A major review of every mine and quarry death in Queensland in the past two decades has provided a ‘sobering assessment’ of the key factors that lead to on-site deaths.
Structural engineer Dr Sean Brady’s report – Review of all fatal accidents in Queensland mines and quarries from 2000 to 2019 – assessed 47 industry deaths during the 19.5-year period.
The report was commissioned by Queensland Mines Minister Dr Anthony Lynham to identify changes to improve health and safety. The minister announced the formal review on 8 July, 2019, immediately after the state recorded its fifth fatality within the 2018-19 financial year.
In his review, Brady made 11 recommendations, highlighting a ‘fatality cycle’ that would only be broken after the implementation of significant operational changes and the elimination of fatalism attitudes.
He also outlined a greater role the regulator could play to improve safety and explained why he believes the industry should move away from using Lost Time Injuries (LTIs) as a safety indicator.
Cement Concrete & Aggregates Australia’s (CCAA) Queensland state director Aaron Johnstone said the organisation welcomes the release of the Brady review.
“It is a comprehensive, though very accessible, report providing a sobering assessment of factors leading to the fatalities in the mining and quarrying sector over the past 20 years,” he said.
“We would urge anyone with an interest in safety in the quarrying industry to read the report. CCAA will work with its members and the State Government in the review and the implementation of the recommendations.”
IQA President Shane Braddy said the review was comprehensive and highlighted the importance of ensuring workers are appropriately trained and competent in the tasks they are undertaking. “The IQA aims to develop relevant training and improve access to assist our members and the industry,” he said.
Breaking the cycle
In his most stark finding, Brady said that unless significant changes occur, the rate of fatalities is likely to continue at current levels. The pattern is characterised by periods where a significant number of fatalities occur, followed by periods of few to none, suggesting the industry goes through periods of increasing and decreasing vigilance.
“The six fatalities that occurred between July 2018 and July 2019 have been described by some in the industry, media and politics as evidence of an industry in crisis, but a bleaker assessment is that this is an industry resetting itself to its normal fatality rate,” he said.
“Perhaps one of the biggest stumbling blocks to reducing the number of fatalities is how the mining industry views itself. Both the mining industry and the general public appear to expect mining to be dangerous. This fatalism may be the biggest stumbling block to preventing the industry taking the next step.”
The report found almost all of the fatalities were the result of systemic, organisational, supervision or training failures, either with or without the presence of human error. Human error alone would not have caused these fatalities.
Brady also said the industry needed to focus on ensuring workers are appropriately trained for specific tasks, and properly supervised.
In total, of 17 of the 47 fatalities involved, no task-specific training and/or competencies for the tasks was undertaken. A further nine had inadequate training. Thirty-two of the deaths involved tasks requiring supervision but 25 of those involved inadequate or absent supervision.
Recommendations for the regulator
Four of Brady’s recommendations related to changes the regulator could make to improve safety and reduce the likelihood of fatalities.
In doing so, he introduced the concept of High Reliability Organisational (HRO). This theory focuses on identifying the incidents that are the precursors to larger failures, which are then used to prevent them from occurring.
To assist the industry to operate in line with HROs, Brady said the regulator should play a key role in collating, analysing, identifying, and disseminating lessons learned from the incident and fatality data.
“The regulator is in a critical position to fulfil this role due to its centralised access to industry-wide incident data,” he said.
The regulatory body, according to Brady, should also develop a simplified incident reporting system that is easy to use, unambiguous and encourages open reporting. At present, the system can be an administrative burden.
The benefit of using Lost Time Injuries (LTIs) and the Lost Time Injury Frequency Rate (LTIFR) as a safety indicator was also questioned in the report.
According to Brady, this method can be problematic. “LTIs are prone to manipulation, are a measure of how the industry manages injuries after they have occurred, as opposed to a measure of industry safety. It is possible, therefore, to reduce the LTIFR without making the industry safer.”
Instead, he suggested the regulator adopt the Serious Accident Frequency Rate as a measure of safety in the industry “because it is a genuine reflection of how many people are getting seriously injured and is least likely to be susceptible to both conscious and subconscious manipulation”.
In terms of reporting industry culture, Brady recommended the regulator adopted the High Potential Incident Frequency Rate as its metric.
Rather than viewing the High Potential Incident Frequency Rate as a measure of the level of safety in the industry, it should be viewed as a measure of the reporting culture.
“High Potential Incident reporting should be encouraged … to better ensure early warning signals of impending incidents and fatalities are captured and disseminated to the wider industry. This provides the best opportunity to identify hazards before they cause harm and ensure they are effectively controlled.”
Quarry deaths 2000-2019
The following examples were cited in the report of safety incidents and fatalities in quarries:
- An operator was fatally injured at a quarry when he became entangled in the rotating tail drum of a conveyor belt.
- A worker operating an articulated dump truck lost control of the vehicle while descending to a lower level area of the quarry. The vehicle rolled over and fatally injured the worker.
- A plant operator was fatally injured after becoming entangled in a conveyor.
- A truck driver died after his vehicle tipped over and crashed when coming down a haul road.
- A maintenance worker was fatally struck by a falling hopper door of a mobile crusher when he was preparing to remove the door from the crusher.
- A plant operator was fatally injured when run over by a loader.