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Brady report on Queensland quarry fatalities explained

 

As part of an educational session for the quarrying industry, forensic structural engineer Dr Sean Brady has presented his recommendations on how the industry can reduce its fatality, serious accident and high potential incident rates. 

In an Institute of Quarrying Australia webinar on Wednesday, 24 June, Dr Brady presented the findings of his report – Review of all fatal accidents in Queensland mines and quarries from 2000 to 2019 – and how it related to quarries. The report, which was released earlier this year, provides an independent analysis of Queensland’s mining and quarrying fatalities, serious accidents and high potential incidents (HPIs) across a 20-year period.

It made its way to the Queensland Parliament in February, ahead of the state’s new provisions to mine and quarry manslaughter laws.

The report assessed 47 of Queensland’s industry-related deaths between 2000 to 2019. There were six fatalities in quarrying across a 20-year period, four being employees and two being contractors. A total of 35,000 incidents were also analysed.

The frequency rate of serious accidents by sector by worker type. According to Brady, serious accidents are one of the more accurate forms of incident data in quarries.

Dr Brady calculated the frequency of the deaths, serious accidents and HPIs in terms of incidents per million hours worked.

“We took the hours worked and calculated the fatality rate, and when you do that, excluding metalliferous and coal exploration, you find that quarrying becomes number one on the list,” he said.

“You are statistically more likely to have a work-related fatality in a quarry than anywhere else per million hours worked, and its head and shoulders above the rest of the resources industry.”

To help promote the findings in the report, the IQA organised the webinar, where Dr Brady provided attendees with a further explanation on what needs to be changed to improve health and safety practices and reduce fatalities and serious accidents.

The comparison of the frequency rates of HPIS vs serious accidents. Brady believes this data points to chronic underreporting of HPIs.

Analysing the data

Figures were revealed in Brady’s report, which analysed serious accident data from 2011 onwards.

“In 2018-19, quarries have faced a serious accident frequency rate of around three (3.0) per million hours worked compared to the industry average of around one (1.0) accident per million hours worked,” Brady explained. “Certainly, quarries are above average in terms of fatalities and they’re above average in terms of serious accidents.”

The decline in HPIs in the same period suggests safety issues are going unreported in quarries.

Serious accidents, according to Brady, are one of the more accurate forms of incident data in quarries due to a third party determining if a serious accident has occurred.

“The serious accident data is reasonably accurate because you have a third party medical practitioner making the decision as to whether or not someone has had a serious accident when they decide to admit them to hospital.

“I believe there is quite chronic underreporting of HPIs,” Brady said. “For every million hours worked, there’s 23 HPIs reported to the regulator.”

According to Brady, that equates to around 1.4 HPIs per person over a 30 year-quarrying career — and it seems highly unlikely the number is this low in reality.

If underreporting is occurring in the quarrying industry, as compared to the rate of HPIs in underground coal mining, Brady suggests it ties back to reporting culture in the workplace. “It’s going to come back to reporting culture whatever way you slice and dice it,” he said.

Brady also noted cumbersome processes involved in reporting HPIs to the regulator can discourage reporting amongst quarries.

“I think if there’s a fear that the regulator is going to jump all over you because the number of reports you submit goes up this can discourage reporting,” he said.

“The other factor that can discourage reporting is if when people report a hazard or incident, and effective controls aren’t put in place, there’s a possibility people may think ‘why bother?’”

Despite the report revealing quarries have a higher frequency rate for serious accidents in 2018-19 compared to other resources sectors such as coal mining, the HPI rate for quarries dropped last year. Brady believes this apparent difference in behaviour between the serious accident reports and HPIs is significant.

“If you believe there is no underreporting happening – in other words, if someone finds themselves in a HPI type situation, they report it – this would suggest that coal exploration, coal underground and metalliferous exploration are more hazardous than quarrying,” Brady explained.

“But if you ask ‘Do I believe underreporting is happening?’ then another way to view this graph is that coal exploration and coal underground have higher reporting rates because they have a better reporting culture.

“Since 2014-15 the number of HPIs reported per million hours worked in quarries increased up until last year. Last year, the serious accident rate has jumped up — the percentage of people put in the hospital has increased — but the number of HPIs has decreased. That suggests to me that there’s underreporting occurring in the HPI data.”

Serious quarrying accidents were blamed on ineffective controls (47 per cent) and hazards not being identified (29 per cent).

Industry-wide, 45 per cent of serious accidents were due to ineffective controls.

Cause for concern 

Many people may feel that there is always one big cause for a fatality, but Brady stressed that out of the 47 fatalities analysed there is “rarely one thing”.

“We’re talking about combinations of factors, like failure of controls, lack of training, or inadequate supervision,” he said.

The report uncovered that 17 of the 47 fatalities involved a lack of specific training, with a further nine having inadequate training.

“We’re not talking about general training, for example we’re talking about where a person was using a piece of equipment and hadn’t been trained,” Brady said. “So you add 17 and 9 together and you find that 26 of the 47 fatalities (a significant percentage) were training-related.”

A total of 32 of the 47 fatalities recorded required supervision. “Of those 32, 25 had inadequate or a lack of supervision,” Brady said. “In some cases, the supervisor wasn’t present and in some cases the level of supervision was inadequate.”

Ineffective controls as a cause of serious accidents is the third and final area Brady discussed in the online seminar. Industry-wide, 45 per cent of serious accidents were due to ineffective controls, with 47 per cent of quarry serious accidents relating to controls.

“In addition, it appears that the quarrying industry is a little more likely to bypass controls than some other sectors of the mining industry,” he said.

After speaking to people in the industry, Brady noted that the quantity of paperwork required in the industry was raised as a concern.

“The level of paperwork that the quarries have to do is significant from a safety perspective. People say it gets in the way of being out and about, walking round the quarry, watching people doing the work and ensuring the work is done in a safe manner.

“One person said if you’re a big mining company with hundreds of employees, you need this paperwork – you need these systems to cope with that many people – but some of those structures and requirements ‘are forced on us as quarries and that’s what gets in the way of actually being out there and ensuring the work is done in a safe manner’.”

About 47 per cent of serious accidents in quarries related to ineffective controls.

Tackling fatalism 

Mistakes are unavoidable in the workplace and Brady suggested that having the correct systems as a failsafe was essential if a person doesn’t follow correct protocol.

“You need to be very careful about blaming human error,” he said. “When you blame human error, you’re missing the opportunity to identify the controls that were ineffective.

“You have to assume that humans are fallible, that they will make mistakes and the goal of every failure investigation should be to identify the controls that failed.

“Further, mining and quarrying is dynamic – things change, sometimes all the time,” Brady said. “You need to constantly be on top of ‘are your controls still going to work?’”

Administrative controls are another area that can work against health and safety practices in a quarry.

“I think that an over-reliance on administrative controls is a massive problem in the industry,” Brady said. “They’re easier to bypass or not follow perfectly. And when this happens, human error can be blamed.

“Also, it’s hardly a reward when you say ‘Please tell us all the hazards’ and then you reward them with a procedures book that’s twice as thick as when they started.

“If you’re implementing more and more administrative controls, you’re multiplying the amount of information you expect an individual to learn, retain and have top of mind when they need it. How much retention that is occurring is questionable. For example, if you set up an induction and you’re under the assumption that the person will understand, remember and be able to implement everything you’ve taught them, that could be a dangerous assumption to make.

“Nobody wants a thicker procedures book, that’s not the solution.”

Brady has provided the industry with several solutions to combat dire trends that the resources industry at large faces. “The level of fatalism in the industry is a real thing,” he said. “In the industry, there’s a general view that mining is just an inherently hazardous industry. I’ve seen that view expressed through all levels in organisations from the frontline to all the way up.

“But the reality is that there’s plenty of other hazardous industries that do not tolerate these hazards causing harm. In the airline industry, if you think about it, flying aeroplanes is potentially incredibly hazardous, yet it’s also incredibly safe. We expect it to be safe, I’m not sure we expect the same from the mining industry.”

Brady says that if operations are implementing more and more administrative controls, they are merely multiplying the amount of information expected of an individual to learn, retain and have top of mind when they need it.

Brady mentioned one effective method used by the airline industry to manage safety is introducing dual reporting of incidents.

“Within the airline industry, pilots and air traffic controllers understand the incredible value there is in reporting and following up on these reports. Yet they still use a dual reporting system, which means that even if the person who made an error doesn’t want to report it, they know the other person is going to report it anyway.

“When you talk to people in the mining industry, people express the view that it’s simply a hazardous industry. That’s taken as a given. And society’s view appears to be the same– that the mining industry is hazardous.

“I don’t think people expect to go to work and get hurt, but I think there’s a general perception that this is what happens.”

The Brady Review can be downloaded from the Queensland Department of Natural Resources, Mining and Energy website.

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