This document discusses two major workplace incidents, the Pike River Mine disaster in 2010 and the Dreamworld theme park accident in 2016, and identifies common causal factors between the two. Ten recurring causes of fatal workplace incidents are identified from past research, and it is shown that many of these were factors in both the Pike River and Dreamworld incidents. These include failures in design, risk assessment, management systems, heeding warning signs, regulatory oversight, and communication with workers. The discussion suggests both incidents could have been prevented by addressing safety concerns raised prior to the events.

1. Michael Quinlan School of Management, UNSW and
Business School Middlesex University London
AVOIDING BACK TO THE
FUTURE
Learning from past failures to
build healthier and more
sustainable work organisation
AIHS Victorian Safety Symposium 5 September 2019
Victoria University City Convention Centre

2. Content
 Fermi’s Paradox and global risk
 Why study failure
 Ten pattern causes of fatal incidents at work
 Human dimensions of harm
 Pattern failures in organisation: financial disasters
 Changes to work organisation and health, safety and
wellbeing
 Observations and lessons/remedies

3.  Apparent contradiction between lack of evidence
and high probability of extra-terrestrial
civilisations
 Physical/technological threats/barriers
◦ Doomsday physics/accidently creating a black-hole
◦ Technological risk – runaway AI (general intelligence) nano-botts
 Or are the barriers/extinction points social?
◦ Over-population, social fracturing
◦ Resource depletion (including species diversity)
◦ Environmental degradation (eg pollution)
◦ Induced climate change
◦ Unsustainable forms of social organisation like rising
inequality/rise of authoritarian regimes/nuclear war

4.  Over-population
◦ 1AD (275m), 1,000AD (300m), 1900 (1.6b), 1950 (2.55b),
2020 (7.66b), 2050 (9.3b)
◦ Urban concentrations (social dislocations/pandemics)
 Resource Depletion
◦ Demands on water, food and energy
◦ Loss of forests, bio-diversity/species extinction (eg 80,000
acres of rainforest & 135 plant/animal species lost per day)
 Environmental Degradation
◦ Fresh water (rivers, lakes and aquifers), clean air
◦ Pollution (eg air in China & India)
◦ desertification, erosion, excess irrigation/salination
◦ Oceans of plastic waste – Glitterati or Litterati?

5.  Rapid Climate Change
◦ More extreme weather events (floods/long-droughts & glacial melts)
◦ Sea level rises/ shifts in disease vectors
 Rising global inequality
◦ USA 1950 CEO/worker salary differential 1/20 2019 1/361 (Oz 1/68)
◦ Precarious work growth (multi-jobholding, under-empt, NEET exclusion)
◦ Wage stagnation (decline in labour share of national income)/wage-theft
◦ Growing inequality not confined to rich countries (ADB report)
◦ Cause of Great depression and GFC
◦ Rise of authoritarian politics (role of social media liberating/stultifying?)
 Does this amount to perfect storm? Risks interact
 urban growth/subsidence with rising sea levels/flood plain vulnerability
 Antibiotics misuse/engineered pathogens/pandemics (biodiversity loss)
 Inequality with drug-use (eg opioids), disease (obesity), suicide
 Unprecedented combination (compare to 1930s crisis)

6.  Sustainability needs to become core to
human organisation and action
 Integration & ‘big picture’ thinking not
thought ‘silos’
 Avoiding Einstein’s definition of insanity/
stupidity
 Learning from mistakes/failures
 OHS provides both evidence of failure/causes
for alarm but also learning from them

7.  In rich countries at least injury risks, and particularly fatalities,
significantly lowered since 1900 (social democracies do best)
though less so regarding disease
 Managing risk and sustainable systems concepts that include the
environment are now common
 We now know reducing routine (high frequency/low impact) harm
doesn’t reduce the risk of non-routine (low frequency/high
impact) harm?
 This requires separate management and regulatory devices,
found in mining and energy but needs to extend (ie Dreamworld)
 Worker rights/involvement integral to OHS laws since 1970s (ILO
Convention 155) though ‘reach’ corroding
 Increasingly OHS research/professional practice looks at patterns
of risk harm but need to get message out (there are education
needs which the SIA is addressing)

8.  Failure can be as instructive as success, especially in
case of low frequency/high impact events where
◦ Statistical records like workers’ compensation, lost day and
medical treatment injuries of little value
◦ Need to use different indices, KPIs and remedies
 Examining series of incidents identifies recurring
causes, why systems fail & how to remedy
◦ Managing risk is about identifying patterns (causes and
effects) and examining series of failures is arguably best way
to identify patterns
 Strategic decision making needs to draw on past
while recognising risk of misinterpretation & change

9. M. Quinlan (2014), Ten Pathways to Death and Disaster: Learning
from fatal incidents in mines and other high hazard workplaces,
Federation Press, Sydney.
 Detailed examination of 24 fatal incidents in coal & Metalliferous
mines in 5 countries (Australia, New Zealand, USA, UK and
Canada) 1990 and 2011. 15 involved 3 or more deaths while 9
single fatalities. Identified 10 repeat/pattern causes.
 Examined over 30 multiple fatality incidents in 10 countries in
other high hazard workplaces (chemical plants, refineries, oil rigs,
aviation, shipping and road transport). Same pattern causes.
 Identified 10 causal pathways to fatal incidents (at least 3 present
in virtually all while majority had 5 or more – some had all 10)
 More thorough the investigation the more pattern causes identified

10.  Design, engineering and maintenance flaws
 Failure to heed clear warning signals
 Flaws in risk assessment
 Flaws in management systems and changes to work
organisation
 Flaws in system auditing
 Economic/production and rewards pressures compromising
safety
 Failures in regulatory oversight
 Supervisor and worker expressed concerns prior to the
incident
 Poor management/worker communication/trust
 Flaws in emergency procedures and resources

11. Pike River Mine Disaster 19 November 2010

12. Dreamworld disaster 25 October 2016

13.  Pike River
◦ Hydro mining
◦ Locating main ventilator UG
 Dreamworld
◦ Evidence to coronial inquest
 Allegations of poor maintenance of rides
 design flaws in spacing between two full-length slats spanning
water channel
 Wiring ‘rats nest’ on Thunder River Ride, electrician agrees could
lead to major malfunction
 water pump failure on ride on day of incident (several instances
prior to event)

14.  Pike River
◦ Board informed of safety concerns prior to incident
◦ Notifiable methane levels exceeded
 Dreamworld
◦ Potentially fatal prior incidents on rides prior to disaster, including
several on same ride
 2001 4 rafts collide on Thunder River Ride
 2014 2 rafts collide on Thunder River Ride
 2014 Cyclone rollercoaster released unharnessed

15. Pike River
 Failure to risk assess hydro mining or UG main
ventilator (Pike River)
Dreamworld
 Failure to do comprehensive risk assessment of HPIs or
safety implications of cuts to operator numbers below
manufacturers specification in at least one case.
 Risk assessment process of staffing changes and ride
maintenance will hopefully receive detailed treatment
in coronial inquest findings

16. Pike River
 Failure to maintain safety critical systems –rock dusting,
ventilation, equipment
 Poor management of contractors
Dreamworld
 Reduced/inadequate staffing on rides seems to have
been serious deficiency (critical in other incidents like
Herald of Free Enterprise)

17. Pike River
 No proper OHS audit (Pike River) although concerns
raised with Board
Dreamworld
 HPIs didn’t lead to reassessment of system, including
staffing levels on rides
 Need to know more about auditing regime

18. Pike River
 Production pressures/financial difficulties
 Time sensitive bonus encouraged unsafe practices
Dreamworld
 Were cuts to staffing or maintenance shortfalls due to
cost-cutting? Need to know more about this.

19. Pike River
 Legislation inadequate re HPIs, systems-requirements (including
principal risk management and TARPS), specification standards on
known hazards, worker involvement, enforcement and penalties
 Inspectors lacked expertise/resources and poor strategic use (also
no Chief Mines Inspector)
 Post-Pike changes addressed these & most other pattern failures
Dreamworld
 Legislation inadequacies, not designated high-hazard workplace
which it was
 Inadequately trained inspectors and poor strategic use/oversight (eg
HPIs)
 Post-Dreamworld changes to inspection/regulation but more needed
& will Coronial Inquest findings address all relevant pattern causes?

20. Pike River
 Leading Hydro Management consultant resigned over
safety concerns
 Management threatened union after it endorse safety-
related withdrawal led by supervisor (later amongst those
killed). Breach of century old principle in mining.
 Worker concerns, at least one planning to leave

21. Dreamworld
 Notice to inspectorate from AWU 6 Feb 2015 ‘Dreamworld has cut back its ride attendants on all its major
amusement rides to a single operator. This practice began around 15 months ago with just a few rides
but now has begun on all rides. In November 2014 the Cyclone Rollercoaster was released from the
station with its safety harnesses up. This was from a direct impact of having one operator working this
ride. Dreamworld fired the operator, they put the sole blame on him. Dreamworld called this a MAJOR
SAFETY BREACH but did nothing to rectify the problem. In February this year the same thing happened
again and this operator was also suspended. This has caused great concern to the Australian Workers
Union. The operators made contact with the union, one operator who had been an instructor for 17 years
has said that it is a disaster waiting to happen. The pressure on a single operator is too much. I have also
been informed that the Madagascar Rollercoaster was released with its safety harness unlocked WITH
PASSENGERS however it was stopped on the conveyor. The major concern to the union is that these rides
should not be able to depart without the harnesses being locked, there should be a device that shuts or
locks the ride down till they are locked, so it is impossible for the ride to start. Also the stress and
pressure that is put on our members and employees due to single operator. The AWU tracked down from
overseas the manufacturers manual for the Cyclone rollercoaster. It clearly states that ride should and I
quote “have one person operating but 2 but preferably more persons on the loading and unloading
operation of the ride”…The AWU would ask that a full investigation into Dreamworld’s dangerous
practices be done asap. Dreamworld’s response to the AWU is that they have conducted a risk
assessment. However, they also admit that what happened at the Cyclone Rollercoaster was a major
safety breach, yet they still continue to operate rides with a single operator. It should also be noted that
the ride-operators do not get rotated around. Dreamworld management say they do, but our members
have told us different.

22. Pike River
 No effective worker input mechanisms (eg HSRs) and
poor management response to worker, supervisor and
union concerns (Pike River)
Dreamworld
 Rejected union/operator concerns – need to know more
about this

23. Pike River How and some incidents where
contributed
 No effective second egress
 Poor safety management (location of ventilator
machinery) made rescue or even recovery more
dangerous
Dreamworld
 Operator at time new and claimed not properly trained in
emergency procedures (doesn’t appear it made difference
but has in some eg Esso Longford)

24.  Pattern causes go long way to explaining recurrent fatal incidents in
high hazard workplaces & focusing on them would minimise fatalities
 Systems as hierarchies of control that corrode over time & better
suited to routine risk? Need to guard against this.
 Pattern causes apply to both single fatalities and multiple fatalities
(both low frequency/high impact events)
 Pattern causes generally latent failures (Reasons), any one could
cause fatal incidents but more you have more likely (only requires
trigger which is often minor of itself and difficult to predict/target)
 Changes to work organisation like subcontracting can weaken
 Safety ‘culture’ was not a pattern cause rather symptom of failure in
OHS management regime and priorities

25. ◦ Identifying & assessing/remedying OHSMS
gaps like
 Does it address all fatality risks?
 Does it sufficiently target both routine & fatality
risks?
 Does it use risk-based systems & rules/remedies
where hazard controls well known?
 Does it ensure risk assessment documented &
changes to work organisation etc considered?
 Does it include appropriate HPIs, KPIs & TARPs?

26. ◦ Informing monitoring, incident reporting &
investigation (effective HPI reporting differentiating
routine/high-impact, upstream focus in incident
investigation)
◦ Strengthening auditing requirements
◦ Mutually reinforcing multiple feedback loops to
identify failures and ensure constructive dialogue (ie
potential for different/critical views)
◦ Deep listening/communication, problem solving and
upstream solutions (design/exposure). Companies
now targeting single fatalities, focus on fatality
mechanisms, pattern causes, involvement and
upstream (eg engineering) remedies

27. Sandra Welsh and her daughter Jenna leave the Burnie
Magistrate’s Court after charges withdrawn against CMT with
regard to the death of Michael Welsh asphyxiated in a mud-rush

28. ◦ 2007-18 study - impact of workplace death
◦ interviews institutional representatives/families & global
survey (respondents 62% Australian, Canada 17%, USA
16%, UK 5%/ respondents 90% female/fatalities 90% male
◦ Survey findings 61% experiencing (PTSD), 44% (MDD) and
42% (PGD)
◦ Also significant effects on children, financial effects
(especially self-employed), key role of self-help groups
◦ What families want regarding prevention
 Clear and timely information of how/why death occurred
 Deceased not dehumanised by legal processes
 Identification of responsibility and timely prosecution if breach with
significant penalties that will act as deterrent
 Remedial measures so other families spared similar tragedy

29. In examining recent calamity exposed by Banking Royal
Commission Stewart Howe identified 8 pattern failures
◦ Economic pressures compromise customer outcome
 Financial performance was pre-eminent in company goals and executive incentives (and
not penalised for failures on operational and regulatory risks). Sales staff were
incentivised by rewards and product commissions.
◦ Prior warning or causes for alarm ignored
 Over 3 years 3 “red flag” audit reports by Audit Committee on CBA’s AUSTRAC failures.
“Fees for no service” and charging unlawful commissions subject of regulatory
investigation. Inherently conflicted appointment of executives as superannuation
trustees widely acknowledged.
◦ Failures in regulatory oversight and inspection
 APRA and ASIC lacked adequate funding, specialist skills and exhibited little bias to use
litigation to penalise serious breaches, preferring negotiated enforceable undertakings.
◦ Employees and others expressing concern
 Cacophony of complaints by customers, ombudsmen and others. Whistle-blowers
harmed and staff compromised by financial incentives

30. ◦ Management process and risk management plan failures
 Most organisations had reasonably resourced and skilled internal audit functions but
subordinated to revenue earning units. Audit actions for breach/risk mitigation not
priorities for revenue units or their executives.
◦ Failures in risk assessment
 Systemic law-breaking not perceived risk/threat to operating license, with inadequate
metrics and escalation processes. Harm to customers, company brand and reputation
apparently a blind spot in risk assessment.
◦ Failures in auditing
 Failure response to defects detected by audits, lack of priority/resources to deliver
remediation in the revenue units. Executive Committee and Board governance failed
to monitor/correct engine room failures.
◦ Product design, and system maintenance failures
 Many failures in product design. Revenue generating features often trumped
legal/regulatory product attributes. Remuneration system design were a latent
hazard driving many other pattern failures. Delays/inability to detect systems failures
indicate poorly maintained infrastructure.
Note: Institute of Company Directors and AFR/SMH weren’t ‘interested’
and Royal Commission only addressed some failures – expect more
financial/banking disasters

31. ◦ Repeated rounds of downsizing/restructuring
◦ Outsourcing/use of subcontractors/supply chains
◦ Growth of labour leasing, franchising and self-employment
◦ Privatisation (note how this ‘improved’ energy supply in Australia)
◦ Decline in full-time ‘permanent’ jobs (once the norm)
◦ Growth of temporary/fixed contract work
◦ Growth of part-time jobs/multiple jobholding
◦ Increased immigration/temporary guest-workers
◦ Growth of home-based work & telework
◦ Automation/digitalisation
Note: Shouldn’t overstate the new digital economy which often entails recycling
very old forms of work (eg Uber etc simply app-enabled subcontracting)

32.  Work scheduling (e.g. extended hours, irregularity &
worker control)
 Psychosocial factors, including effort/reward, control,
harassment/bullying
 Worker involvement/participation
 Critical assessment of OHS regulation
 including political economy of disasters
 Exposure & response to hazardous substances
 Precarious employment & vulnerable workers
 Now have persuasive models of work organisation &
health connections – ERI, JDCS & PDR

33. Effort/ Reward
Pressures
Disorganization Regulatory Failure Spill-over
Effects
Insecure jobs
(fear of losing
job)
Short tenure,
inexperience
Poor knowledge of
legal rights,
obligations
Extra tasks,
workload
shifting
Contingent,
irregular
payment
Poor induction,
training &
supervision
Limited access to
OHS, workers comp
rights
Eroded pay,
security,
entitlements
Long or
irregular work
hours
Ineffective
procedures &
communication
Fractured or
disputed legal
obligations
Eroded work
quality, public
health
Multiple jobs/
under-
employment
Ineffective OHSMS
/ inability to
organise
Non-compliance &
regulator oversight
(stretched
resources)
Work-life
conflict

34.  Temp agency worker study (Underhill & Quinlan 2011)
◦ Economic pressure (low/irregular pay, easily replaced)
◦ Disorganisation (placement mismatch, less training/induction)
◦ Regulatory failure (afraid to report problems, less RTW if
injured)
 Hotel cleaners study (Knox et al 2017) of bullying and
intention to leave
◦ The path model indicated that disorganisation and regulatory
failure had direct positive associations with bullying.
◦ Financial pressure and bullying had direct positive associations
with ITL.
◦ Bullying and turnover are significant problems but the
◦ contribution of work organisation is poorly understood. Study
preliminary evidence on role of PDR as an antecedent of both
bullying and ITL.

35.  More knowledge always valuable but we actually know a lot about why
organisations fail/features of work that harm health.
 Organisations, professions and government need to target key failure
points and reshape work arrangements to remove health-harming
aspects – this is practical/achievable
 Organisations focusing on sustainability in their operations,
products/services and work that is secure/stable, adequate rewards,
effort/control balance, trained, clear OHSMS targeting both routine
and non-routine hazards, genuine worker rights to report/participate
and effective regulatory oversight
 Informed professions committed to the ethic of safeguarding human
health, safety and wellbeing (licensing?)
 Engaged unions, devoting more resources to OHS
 Boards/CEOs and governments taking genuine responsibility for the
human consequences of their activities

36.  M. Quinlan (2014), Ten Pathways to Death and Disaster: Learning from fatal incidents in mines and
other high hazard workplaces, Federation Press, Sydney.
 Hopkins, A. & Maslen, S. (2015) Risky rewards: how company bonuses affect safety, Ashgate, Farnham,
Surrey.
 Howe, S. (2019) 10 Pathways to Death and Disaster, unpublished paper.
 Underhill, E. and Quinlan, M. (2011) How precarious employment affects health and safety at work: the
case of temporary agency workers.Relations Industrielles 66(3):397-421
 Bohle, P. Quinlan, M. McNamara, M. Pitts, C. & Willaby, H. (2015) Health and wellbeing of older workers:
Comparing their associations with Effort–Reward Imbalance and Pressure, Disorganisation and
Regulatory Failure, Work & Stress, 29(2):114-127
 Quinlan, M. Hampson, I. Gregson, S. (2013) Outsourcing and offshoring aircraft maintenance in the US:
Implications for safety, Safety Science, 57:283-292.
 Quinlan, M., Fitzpatrick, S. J., Matthews, L. R., Ngo, M., & Bohle, P. (2015) Administering the cost of
death: Organisational perspectives on workers’ compensation and common law claims following
traumatic death at work in Australia. International Journal of Law and Psychiatry. 38:8-17
 Bohle, P. Knox, A. Noone, J. Mc Namara, M. Rafalski, J. Quinlan, M. (2017) "Work organisation, bullying
and intention to leave in the hospitality industry", Employee Relations, Vol. 39 Issue: 4, pp.446-458, doi:
10.1108/ER-07-2016-0149
 Matthews, L. Quinlan, M. Rawling-Way, O. and Bohle, P. (in press) Work Fatalities, Bereaved Families and
the Enforcement of OHS Legislation, Journal of Industrial Relations,
 Walters, D. Quinlan, M. Johnstone R. & Wadsworth, E. (2017) Representing miners in arrangements for
health and safety in coalmines: A study of current practice, Economic and Industrial Democracy, DOI:
10.1177/0143831X16679891
 Matthews, L. Quinlan, M. Bohle, P. (2019) Prevalence and correlates of post-traumatic stress disorder,
depression, and prolonged grief disorder in families bereaved by a traumatic workplace death Frontiers of
Psychiatry https://www.frontiersin.org/articles/10.3389/fpsyt.2019.00609/abstract