Education, Features, Industry News, Management, OH&S News, Regulation, Regulation News, Safety

Learning from disasters: Recognising the signs


Injuries and fatalities in the extractive industry often occur – and reoccur – because of systemic failures. Tony Ferrazza explains how a course being run by the IQA on behalf of the NSW Resources Regulator is educating quarry professionals to recognise the underlying causes of past safety incidents in their own operations.

History shows we work in a dangerous industry. The 1966 Aberfan waste dump failure in Wales killed 144 people, including 116 children in their school classrooms. Australia has had its share of mining disasters over recent years including the 1999 North Parkes mine collapse that claimed four lives. More recently in New Zealand, the 2010 Pike River disaster killed 29 mine workers. Disastrous events such as these have been responsible for wide-reaching reform to the workplace health and safety legislative environment, yet fatalities and serious injuries in our industry continue. The quarry industry is not immune from tragedy either, with a steady string of fatalities over the years. 

Winston Churchill once wrote: “Those that fail to learn from history are doomed to repeat it.” The Learning from Disaster program, developed by the New South Wales Resources Regulator, provides an opportunity for participants to reflect on some of these past devastating events. If we can learn the underlying causes of past mining disasters, we may be able to prevent similar recurrences and improve the health and safety of all those working in the sector.

The Learning from Disaster program encourages participants to recognise the recurring patterns that have underpinned previous disasters, fatalities and near fatalities. Historic NSW mining disasters are presented, and investigation findings are discussed which identify the systemic failures and learnings which subsequently lead to changes in mining legislation. The program aims to ensure that those in leadership positions understand the link between current legislative obligations and how that legislation has been shaped by a history of mine safety incidents, disasters and fatalities. 

The Institute of Quarrying Australia (IQA) has been running the Learning from Disaster program on behalf of the NSW Resources Regulator as a one-day, online workshop for the quarrying and associated industries. This delivery mode provides an opportunity for participation of regional and interstate workers with minimum disruption to work commitments. Workers from a range of backgrounds and organisations participate, including quarry operations managers, supervisors, leading hands and maintenance personnel from across large established companies to medium and small quarrying operations. For NSW participants, the program contributes to the maintenance of competence requirements for practising certificate holders.

Figure 1: Professor Michael Quinlan’s Ten Pathways to Death and Disaster.


The program is based around research by Professor Michael Quinlan who analysed 24 mine disasters and fatal incidents occurring in five countries. His research concluded that there were 10 pattern causes (refer to Figure 1) that repeatedly recurred in these incidents. He found the vast majority of major safety incidents in mines involved at least three of the 10 pathways and many exhibited five or more.

Participants in the program are introduced to Quinlan’s book Ten Pathways to Death and Disaster, and asked to identify principal hazards present at their own operations. A series of case studies of mining disasters are then presented to the class through videos and investigation findings and linked to the principal hazards. At the end of selected case studies, the class breaks up into small groups to discuss the case study, identify the pattern causes and then present their findings back to the class.

This approach involves a lot of discussion between individual participants about the pattern causes and results in the sharing of experiences and information relating to controlling principal hazards at their own operations. These discussions often lead to “aha” moments for individuals with a sudden realisation that it is not “all up to me” and that consultation is an essential element in reducing risks to workers’ health and safety.

The case studies not only identify the systemic failures but also present the impact these disasters have on the victims’ families and communities and strongly bring out the totality of the human tragedy related to these disasters and the importance of preventing them from happening in the future. The program ends with the participants listening to the family members of the Pike River disaster describe the impact of the event on their lives and an acknowledgement of the people who have died in work-related incidents in the resources sector.

At the conclusion of the workshop, participants are encouraged to look beyond the specific factors in the case studies and reflect on their own workplace to identify three of Professor Quinlan’s pathways that they believe present the greatest risk to a safety failure in their own workplace. All participants present three actions they propose to implement when they return to their workplace. Examples of actions from previous workshops include: evaluating the effectiveness of the risk management process; reviewing and revising the traffic management plan; reviewing the emergency management plan; strengthening the communication and worker consultation process; reviewing the change management process; ensuring contractor competency and participation; maintaining the consultation process; and leading by example.

The risk of fatality and serious injury occurs in all parts of the resources sector, including quarries. The Learning from Disaster workshop exposes the fragility of workplace safety under the influence of complacency. It reinforces the legislative requirement of workplace leaders as duty holders to provide a workplace that is safe and free from harm by implementing safe systems of work. The workshop motivates everyone to remain vigilant and proactive in meeting their health and safety responsibilities in what is a dangerous environment. •

Tony Ferrazza is a quarrying safety and training consultant for Quarry Wise, and the facilitator of the Learning from Disasters workshop on behalf of the IQA and the NSW Resources Regulator. 

For more information about participating in the workshop, contact the IQA for further information, tel 02 9484 0577, email or visit

Send this to a friend