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Causes of mine disasters and lessons learnt
This presentation looks at the valuable lessons to be learned from past disasters; how analysing incidents and identifying pattern causes provides a valuable opportunity to identify common pathways that lead to fatalities and serious health and safety incidents in the mining industry and other high-risk industries.
Causes of mine disasters and lessons learnt
- 1. Causes of minedisasters and lessons learned November 2019Alaster Wylie State Operations Manager NSW Mines Rescue
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- 3. Mount Kembla 1902 96 fatalities NSWmining disasters Appin 1979 14 fatalities Bellbiird 1923 21 fatalities Gretley 1996 4 fatalities Bellbird 1923 – 21 fatalitiesMount Kembla 1902 – 96 fatalities Appin 1979 – 14 fatalities Gretley 1996 – 4 fatalities
- 4. Our history 1923 19251926 1996 2002 2004 Bellbird mining disaster 1993 First mines rescue station established (Abermain) Mines Rescue Act Mines Rescue restructured to position the organisation as a training body The first virtual reality simulator officially opens at Newcastle Mines Rescue Coal Services is created under the Coal Industry Act 2001 (NSW) Mines Rescue is established as an RTO 2019 Planning for the future
- 5. Ten pathways todeath and disaster Professor Michael Quinlan Pathway 2 Failure to heed clear warning signals Pathway 3 Flaws in risk assessment Pathway 5 Flaws in system auditing Pathway 8 Worker, consultant and supervisor concerns prior to incident Pathway 10 Flaws in emergency procedures / resources Pathway 1 Design, engineering and maintenance flaws Pathway 4 Flaws in management systems Pathway 6 Economic /reward pressures comprising safety Pathway 7 Failures in regulatory oversight Pathway 9 Poor management / worker communication / trust
- 6. Due to thepotentially distressing nature of the content of the program, please note the following contact information for support services: Beyond Blue: Phone: 1300 224 636 (24 hours) Web chat also available between 3pm and midnight at www.beyondblue.org.au Lifeline: Phone: 13 11 14 (24 hours) Web chat also available between 7 pm and midnight at www.lifeline.org.au Internal organisational welfare and support services Support services available
- 7. Case studies The followingcase studies provide an examination of the history of mining disasters. 1. Aberfan, United Kingdom, 1966 – 144 fatalities (116 children) 2. Gretley, Hunter Valley, NSW, 1996 – 4 fatalities 3. Northparkes Mine, Parkes, NSW, 1999 – 4 fatalities 4. Pike River, New Zealand, 2010 – 29 fatalities 5. Cadia East Mine, Orange, NSW, 2010 – 7 near miss 6. Ravensworth Mine, Hunter Valley, NSW, 2013 – 1 fatality 7. Cudal Limestone Quarry, Cudal, NSW, 2014 – 1 fatality 8. Moolarben Coal Operations, Ulan, NSW, 2015 – near miss
- 8. Case study: PikeRiver, New Zealand Pattern of failure: 1. Design, engineering and maintenance flaws Decision to use hydro mining and the positioning of the main ventilation fan. 2. Failure to heed clear warning signals Failure to respond to trends in atmospheric pressure and methane levels. 3. Flaws in risk assessment Failure to risk assess hydro mining or UG main fan ventilation 4. Flaws in management systems Failure to maintain safety critical systems – rock dusting, ventilation, equipment. Fatalities: 29 miners 19 November 2010 - Principal Hazard – (ix) Fire/explosion
- 9. Case study: PikeRiver, New Zealand Pattern of failure: 5. Flaws in system auditing No proper OHS audits conducted. 6. Economic/reward pressures compromising safety Production pressure/cost cutting compromising safe work practices and incentive pay systems encouraging unsafe work practices. 7. Failures in regulatory oversight Insufficient/inadequately trained or supervised inspectors. Inadequate/poorly targeted enforcement. Flaws in legislation – standards, reporting requirements, sanctions, workers rights. Fatalities: 29 miners
- 10. Case study: PikeRiver, New Zealand Fatalities: 29 miners Pattern of failure: 8. Worker, consultant and supervisor concerns prior to incident Failure to respond to supervisor, consultant and worker concerns about safety. 9. Poor management, worker communication and trust Poor management response to worker, supervisor and union concerns leading to non-productive relationships. 10. Flaws in emergency procedures/resources No second egress. Unsatisfactory emergency response procedures post incident.
- 11. Learnings to takeback to the workplace • The 10 pathways and how they relate to principal mining hazards • Importance of having effective regulation and enforcement • Implementing the lessons learned – what are you going to do to address these high risk areas when you go back to the workplace?
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- 13. What can youdo? • Can you identify any pathways that present a safety failure risk in your workplace? • What can you do to address these? • Do you want to learn more? NSW Mines Rescue is approved by the NSW Resources Regulator to deliver Learning from disasters one day program. Approved Training Provider number 0003650
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Editor's Notes
- #2 Summary of MoC Module Learning from Disasters – Id like to giver everyone an overview Regulators Learning from Disasters / one day program that must be completed 5 years for prac. certificate / OR 7 hours of formal learning from disasters MR doesn’t own the course but is an Approved Training Provider Program focuses lessons learned of past to ensure the development of a systematic approach to safety The focus is on generating discussion + completing group activities + analysing the learnings + reflect on mine site Analysing incidents in the course using the Ten Pathways to Death and disaster and I recognise the theme “Electrical Engineering Safety; Maintaining Control”. IMRB recent disasters and NSW mines safety record Acknowledge the content of the material can be distressing
- #3 Facilitator/key points: As you can see from the table, there have been a number of major mining disasters in NSW since the late 1800s. These include the: Bulli Mine explosion in 1887 with 81 fatalities Dudley Mine explosion in 1898 with 15 fatalities Mt Kembla explosion in 1902 with 96 fatalities Bellbird Colliery explosion in 1923 with 21 fatalities Appin Colliery explosion in 1979 with 14 fatalities. And in more recent times the: Gretley Colliery flooding in 1996 with four fatalities Northparkes Copper and Gold mine airblast in 1999 with four fatalities Austar rib/sidewall burst in 2014 with two fatalities.
- #4 Mount Kembla 1902 – 96 fatalities Worst post settlement- peace time disaster in Australia until 2009 Black Saturday Bushfires Accumulation of gas in goaf + goaf fall + ignited by naked flame + propagated to coal dust explosion No one knew what caused the explosion / Mine considered non-gassy + other theories raised to protect the status “absolutely no danger from gases” “best ventilated mine in NSW” Royal Commission concluded explosion and safety lamps substitute flame lights prevent accident Bellbird 1923 – 21 fatalities Explosion killed 21 people, one was John Brown, Manager of Aberdare attempting rescue Working conditions very poor, some didn’t have safety lamp Smoking, unreliable phones / lack of hazard reporting + controls Highlighted importance of having mines rescue equipment and brigadesman available “Proto” suits used to recover mine + remaining 5 bodies + last in 1965 Contributed to the Mines Rescue Act 1925 as well as change in government to labour MR set up in 1926 Appin 1979 – 14 fatalities Explosion K Panel / 3 hdg panel undergoing vent change to set up 2 aux fans / long stub poorly ventilated / reports that brattice was constantly being driven through with machine Fan in reverse / started in a non expl. protected state / found with one stud in the control panel / Electrical Engineering Safety; Maintaining Control”. Initial thoughts were safety lamp / ignition started at fan and travel through vent duct, explosion then coal dust explosion 8 days before explosion “the quantities of methane give me cause for considerable concern -Regulatory oversight and enforcement Vent changes considered simple Recommendations: VO , Deputies to use methanometers, inspectors not leaving record of inspection, driving long stubs – brattice, interlocking of face equipment Multiple explosions in the 70s which resulted in improved gas monitoring, trending Gretley 1996 – 4 fatalities Developing C hdg 50/51 panel, holed into Young Wallsend Colliery – water pushed miner back 17m -Miner weighed 35-50 T Mine Plan showed Young Wallsend Colliery 100m away Mine Plan was redrawn incorrectly. Original plan had two tracings in two colours and was assumed it was two seams but was one seam and the a resurvey of the seam Numerous warning sign “there is water gathered at 7 c/t – we are not close to an old mine are we” No risk assessment or verification Learnings – DMR confirmed all abandoned mine record tracings / development of MDG / proving barriers through drilling, lead to adoption of risk management and principal hazard management plans
- #5 1923-1925 1887 and 1921 - 293 people in NSW. Royal Commission + value of breathing apparatus + establishment of a mines rescue service. 1923-1925 The Mines Rescue Act 1925 governed the establishment of rescue stations and brigadesmen teams, and instigated equipment and maintenance standards. 1926 Mines rescue station in NSW began 20 March at Abermain. Stations in Newcastle, Wollongong and Lithgow opened shortly thereafter. 1993 Mines Rescue was restructured to position the organisation clearly as a training body. 1996/97 Mines Rescue became a Registered Training Organisation (RTO) in October. New courses Coal Mines Qualifications Board Emergency Preparedness and Mines Rescue Program for Mine Managers and Undermanagers. A Safe Working at Heights course was also developed following a number of fatalities at surface operations. 2002 On 1 January 2002 the Coal Industry Act 2001 was enacted, creating Coal Services and its subsidiary entities to undertake the functions formerly performed by the Joint Coal Board and the NSW Mines Rescue Board. 2004 In October the first Virtual Reality Technologies simulator was officially opened at the Newcastle Mines Rescue Station. 2019 Planning for the future using free roam virtual reality technology where we can put people in just about any scenario
- #6 Professor Michael Quinlan is a professor in the School of Management and Director of the Industrial Relations Research Centre UNSW. His major expertise is the field of occupational health and safety (OHS) and risk Quinlans research studies 24 disasters from 1975 to 2011 Researched across 5 countries with similar regulation – (Aus/USA/Britain/Canada/NZ) Research concluded that there were 10 pattern causes that repeatedly recur in these incidents. Incidents entailed at least three of these pattern deficiencies and many exhibited five or more. Professor Quinlan’s research indicated that there was little to differentiate the failures that led to a single death or multiple deaths.
- #7 Facilitator/key points: We are about to go through the 8 case studies the module covers Remind participants of the support services available if they find the content disturbing.
- #8 During our MoC courses, we pick 4 of the above case studies to review and discuss and identify principal mining hazards in the case studies Aberfan – 144 fatalities (116 children). Catastrophic collapse of a colliery spoil tip - build-up of water in the accumulate rock and shale Gretley – 4 fatalities – inrush Pike River – 29 Miners – fire or explosion Cadia East Mine – Inrush - mud and water from a ventilation shaft being developed through raise bore partially flooded the underground workings. Inrush pushed a manned bogger 30-40m. 7 people at direct risk Northparkes Mine – 4 fatalities – Airblast. Ore body above the cave-back collapsed into the void, creating an air blast that travelled through underground workings of the mine Ravensworth Mine – 1 fatality –. Light vehicle collided with a haul truck Cudal Limestone Quarry – 1 fatality. Under WHS act. A resident of a neighbouring property to the Cudal Limestone Quarry was found dead. The house was supplied with electricity from the quarry’s electrical supply. electrical supply was on and the crushing plant was operating, excessive voltage appeared at the house earth stake and water pipes. A phase-to-earth fault was identified on a motor supply cable. Moolarben Coal Operations - Section of the highwall adjacent to a public road failed. No one in vicinity but was 40m from public road.
- #9 Vent circuit in effective – decision to abandon 2nd egress drivage and set up hydro mine Design of the gas monitoring system – 5 sensors but only one working for last 2 weeks Minimal geological data resulting in poor mine design Use of non flame proof and IS equipment -Electrical Engineering Safety; Maintaining Control”. Numerous incidents reported from UG workforce ignored – backlog was written off to start fresh Only one gas monitor working bottom of shaft – flat lining at 2.96% CH4 Electrical Engineering Safety; Maintaining Control”.
- #10 6. Major cost pressures on the company – Hit sandstone graben – significant delay to get through Ventilation shaft collapse costing $20M 7. Repeal of the 1975 Coal Mines Act in 1992 and replaced with Health & Safety Employment Act – gave onerous to companies to manage the health and safety of workers Non – prescriptive, Coal Mines Act was and was built through learning from disasters Deregulated industry and then lost a lot of experienced inspectors through resignation 12 frictional ignitions reported and nothing was done by the regulator Regulator under resourced to regulate the industry
- #11 8. Incident reports ignored – wrote off because there were so many Culture of what management says goes 9. High turnover of management Mainly Australian and South African management – much different geology 10. Old legislation stated two means of egress required Evidence found of numerous times where gas levels were up to 5% and no withdrawal As you can see, the Pike River disaster has failures across all ten pathways and is important to learn about
- #12 Disasters before 1970 primarily focused on mining environment characterised by the non-mechanised manual labour and limited gas detection + hazard monitoring 1970s – Box Flat / Kianga / Appin lead to improved gas monitoring 1990s – Moura / South Bulli Outburst / Gretley / Northparkes lead to adoption of risk management and principal hazard management plans Pike River in 2010 startk reminder of how important it is to take lessons of the past seriously
- #13 We recognise the importance of the role that we play building safety leaders (with over 20,000 workers through our doors each year) We are a small cog in assisting mine operators to get their workforce home safe When Coal services established 2001 – claims frequency rate was 25%, its been on a downward trend every year and now sits at 5% Its training such as learning from disasters is where we can contribute to play building safety leaders The safer we get, the easier it is to think it cant happen to you Work closely with industry and the NSW RR to build out MOC training and other safety training for industry
- #14 Everyone operating in this high-risk sector must remain vigilant – the safer we get, the easier it is to forget that disasters can happen Encourage people to contact NSW Mines Rescue or the RR for more information about Learning from Disasters.