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Loss Causation

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APPLICATION OF A APPLICATION OF A LOSS CAUSATION MODEL LOSS CAUSATION MODEL TO THE WESTRAY TO THE WESTRAY MINE EXPLOSION MINE EXPLOSION Paul Amyotte Paul Amyotte 1 1 and and Adrian Oehmen Adrian Oehmen 2 2 Department of Chemical Department of Chemical Engineering Engineering 1 1 Dalhousie University Dalhousie University 2 2 University of Queensland University of Queensland
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Page 1: Loss Causation

APPLICATION OF AAPPLICATION OF ALOSS CAUSATION MODEL LOSS CAUSATION MODEL TO THE WESTRAYTO THE WESTRAYMINE EXPLOSIONMINE EXPLOSION

Paul AmyottePaul Amyotte11 andandAdrian OehmenAdrian Oehmen22

Department of Chemical Department of Chemical EngineeringEngineering11Dalhousie UniversityDalhousie University22University of QueenslandUniversity of Queensland

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Lacking the simplest protective gear, miners struggle through toLacking the simplest protective gear, miners struggle through toxic xic fumes to carry hundredfumes to carry hundred--plusplus--pound loads of sulfur out of an active pound loads of sulfur out of an active volcano in Java (Indonesia). Greedy for economic growth, the nowvolcano in Java (Indonesia). Greedy for economic growth, the nowdefunct 32defunct 32--year Suharto regime year Suharto regime paid scant attention to paid scant attention to worker safetyworker safety.. National Geographic, March 2001National Geographic, March 2001

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This could never happen in Canada This could never happen in Canada –– or could it? (i.e. paying scant or could it? (i.e. paying scant attention to worker safety)attention to worker safety)

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OUTLINEOUTLINE

•• Scope & ObjectivesScope & Objectives•• IntroductionIntroduction

–– WestrayWestray–– Loss Causation ModelLoss Causation Model

•• Model ComponentsModel Components•• Lessons LearnedLessons Learned•• Concluding RemarksConcluding Remarks

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SCOPE & OBJECTIVESSCOPE & OBJECTIVES•• ScopeScope

–– Case study developed using public Case study developed using public domain resources (particularly domain resources (particularly Report of the Westray Mine Public Report of the Westray Mine Public Inquiry)Inquiry)

•• ObjectivesObjectives–– Systematically analyze accident Systematically analyze accident

causescauses–– Identify lessons to be learnedIdentify lessons to be learned–– Ultimately, prevent similar Ultimately, prevent similar

accidents in futureaccidents in future

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INTRODUCTIONINTRODUCTIONWestrayWestray•• Coal mining has been an integral part of Coal mining has been an integral part of

Pictou County (Nova Scotia) history Pictou County (Nova Scotia) history since the first commercial mine opened since the first commercial mine opened in Stellarton in 1807, to the closing of in Stellarton in 1807, to the closing of the Drummond mine in Westville in the Drummond mine in Westville in 1974. On September 11, 1991 Westray 1974. On September 11, 1991 Westray opened a new mine in Plymouth.opened a new mine in Plymouth.

•• At 5:20 am on May 9, 1992 after only At 5:20 am on May 9, 1992 after only eight months of operation, an explosion eight months of operation, an explosion ripped through the mine killing 26 men ripped through the mine killing 26 men who were underground at the time.who were underground at the time.

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Nova Scotia Nova Scotia –– East East Coast of CanadaCoast of Canada

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Pictou County Pictou County ––Northeastern Nova ScotiaNortheastern Nova Scotia

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Westray Westray –– Plymouth, NSPlymouth, NS

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INTRODUCTIONINTRODUCTIONLoss Causation ModelLoss Causation Model

•• Tool used in accident Tool used in accident investigation to determine root investigation to determine root causescauses

•• Many variations of such modelsMany variations of such models•• Domino model used hereDomino model used here•• Structured method of identifying Structured method of identifying

and categorizing multiple causesand categorizing multiple causes•• Management issues (inspectorate Management issues (inspectorate

and other government officials and other government officials outside scope)outside scope)

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MODEL COMPONENTSMODEL COMPONENTS

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LOSSLOSSPeoplePeople

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LOSSLOSSPropertyProperty

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LOSSLOSSPropertyProperty

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LOSSLOSSPropertyProperty

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LOSSLOSSPropertyProperty

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LOSSLOSSProcessProcess

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LOSSLOSSProcessProcess•• Curragh Resources bankruptCurragh Resources bankrupt•• Loan defaults (provincial and Loan defaults (provincial and

federal governments)federal governments)•• Severance, worker’s compensation, Severance, worker’s compensation,

pension plan, and UI paymentspension plan, and UI payments•• Cost of criminal investigation and Cost of criminal investigation and

trialtrial•• NS Power loss of coalNS Power loss of coal•• Future wages/income/personal Future wages/income/personal

losseslosses

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INCIDENTINCIDENT

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Mine LayoutMine Layout

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Coal Dust ExplosibilityCoal Dust Explosibility

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IMMEDIATE CAUSESIMMEDIATE CAUSESSubstandard PracticesSubstandard Practices

•• Improper use of ventilationImproper use of ventilation•• Poor housekeeping with Poor housekeeping with

respect to coal dustrespect to coal dust•• Continuation of mining in spite Continuation of mining in spite

of inoperable methanometersof inoperable methanometers•• Storage of fuel and reStorage of fuel and re--fueling fueling

of vehicles undergroundof vehicles underground•• Inadequate rock dustingInadequate rock dusting

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Rock Dust RequirementsRock Dust Requirements

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IMMEDIATE CAUSESIMMEDIATE CAUSESSubstandard ConditionsSubstandard Conditions

•• Inadequate ventilation system Inadequate ventilation system design and capabilitydesign and capability

•• Poor state of mine roofPoor state of mine roof–– Frequent roofFrequent roof--fallsfalls

•• Thick layers of coal dustThick layers of coal dust–– Unacceptably high level of Unacceptably high level of

combustible mattercombustible matter•• Inadequate system to warn of Inadequate system to warn of

high methane levelshigh methane levels

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BASIC CAUSESBASIC CAUSESPersonal FactorsPersonal Factors•• Lack of mining experience of Lack of mining experience of

personnel working in minepersonnel working in mine•• Lack of knowledge of safe Lack of knowledge of safe

underground work practicesunderground work practices•• Physiological stressPhysiological stress

–– Methane overexposureMethane overexposure–– Fatigue due to 12Fatigue due to 12--hour shiftshour shifts

•• Psychological stress Psychological stress -- fear of reprisalfear of reprisal•• Improper motivationImproper motivation

–– Production at expense of safetyProduction at expense of safety

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BASIC CAUSESBASIC CAUSESJob FactorsJob Factors•• Lack of proper orientation and trainingLack of proper orientation and training•• Inadequate followInadequate follow--through from through from

inspectionsinspections•• Poor communication of standards (e.g. Poor communication of standards (e.g.

JOSH Co.)JOSH Co.)•• Inadequate purchasing of rock dustInadequate purchasing of rock dust•• Inadequate leadership in terms of Inadequate leadership in terms of

assignment of responsibilityassignment of responsibility•• Lack of safe work practices and Lack of safe work practices and

proceduresprocedures•• Inadequate engineering during mine Inadequate engineering during mine

design and planningdesign and planning

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LACK OF MANAGEMENT LACK OF MANAGEMENT CONTROLCONTROLInadequate Program ElementsInadequate Program Elements

•• Management commitment and Management commitment and accountability to safety mattersaccountability to safety matters

•• Management of change proceduresManagement of change procedures•• Incident investigationIncident investigation•• TrainingTraining•• Task definition and safe work Task definition and safe work

practices and procedurespractices and procedures•• Workplace inspections and hazard Workplace inspections and hazard

IDID•• Program evaluation and auditProgram evaluation and audit

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LACK OF MANAGEMENT LACK OF MANAGEMENT CONTROLCONTROLInadequate Program StandardsInadequate Program Standards

•• Concern expressed by management Concern expressed by management toward safety matterstoward safety matters

•• FollowFollow--through on inspections for through on inspections for substandard practices and substandard practices and conditionsconditions

•• Action on hazard reports submitted Action on hazard reports submitted by employeesby employees

•• Job instructions for employeesJob instructions for employees•• Equipment maintenanceEquipment maintenance•• Scheduling of management/employee Scheduling of management/employee

meetings to discuss safety concernsmeetings to discuss safety concerns

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LACK OF MANAGEMENT LACK OF MANAGEMENT CONTROLCONTROLInadequate Compliance FactorsInadequate Compliance Factors

•• Poor correlation between Poor correlation between management actions and official management actions and official company policy concerning company policy concerning relationship between safety and relationship between safety and productionproduction

•• Compliance to industry practice Compliance to industry practice and legislated standardsand legislated standards–– Methane concentrations, rock Methane concentrations, rock

dusting, control of ignition dusting, control of ignition sources underground, etc.sources underground, etc.

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LESSONS LEARNEDLESSONS LEARNED

•• Don’t do things the Westray way!Don’t do things the Westray way!

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PrePre--Contact ControlContact Control

•• ATTITUDEATTITUDE•• Internal Internal

Responsibility Responsibility System: IRSSystem: IRS

•• Everyone Everyone responsible for responsible for health and health and safety to extent safety to extent of authority and of authority and ability

•• SYSTEMSYSTEM•• Loss Loss

Management Management System: PSMSystem: PSM

ability

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CONCLUDING REMARKSCONCLUDING REMARKS•• Loss causation model is a useful tool Loss causation model is a useful tool

for identification of root causes of for identification of root causes of accidentsaccidents

•• Accident prevention requires Accident prevention requires leadership by management on safety leadership by management on safety issuesissues

•• PrePre--contact stages afford greatest contact stages afford greatest opportunities for loss preventionopportunities for loss prevention

•• Loss management system and Loss management system and attitude towards safety go handattitude towards safety go hand--inin--handhand


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