Holstein Wong, RedEye’s Account Manager for Mining & Power customers reflects on the recommendations from the Brady Review of all fatal accidents in Queensland mines and quarries from 2000 to 2019. The recent underground incident at Grosvenor Mine near Moranbah shows that we must not lose sight of high potential incident controls to protect workers from harm.
Current industry focus is on mitigating the spread of COVID-19, and early results show that the Queensland mining sector is rising to the challenge and keeping people safe.
Amidst the current pandemic situations’ social distancing measures, it is important that we help our clients to maintain focus on preventing fatalities from their regular hazards too. To quote Bobbie Foot (Head of Health Safety Environment, BHP Mitsubishi Alliance), “…while we are focused on the people within 2m of us, we can’t lose sight of the suspended load above us, the excavation in front of us, or the heavy vehicle beside us”.
The Brady Review, published earlier this year, suggested 11 recommendations that we must act upon now if we are to eliminate fatalities in our sector. While the focus is, and should be on COVID-19, we must not forget the unacceptable number of fatalities in the last 24 months that occurred due to everyday, banal factors1.
The Review suggests that one of the biggest barriers to reducing the number of fatalities is the mining industry’s self-perception as a hazardous industry, and the industry’s failure to respond to early warning signals, like near-misses. The industry is realising the need to shift from “Safety 1.0” approaches, to “Safety 2.0” practices, such as High Reliability Organisations theory (HRO). Better reporting tools, with easy-to-understand user interfaces, can help with the recording and sharing of these near-miss events.
METS technology platform providers like RedEye can play a part by enabling our clients to maintain a culture of safety and accountability. Especially during these times of changed work practices – split shifts, potentially less supervision, potentially less training on unfamiliar tasks – suppliers like RedEye have the capability to help our clients keep their workforces safe through tools for training, supervision, auditing of controls, and real-time reporting.
Rather than speaking of going “back to” work, there are potential opportunities for the industry to “go forward” from the current global health crisis. Here are our key takeaways from the Brady Review.
Recommendation #1: The industry should recognise that it has a Fatality Cycle
The 6 fatalities that occurred in the 12 months to July 2019 have been described by some as evidence of an industry in crisis, but a bleaker assessment is that this is an industry resetting itself to its normal fatality rate. Periods with few to no fatalities should be viewed as simply part of the fatality cycle – they are not evidence of the industry becoming safer over the long term. This may appear a bleak stark prediction, but this cycle has proven surprisingly resilient over the past 20 years. [The combination of a downturn in the industry and aging workforce may be exacerbating this, and the sudden moves to remote supervision and automation are changing sites very quickly]
Recommendation #2: The industry should recognise that the causes of fatalities are not freak accidents
Many of the fatalities were preventable, and there was rarely a single significant cause. This is likely to be an uncomfortable finding for many; there is a tendency to assume that when a fatality occurs, it must have a sinister cause. The causes of fatalities are typically a combination of everyday, straightforward factors; a large number of the fatalities involved a mine worker in a situation that they were inadequately trained for, with the controls meant to prevent harm being ineffective, unenforced or absent, with no or inadequate supervision to identify and remedy these shortfalls. It then took an initiating event, in the form of a freak incident or bad luck for instance, to result in a fatality.
Recommendation #3: The industry needs to focus on Training
A total of 17 of the 47 fatalities involved a lack of task specific training and/or competencies for the tasks being undertaken. A further 9 had inadequate training. These tasks were often undertaken at the direction of supervisors or others who were aware of these deficiencies. In many cases this lack of training resulted in the worker being unaware of the hazards involved in completing the task or the worker operating equipment in a manner that exposed them to hazards.
Recommendation #4: The industry needs to provide adequate Supervision
In 32 of the 47 fatalities, the worker was required to be supervised when undertaking the task (not routine tasks such as driving). 25 of these 32 fatalities involved inadequate or absent supervision. Not only does absent or inadequate supervision allow tasks to be approached in an unsafe manner, but it also greatly amplifies the consequences of a lack of training or ineffective or unenforced controls.
Recommendation #5: The industry needs effective Controls to manage hazards
A significant number of the controls reported put in place in the aftermath of an incident were administrative in nature, rather than more effective controls on the Hierarchy of Controls (elimination, substitution, isolation, or engineering controls). The majority of the 47 fatalities involved at least one failed or absent control that could have prevented the fatality. The underlying factors for these absent controls often stemmed from decisions made at a supervisory and/or organisational level in organisations.
Recommendation #6: The industry should adopt High Reliability Organisation principles and focus on identifying near-misses
HRO theory focuses on identifying the incidents that are the precursors to larger failures and using this information to prevent these failures occurring. A High Reliability Organisation (HRO) understands that periods where there are few to no fatalities are typically periods where a “drift into failure” occurs; safety is compromised for a variety of (often benign) reasons over time, typically resulting in a series of minor near-miss incidents. HROs actively seek out these near-miss signals, as they provide an opportunity to identify and act on existing hazards, in order to remove them from the workplace.
Recommendation #7: The Regulator should disseminate the lessons learned
When reported correctly, incident information can be actively used as a preventative tool to educate the wider industry. The Regulator is in a critical position to fulfil this role due to its centralised access to industry wide incident data.
Recommendation #8: The Regular should develop a simplified Reporting system
The Brady Review recommends that the Regulator should develop a simplified incident reporting system that is easy to use by those in the field, that aims to encourage open reporting. While the review did not intend to set out the specific details of such a system, it suggested that:
- any new system should be in line with modern mobile technology, preferably app based
- the Regulator should ensure that the administrative burden of reporting is minimised
- The Regulator should also consider the development of a dual reporting system to discourage potential under-reporting of incidents e.g. hospitals can make independent reports on admissions for serious accidents.
RedEye, as part of the METS sector, is committed to contributing to positive change in the safety culture of our industry, through our tools that enable transparency and governance of critical data. Our cloud-based products RedEyeDMS and RedEyeWFM facilitate rapid access to critical site information, to support remote work practices which are more relevant than ever in the current environment. Please be sure to contact us if you have any questions or comments.
Many thanks to Christian Young (Impress Solutions) for drawing our attention to this Review. For a full list of the 11 recommendations from the Brady Review (not all discussed here), please refer to the original report (link).
Written by Holstein Wong – Account Manager, Mining. For more information email holstein