should adopt the principles of high reliability organisations as a way to improve safety. As an industry, we are currently on a journey to implement these principles, and some organisations – often under different terminologies – have been at it for many years. While I don’t think there is a ‘one-size-fits-all’ way to navigate this journey – and what works for one organisation may not work for another – it is clear that the industry needs to reconsider how it approaches safety and health.

To continue on our safety and health journey, as an industry we need to ask some difficult and uncomfortable questions:

• Are we learning from our past mistakes and the near misses and not normalising hazards?
• Are we collecting the right data to inform our safety and health decisions?
• Are our procedures too complex and/or overly administrative?
• Are our critical controls designed and implemented correctly and are we verifying that they are working?
• Are we empowering workers to identify incidents and hazards?

If we don’t answer these questions, my fear is that we will continue along what Dr Brady described as a fatality cycle, which is characterised by periods where a significant number of fatalities occur, followed by periods where there are few to none.

These are not new concepts and nothing here should be a revelation to anyone. As leaders in the industry, I challenge you to think about these questions and critically evaluate whether they are being asked and, most importantly, answered within your organisation.

Kate du Preez
Commissioner for Resources Safety and Health

Originally published in the September edition of the AusIMM Bulletin.