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• \ •• •• i " . -''i : " • ' Ï i. - v- ^ . •• - .. V-'.^-v.- ' PLEASE TYPE THE UNIVERSITY OF NEW SOUTH WALES Thesis/Dissertation Sheet

Surname or Family name: Parkin

First name: Raymond other name/s: John

Abbreviation for degree as given in the University calendar: ME

School: Mining Engineering Faculty: Engineering

Title: The Impact of Legislation And Other Factors On The Safety Performance Of Australian Coal Mines

Abstract 350 words maximum: (PLEASE TYPE)

The theme of the thesis is to investigate the current safety paradigm in the Australian coal mining industry and establish if the safety performance

is improving. The number of fatalities, serious bodily injuries and high potential injuries is unsatisfactory according to community standards.

People are still being killed and there is little evidence of a sustained improvement trend over the last decade. Lost time injuries have reduced

dramatically, but are now plateauing and over the last few/ years along with high potential injuries and other safety indicators are trending upwards.

This research has found that hundreds of serious injuries are not being reported which would have a significant effect on safety indicators in the

Industry. Fatigue and awareness issues as well as travel times to work are having a major impact on safety at work, which is particularly evident

when employees are working 12-hour shifts. The rapid expansion of the mining industry has required the growing use of contractors, hence

creating a more inexperienced workforce. Another significant finding is that there is a close association between the level of fatalities recorded and

the growing use of contract labour in the industry. This research has demonstrated that the current approach to prosecution is counter productive,

as it inhibits thorough safety investigation and creates a defensive rather than a proactive safety culture. This approach has resulted in an

unwillingness by companies to examine the root causes of accidents and incidents for the fear of being prosecuted. This research has shown there

is a lack of trust between mining companies, the unions and the inspectorate. It has been stated that miners lives are at risk because of the

shortage of Inspectors in Queensland and that the inspectorate was not meeting its compliance obligations. There is a "disconnect" between what

mining companies aspire to achieve at the corporate level with their safety management systems and what is achieved at the coal face. The thesis

has demonstrated that safety performance is deteriorating and in order to improve this situation recommendations have been made regarding

prosecution, contractors, fatigue, safety and health management systems, hours of work, audits and remuneration for inspectors.

Declaration relating to disposition of project thesis/dissertation

I hereby grant to the University of New South Wales or its agents the right to archive and to make available my thesis or dissertation in whole or in part in the University libraries in all forms of media, now or here after known, subject to the provisions of the Copyright Act 1968.1 retain all property rights, such as patent rights. I also retain the right to use in future works (such as articles or books) all or part of this thesis or dissertation.

I also authorise University Microfilms to use the 350 word abstract of my thesis in Dissertation Abstracts International (this is applicable to doctoral theses only).

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M hereby grant the University of New South Wales or its agents the right to archive and to make available my thesis or dissertation In whole or part in the University libraries in all forms of media, now or here after known, subject to the provisions of the Copyright Act 1968. I retain all proprietary rights, such as patent rights. I also retain the right to use in future wori

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'I hereby declare that this submission is my own work and to the best of my knowledge it contains no materials previously published or written by another person, or substantial proportions of material which have been accepted for the award of any other degree or diploma at UNSW or any other educational institution, except where due acknowledgement is made in the thesis. Any contribution made to the research by others, with whom I have worked at UNSW or elsewhere, is explicitly acknowledged in the thesis. I also declare that the intellectual content of this thesis is the product of my own work, except to the extent that assistance from others in the project's design and conception or in style, presentation and linguistic expression is acknowledged.'

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Date THE IMPACT OF LEGISLATION AND

OTHER FACTORS ON THE SAFETY

PERFORMANCE OF AUSTRALIAN COAL MINES

Raymond John Parkin

A thesis submitted in the fulfilment of the requirements for the degree of Master of Engineering in Mining Engineering

School of Mining Engineering University of New South Wales

August 2009 ABSTRACT

The theme of the thesis is to investigate the current safety paradigm in the Australian coal mining industry and establish if the safety performance is improving. The number of fatalities, serious bodily injuries and high potential injuries is unsatisfactory according to community standards. People are still being killed and there is little evidence of a sustained improvement trend over the last decade. Lost time injuries have reduced dramatically, but are now plateauing and over the last few years along with high potential injuries and other safety indicators are trending upwards. This research has found that hundreds of serious injuries are not being reported which would have a significant effect on safety indicators in the hidustry.

Fatigue and awareness issues as well as travel times to work are having a major impact on safety at work, which is particularly evident when employees are working 12-hour shifts. The rapid expansion of the mining industry has required the growing use of contractors, hence creating a more inexperienced workforce. Another significant finding is that there is a close association between the level of fatalities recorded and the growing use of contract labour in the industry.

This research has demonstrated that the current approach to prosecution is counter productive, as it inhibits thorough safety investigation and creates a defensive rather than a proactive safety culture. This approach has resulted in an unwillingness by companies to examine the root causes of accidents and incidents for the fear of being prosecuted.

This research has shown there is a lack of trust between mining companies, the unions and the inspectorate. It has been stated that miners lives are at risk because of the shortage of hispectors in Queensland and that the inspectorate was not meeting its compliance obligations.

There is a "disconnect" between what mining companies aspire to achieve at the corporate level with their safety management systems and what is achieved at the coal face. The thesis has demonstrated that safety performance is deteriorating and in order to improve this situation recommendations have been made regarding prosecution, contractors, fatigue, safety and health management systems, hours of work, audits and remuneration for inspectors.

n ACKNOWLEGEMENTS

This thesis would not have been completed without the support and encouragement of a number of people.

First of all I would like to thank my supervisors Emeritus Professor Frank Roxborough and Associate Professor David Laurence for their encouragement and direction, which has enabled me to achieve my objectives regarding this thesis.

I would like to acknowledge the many industry colleagues and friends that I have had discussions with, which has enabled me complete this work.

On a personal note, I would like to acknowledge my son Simon for his invaluable help with computer technology.

Finally, I would like to thank my wife Rosemary for her support, patience, understanding and encouragement throughout the writing of this thesis.

m

TABLE OF CONTENTS

1 INTRODUCTION - AN HISTORICAL REVIEW OF MINING, LEGISLATION AND SAFETY PERFORMANCE IN THE AUSTRALIAN MINING INDUSTRY 1

1.1 History Of Coal Mining 1 1.1.1 World Coal Production 2 1.2 History of Legislation 4 13 The Impact of Coal Mining Disasters on the Progress Mining Safety 6 1.4 Fatalities in the UK Coal Mining Industry 10 15 Safety Performance in the Australian Mining Industry 11 1.6 Safety Performance in the International Mining Industry 18 1.7 Recent Progress in Mine Safety Performance and Reporting in Australia 20 1.8 Aims of the Research Programme 29

2 SAFETY PERFORMANCE AND LEGISLATION REVIEW IN QUEENSLAND AND NEW SOUTH WALES COAL MINES 31

2.1 Queensland Coal Mine Safety Performance 31 2.1.1 High Potential Incidents in Queensland Open Cut Coal Mines 32 2.1.2 High Potential Incidents in Underground Coal Mines 34 2.1.3 Medical Treatment and Disabling Injury Cases 35 2.2 New South Wales Coal Mine Safety Performance 38 2.2.1 Lost Time Injury Frequency Rate and Serious Bodily Injuries 38 23 Employment Numbers in Queensland and NSW 39 2.4 Legislation in Queensland and New South Wales 40 An Historical Overview of New South Wales Mining Legislation 41

2.6 The Regulatory Framework in New South Wales Coal Mines 43

2.7 A Historical Overview of Queensland Coal Mining Legislation 44

2.8 The Robens Report 45

2.9 The Impact on the Change of Legislation in Queensland when Compared with New South Wales 47

2.10 The Reform of Australian OHS Law 48

2.11 Changes that have occurred in Queensland Coal Mining Legislation 50

2.12 Requirements of Duty Holders in Queensland Coal Mines 51

2.13 Current Legislation Requirements - Coal Mine Health and Safety Act 1999 53

2.14 Qualifications for Appointment as Inspector 2003 55 2.14.1 Qualifications for Appointment as an Inspector May 2007 56 2.14.2 Qualifications for appointment as Inspection Officer 57

2.15 Requirements of Duty Holders in the New South Wales Coal Mining Industry 58

2.16 Comparison of Levels of Competence Required for Duty Holders

in Queensland and NSW 59

2.17 The National Mine Safety Framework 62

2.18 Discussion 63

3 THE MINING SAFETY ENVIRONMENT 73

3.1 The Mining Safety Environment 73

3.2 Safety Culture On Mine Sites 73 3.2.1 Callide Mine Safety Culture 75 3.2.2 Visible Management Commitment 77 3.2.3 Quality and Quantity of Communication 78 3.2.4 Workforce involvement 78 3.2.5 Housekeeping 78

33 Safety Roadmap 79

3.4 Safety and Health Management Systems 81 3.4.1 The "Enhanced Safety Management System 82 3.4.2 Communication and Consultation 84 3.4.3 Methods of Communication 85

3.5 A Positive Safety and Health Management System 85

3.6 Issues with Safety Management Systems 86

3.7 Risk Management in the Mining Industry 90

3.7.1 Risk Management Systems 91

3.8 Industry Concerns Regarding Risk Management Philosophy 94

3.9 The Impact That Disasters Have Had On The Australian Mining Industry 96

3.10 Moura No 2 Mine 97

3.10.1 Task Groups Review and Recommendations 101

3.11 GretleyMine 102

3.12 Discussion 104

4 HOURS OF WORK AND FATIGUE MANAGEMENT 109

4.1 Hours of Work and Fatigue Management 109

4.2 Recent Research 110

43 Cognitive Psychomotor Performance and Decrement Associated with Sustained Wakefulness (SW) and Alcohol Intoxication 112

vn 4.4 Fatigue Related Issues 113

45 Rosters in the Mining Industry 114 4.5.1 Shift Pattern Characteristics 116 4.5.2 Fatigue and Awareness Issues 117 4.5.3 Vehicle Crashes On The Way To and From Coal Mines 118

4.6 Research Findings of Fatigue and Shift Work in NSW and Queensland 118

4.7 A Study Conducted by the Sleep Research Centre in

South Australia 120

4.8 Hours of Work 121

4.9 Fatigue Risk Factors 124

4.10 Industry Issues with Hours of Work and Fatigue 125

4.11 Industry Response to Long Work Hours and Fatigue 127 4.11.1 Fitness for Work 127 4.11.2 Response to Fatigue Issues by Industry 128 4.11.3 Fatigue Management Plans 129 4.11.4 Management of Fatigue 130 4.11.5 Management of Fatigue at Gregory Crinum Mine 132

4.12 Road Safety Alliance Programme 133

4.13 Discussion 133

5 ACHIEVING COMPLIANCE THROUGH PROSECUTION 137

5.1 Achieving Compliance Through Prosecution 137

5.2 Prosecution Policies 138

53 Prosecution for Offences in Occupational Health and Safety 139

5.4 The NSW Mineral Council Position on Prosecution Policy 139

vm 5S The Unions Position on Prosecution Policy 141

5.6 Trust Between Management and the Mines Inspectorate 141

5.7 Gretley Prosecutions 142

5.8 Moura No 2 Inquiry Process 146

5.9 Gretley Inquiry Process 148

5.10 Differences Between the Moura No 2 and Gretley Inquiries 149

5.11 Outcomes of the Queensland Wardens Court from November

1998 to March 2001 151

5.12 Prosecutions in NSW from August 1995 to April 2007 152

5.13 Findings of the Coroners Court in Queensland from December 2002

to March 2007 156

5.14 Issues with the Prosecution Policies 158

5.15 The NSW Investigation Unit 159

5.16 Discussion 161 6 THE "DISCONNECT" OF SAFETY MANAGEMENT SYSTEMS 167

6.1 The "Disconnect" of Safety Management Systems 167

6.2 The Impact of Disconnect associated with Safety Management Systems in Western Australia 168 6.2.1 Employee Workplace Agreements 169 6.2.2 Corporate Visions Policies and Standards 169 6.2.3 Mt Whaleback Mine 170 6.2.4 Employee Employer Relationships 171 6.2.5 Issues Raised at the Ritter Inquiry 172

63 Management Response 177 6.4 The Issues of "Disconnect" and Mistrust in NSW 177

65 The Corporate Mining Industry View 178

6.6 The Unions View 179

6.7 Discussion 180

7 CONCLUSIONS AND RECOMMENDATIONS 185

7.1 Conclusions 185

7.2 Recommendations 195 LIST OF FIGURES

Figure 1.1 Fatal Injuries Australian Mines from 1995-96 to 2005-06 12 Figure 1.2 Fatality Frequency Rate - Australian Mines - 1995-96 to 2005-06 (MCA 2006) 14 Figure 1.3 Lost Time Injuries - Australian Mines - from 1995-96 to 2005-06 (MCA) 15 Figure 1.4 Lost Time Injuries by Sector - Australian Mines - 2005-06 16 Figure 1.5 Lost Time Injury Frequency Rate (LTIFR) - Australian Mines from 1995-96 to 2005-06 (MCA) 17 Figure 2.1 High Potential Incidents in Queensland Open Cut Mines from 1999-00 to 2006-07. Sourced from Queensland Mines and Quarries Health and Safety Reports 33 Figure 2.2 High Potential Incidents in Qld Underground Mines from 1999-00 to 2006-07 34 Figure 2.3 High Potential Injuries from 1999-2000 and 2006-07 in Queensland Underground and Open Cut Mines. (Sourced from Queensland Mines and Quarries Health and Safety Reports) 35 Figure 2.4 Safety Indicators Over Captioned Period 66 Figure 3.1 A Basic Risk Management System 91 Figure 3.2 A Risk Management Matrix 94 Figure 4.1 Roster Safety and Health Considerations 132 xn LIST OF TABLES Table 1.1 World Coal Production from 1903 to 1905 2 Table 1.2 Top Ten Hard Coal Producers (2006 estimated) 3 Table 1.3 Global Hard Coal Consumption 3 Table 1.4 Fatalities in the UK between 1853 and 1985/86 11 Table 1.5 Fatalities by State Australian Mines from 1995-96 to 2005- 06 13 Table 1.6 International Comparisons of Fatality Incidence Frequency Rate and Lost Time Injury Frequency Rates for the year 2005-06. (MCA) 2005-06 Report 19 Table 1.7 Comparison of LTIFR Safety Performance by State. (MCA) 2005-06 Report 20 Table 1.8 Information Derived from Significant Incident Reports in Queensland, New South Wales and Western Australia between 2004 & 07 (Sourced from Departmental web sites) 26 Table 2.1 Lost Time Injury Frequency Rate in Queensland Open Cut and Underground Mines from 199-00 to 2006-07 Sources from the Queensland Mines and Quarries Safety and Health Reports 1999-00 to 2006-07 32 Table 2.2 Medical Treatment and Disabling Injury Cases in Queensland Open Cut and Underground Mines from 2003-04 to 2006-07 36 Table 2.3 Lost Time Injury Frequency Rate and Serious Bodily Injuries in NSW coal mines from 1999-00 to 2006-07 38 Table 2.4 Employment numbers in Queensland and NSW from 1999-00 to 2006-07. Sourced from the Queensland Mines and Quarries and the NSW Department of Primary Industries Annual Reports 40 Table 2.5 Comparisons of Levels of Competence Required Between Queensland and NSW 60 Table 2.6 Percentage Increase in the Safety Indicators 65 Table 3.1 The Take Five Process 93 Table 3.2 Analysis of Australian Coal Mine Disasters involving 4 or more mining fatalities from 1965 to 1996 96 Table 4.1 Average Hours of Work in the NSW Coal Mining Industry 122 Table 4.2 Hours Worked in Different Occupations in the NSW Coal Mining Industry 123

xm Table 4.3 Roster Risk Parameters 125 Table 4.4 Rules for Hours of Work 130 Table 5.1 Differences between the Moura No 2 and Gretley Inquiries 149 Table 5.2 The Time Taken to Complete the Moura and Gretley Inquiries 151 Table 5.3 Outcomes of the Queensland Wardens Court from November 1998 to March 2001 152 Table 5.4 Prosecutions in NSW Coal Mines from August 1995 to April 2007 154 Table 5.5 5 Findings of the Coroners Court in Queensland from December 2002 to March 2007 157 Table 5.6 Comparison of the Time Taken to Conduct Inquiries 163 A GLOSSARY OF TERMS AND ACHRONYMS

Definitions

As Low As Reasonably Possible - ALARP

Australian Workplace Agreements - AWA

Consolidated Rutile Limited - CSR

Construction Forestry Mining and Energy Union - CFMEU

Corporate Mining Industry - CMI

Disabling Injury - DI

A work related injury or disease resulting in a worker being unable to fully perform their regular job. (Either light duties or alternative duties are performed)

Duration Rate - (DR) The average time lost for every lost time injury. This is a measure of the severity of the injuries occurring. This rate is calculated using the following formula: (total number of days lost) (Number of lost time injuries)

Fatal Injury - (F) An injury that results in death.

Fatal Injury Frequency Rate - (FIFR) The number of fatal injuries per one million hours worked. Frequency Rate - (FR) The number of occupational fatalities or injuries expressed as a rate per million hours worked. This rate is calculated using the following formula: (number of occupational fatalities or injuries) x (1,000,000) (number of hours worked)

Health Safety Environment and Community - HSEC

High Potential Injuries - HPI

A high potential injury at a coalmine is an event, or series of events, that causes or has the potential to cause a significant adverse effect on safety or health of a person.

Incidence Rate - (IR) The number of fatalities or injuries per 1000 employees. This rate is calculated using the following formula: (number of occupational fatalities or injuries) x (1000) (number of employees)

Incident Cause Analysis Method - (ICAM) It enables identification of health and safety or environmental deficiencies and assists investigation teams to find out what went wrong and what needs to be done to prevent a recurrence.

Job Safety Analysis - JSA

Lost Time Injury - (LTI) An injury that results in a minimum of one full shift's absence (AS 1885.1 - 1990).

Lost Time Injury Frequency Rate - (LTIFR) The number of lost time injuries per one million hours worked.

Medical Treatment Case - (MTC) A medical treatment case is an injury requiring treatment by a doctor, nurse or a person required to give first aid. Notifiable Injuries - (NI)

Injuries that have to be notified to the Inspectorate

Occupational Health and Safety Management Systems - OHSMS

Safety and Health Management Systems - SHMS

Safety Management Plan - SMP

Safe Working Plan - SWP

Site Senior Executive - SSE The site senior executive is the most senior officer employed by the coal mine operator for the coal mine who is located near the mine and has full responsibility for the mine.

Severe Injury - (SI) An injury that results in a minimum of two weeks off work. This definition is used by South Africa as an injury measure.

Severity Rate - (SR) The average number of days lost per one million hours worked, (number of days lost) x (1,000,000) (number of hours worked)

xvn xvm CHAPTER 1

1 INTRODUCTION • AN HISTORICAL REVIEW OF MINING, LEGISLATION AND SAFETY PERFORMANCE IN THE AUSTRALIAN MINING INDUSTRY.

1.1 History Of Coal Mining Mines, most especially underground coal mines, are hazardous work environments, where the possibility of fire, flood, explosion and collapse have the potential to harm large numbers of people. Coal exists in abundance throughout the world and has been used as a fuel since pre-historic times. However, its use remained small and isolated until the IS^*" Century with the onset of the industrial revolution primarily in Great Britain. From the early 1800's Great Britain's coal production increased rapidly exceeding 10 million tons per annum, as coal became the main energy source to power the industrial revolution. The rapid development of the steam railway system, which started in 1825, significantly increased the demand for coal and production continued to increase reaching its peak in 1913 when over 270 million tons was produced annually.

The industrial revolution started in Britain in the 1700s and over time spread to Europe, North America and Japan. Since coal was cheaper and more efficient than wood it was the preferred fuel for steam engines. In addition to powering the railways, steam engines were rapidly adapted for marine use and the advent of steamships caused international trade to expand rapidly between 1810 and 1880.

Although coal was found in abundance in central and northern England, coal production was not able to keep up with demand due to the low yield small-scale near surface mining operations. As a result operations moved to deep shaft mining as the Industrial Revolution progressed. Coal was first discovered in Newcastle, New South Wales, Australia in 1791 (Martin et al. 1993). At the time, the mining workforce was made up mainly of convicts where there was less need of humane considerations since mining work was used as punishment for recalcitrant convicts in both NSW and Tasmania. However these mining activities made a significant contribution to the progress of early settlement in Australia. The first mineral discovered in Australia was coal. It was the first to be mined and today remains the most important mineral in terms of local use for power and foreign earnings from its export.

1.1.1 World Coal Production Table 1.1 shows the major coal producing countries of the world at the beginning of the century (Hull 1881). It can be seen from Table 1.1 that in 1905 the United States of America was the highest producer at in excess of 350 million tons per annum followed by the United Kingdom producing 236 million tons/annum and Germany the third highest producer at 175 million tons/anum.

Table 1.1 World Coal Production from 1903 to 1905

World Coal Production from 1903 -1905 Country Year Tons United Kingdom 1905 236,128,936 Germany (Coal) 1903/05 121,298,167 Germany (Lignite) 1903/05 52,498,507 France 1903/05 35,869,497 Belgium 1903/05 21,775,280 Russia 1904 19,318,000 India 1905 8,417,739 Japan 1903 10,088,845 United States 1905 350,821,000 Canada 1904 7,509,860 Australia 1905 7,161,464 The demand for steaming coal for navies and steam ships was at its height just before World War 1. Coal output in the UK reached its peak of 273 million tons in 1913, and the industry employed well over 1 million miners. With such intensive industrial activity gas and coal dust explosions were frequent and involved substantial loss of life.

It is significant to contrast the current world situation with that of the early 20 th Century. In the information sourced from the World Coal Institute (Table 1.2) it can be seen that in 2006 the world's top producer is China producing 2482 mt, followed by the USA at 990 mt. Third is India at 427 mt tonnes and Australia is the worlds fourth highest producer at 309 mt. This growth in world production, over the past 25 years is calculated at 92% and is currently increasing at about 8.8% per year. China currently produces 2.5 times more hard coal than the USA. In 2006 UK coal mining produced about 30mt.

Table 1.2 Top Ten Hard Coal Producers (2006 estimated)

PR China 2482 Mt Russia 233 Mt USA 990 Mt Indonesia 169 Mt India 427 Mt Poland 95 Mt Australia 309 Mt Kazakhstan 92 Mt South Africa 244 Mt Colombia 64 Mt

Table 1.3 shows global hard coal consumption to have grown by 65% between 1986 and 2006 and in this context of world coal consumption, Australia is the largest exporter of coal which in 2006 was 231Mt followed by Indonesia at 129Mt. The world's largest consumer of coal is China. According to the World Coal Institute, it consumes 46% of the total amount of coal produced in the world.

Table 13 Global Hard Coal Consumption

1986 1996 2006e

World 3232 Mt 3773 Mt 5339 Mt 1.2 History of Legislation It is understandable that the basis of coal mining legislation in Australia derives primarily from Britain and so the history of Australian and British legislation is intimately connected.

The historical evolution of the legislation in Britain was primarily driven by catastrophic events, which progressively led to new laws, expanded and consolidated existing laws and gradually changed the nations philosophy relating to safety and health in the workplace.

Britain was the first of the leading countries of the world to develop its substantial coal resources and as a result was the first to become industrialised. However it is interesting to note that it was ''France who early in the century first established the principle of government inspection of collieries'"(TdiyXox 1986).

The mining legislation of today came about following events, which occurred in the first half of the century. It was during the industrial revolution following horrific disclosures regarding the conditions of employment of women and children in factories when the first legislation came into force. This was the Health and Moral Apprentices Bill, which became law in 1831 (Taylor 1986). This bill faced considerable opposition from mill owners and their supporters because of increases in costs. It was a major milestone in the industrial history in the UK being the first ever factories act. This resulted in the first government inspectors being appointed in 1833. The early primitive mining methods gradually developed in scope and sophistication over time and by 1830 the establishment and application of basic mining engineering principles had enabled mining to proceed to depths of close to 100 metres. Then, the availability of the steam engine for winding and dewatering purposes allowed mines to extend even deeper and into more gassy and geologically complex seams which brought a new range of safety and ventilation problems. In order to improve safety conditions double entries were employed providing simple ventilation circuits. Gas and coal dust explosions, leading to huge loss of life, became more frequent and costly. They were commonly caused by the naked flames used by the miners for illumination purposes. Such catastrophic events highlighted the need for safe illumination underground and as a consequence the flame safety lamp was invented in 1815 and quickly gained acceptance in gassy mines.

An increasing number of explosions were occurring in coal mines and at the same time the deplorable working conditions in the mines were progressively being revealed. There was growing public disquiet and formal enquiries into major mining disasters were being called for. A notable early instance was the establishment of the South Shields Committee in 1839, following an explosion at the St Hilda mine, causing the death of 52 men and boys. The Committee was set up specifically to investigate the cause of this and other similar accidents and to find means to prevent them happening in the future. The committee was composed of non-mining people and its report stressed several important issues, which included the prohibition of single shafts.

It was not until 23 years later that single entry mines were made unlawful following the Hartley Colliery disaster where 204 men and boys died, all but 5 from suffocation, because of their inability to exit the mine when the single shaft entry collapsed.

In 1882, 92 persons were killed in an explosion at the Felling mine in South Tyneside where local society was sufficiently disturbed that the Sunderland Committee, like the South Shields Committee before it, was formed to enquire into mining accidents and find means of preventing them. These Committees played a major role in the process of formulating coal-mining regulations at national level

Mining technology was developing quite rapidly. Hempen ropes were being used for hoisting and haulage until wire ropes were invented in 1840. Endless rope haulage for underground coal transport was introduced in 1844 with steam engines and sometimes boilers being placed underground (Martin et al. 1993).

A Royal Commission in Britain was established in 1840 to enquire into the employment of young children and women in mines. ''The report was issued in 1842 and was described as the most depressing Royal Commission report ever written" (Taylor 1986). A Government Bill seeking to limit the employment of women and children underground was presented to Parliament but it met violent opposition in the House of Lords. However the Bill was passed and the employment of women and boys under the age of 10 was prohibited. At the same time provision was made for the introduction of inspectors of mines. The next most prominent legislation to follow was the Coal Mines Act 1911 which remained in force until superseded by the Mines and Quarries Act 1954, together with the attendant regulations. The 1954 Act continued in force, with attendant Regulations being amended or added as required until 1974 when the Health and Safety at Work Act was passed which brought some eight million persons within safety and health legislation for the first time ever which, also included employers. The 1972 Robens Report fathered the Health and Safety at Work Act, 1974, which controversially championed the idea of self-regulation by employers. Significantly the author of the report, Lord Robens, had been Chairman of British Coal from 1961 to 1971. In January 1994 the British Government introduced the Coal Industry Bill (1994) into Parliament with the intention of privatising the core mining activities of British Coal by the end of the year.

13 The Impact of Coal Mining Disasters on the Progress Mining Safety. The way in which some of the mining catastrophes that shaped the mining safety ethos in Britain is significant and worthy of review. Coal mining has a long history of disasters that have caused unbelievable suffering to mining communities over more than two centuries. The disasters of the past have shaped the course of legislation through the efforts to remedy such catastrophic events. This in turn progressively and dramatically improved safety performance in the coal mining industry. To be classified as a disaster, an accident or explosion has to claim more than 10 lives.

Some of the most important ones in regard to improving the safety of miners and changing legislation have been investigated by Galloway (1969).

The Felling Mine disaster occurred in Felling, South Tyneside on the 25^^ of May 1812 killing 92 miners. The mine was equipped with two shafts about 600 feet deep. Like many other mining disasters, the accident was caused by an ignition of methane, which then propagated into a coal dust explosion. At the time adequate lighting was hazardous since open flame lamps could easily ignite any combustible gases that were present.

The only current option was to deliberately destroy the gas accumulations by a fire monkey, who covered himself in a wet blanket and poked a candle on a long stick into the gas accumulations. This particular tragedy stimulated an engineer called George Stevenson to design a safety lamp and about the same time Humphry Davey also devised an oil lamp where the flame was surrounded by iron gauze. The gauze would not allow a flame to pass through, but was able to admit methane, which could bum harmlessly inside the lamp.

However, the risk of an explosion was still present as there were other sources of ignition, such as sparks from metal tools. Upon their development, electrical equipment and explosives used for blasting purposes provided a further potential source of ignition to cause a gas explosion.

The Hartley Colliery disaster occurred in Hartley, Northumberland on of January 1862 killing 204 men and boys. Methane and coal dust explosions were common at the time but this disaster was different because it was caused by the fracture of a steam engine beam, which was used to dewater the mine. The beam suddenly broke, and one end plunged into the shaft of the mine. The colliery was being worked by a single shaft, which had been divided into two parts by a wooden partition, which was made airtight by brattice cloth. This allowed air to pass down one side of the wooden brattice structure and after ventilating the mine return up the other side, the air current being driven by an open furnace at the shaft bottom. When the broken half of the beam fell down the shaft, it smashed the partition, collapsed the shaft walls and created a dense pile of debris towards the base of the of the shaft. It entombed 204 men and boys, who could not be rescued. It took a week to reach them in which time all but 5 had suffocated and died from carbon monoxide produced by the furnace. The cause of the fracture to the beam was attributed to over load from the pump rod system to which one end of the beam was attached. The beam, made from cast-iron, was highly susceptible to metal fatigue where repeated loading was involved.

This tragedy led to changes in legislation requiring all collieries to be worked with a minimum of two entries separated by not less than 15 metres of natural ground. This would facilitate mine ventilation but most importantly would provide a second means of egress from the mine.

The Senghenydd Colliery explosion occurred in Senghenydd, Glamorgan, Wales on the of October 1913, killing 438 miners. This is regarded as the worst mining accident in The United Kingdom, and probably one of the most serious in terms of loss of life globally. This terrible accident occurred as a result of a coal dust explosion that travelled through most of the underground workings. It is most probable that it was started by a methane explosion, which may have been ignited by an electric spark. The methane explosion caused the propagation of a coal dust explosion. Those miners not killed immediately by the fire and explosion would have died from the noxious gases formed by the combustion.

The Hulton Colliery (known locally as Pretoria Pit) explosion occurred in Hulton, Lancashire on the December 1910 killing 344 miners. The colliery employed 2500 men and boys prior to the accident and at the time a number of miners had complained of gas and hot air. The published conclusion was that a roof collapse had caused a build up of gas and a faulty lamp had ignited it.

The Gresford Colliery explosion occurred in the Dennis section of the mine in Gresford near Wrexham, Wales on the 22"^^ September 1934 killing 266 miners. The colliery employed 2200 miners and prior to the explosion there was evidence of heat and gas in the colliery. Only 11 bodies were recovered. However the Dennis section of the mine was never reopened sealing the bodies of the 255 victims in the mine. An inquiry highlighted management failures, lack of safety measures, bad working practices and poor ventilation in the pit as contributory factors of the disaster. The Cresswell Colliery disaster occurred in Cresswell, North Derbyshire on the September 1950 when a fire killed 80 miners. At the start of night shift at about 11pm a transfer attendant noticed that between 6 to 8 yards of belt had been damaged on number 2-trunk belt. Later that morning he noticed that the belt had torn with a trailing end. Upon further examination he saw smoke and a fire at the transfer chute. He along with another person tried to fight the fire using fire extinguishers but they were unsuccessful. The nearest mine safety fire station was on the inbye side of the fire. Rescue members tried to fight the fire with sand and dust because the water pressure at the fire site was so low.

Eighty men were trapped inbye of the fire and at this stage the fire was out of control, which led to the decision to seal the mine. The following year thirty-three bodies were recovered from the mine. It was concluded that friction between the damaged belt and rollers had built up and started the fire.

After this disaster the coal mining legislation was changed such that all rubber conveyor belt underground were to be replaced with fire resistance belt.

In the following year, 1951, an explosion at Easington Colliery, Durham killed 83 miners including 2 rescue workers. Easington's workings extended several kilometres under the North Sea where retreat longwall mining was practiced. A surge of methane from roof caving in the unventilated goaf caused an explosive methane air mixture at the working face. This was ignited by sparks from machine cutter picks striking pyrites nodules in the seam floor. The methane explosion propagated into a coal dust explosion.

New legislation followed relating to the provision of stone dust barriers in conveyor roads and also introduced legislation relating to goaf support and ventilation in retreat mining.

The Markham Colliery disaster occurred near Chesterfield, Derbyshire on the July 1973 killing 18 miners and seriously injuring 11. The accident was caused by a brake rod failure due to a fatigue crack whilst the cage was descending to the bottom of the shaft killing 18 men. It was the second major disaster at the colliery following an explosion in 1938, which killed 79 miners, and seriously injuring 40 others.

Legislation was changed such that all winding gear had to be crack detected at periodic intervals in order to avoid a recurrence of this tragic incident.

These key tragedies, spanning a period of 162 years, were all different in nature and occurrence and each was pivotal in bringing about changes in safety attitudes and the progression of coal mine safety legislation. As described, they ranged from the invention of the flame safety lamp to the requirement for 2 separate means of egress at all mines; from the provision of stone dust barriers to fire resistant conveyor belting and from routine crack detection to goaf support and ventilation. They are however, mere examples of a broader canvas in coal mining of how major incidents have driven change.

1.4 Fatalities in the UK Coal Mining Industry In order to understand the benefits that the introduction of legislation has achieved it is necessary to analyse the numbers of fatalities over a long time period, say a century. Reliable figures are available from 1853 to 1985/86, the latter being the onset of the rapid decline on British coal mining.

In 1853 some 259,000 people were employed in coal mines and the number of fatalities was 1012, which means that a miner had a 1 in 256 chance of being killed within that year. In 1985/86, 132 years later about 138,500 people were employed and the number of fatalities was 28. This means that a miner had a 1 in 4946 of being killed within that year. Therefore it can be said that the safety performance in mines between 1853 and 1985/86 has improved dramatically and that the introduction of legislation has played a significant part in improving the safety and health of people working in coal mines. The introduction of technology has also played its part in safety improvement over the same time period. (Information sourced from http://vvww.cmhrc.co.uk/site/home/). The progression of safety improvement, in terms of loss of life, can be gauged from Table 1.4.

Table 1.4 Fatalities in the UK between 1853 and 1985/86 Year Number Employed Fatalities Risk 1853 259,000 1,012 1/256 1930 943,000 1,013 1/931 1946 716,000 543 1/1319 1970 304,000 91 1/3340 1986 138,500 28 1/4,946

British coal mining history and the development of legislation have been central to the evolution of safety improvement in the industry worldwide. The demonstration of this fact is highly relevant to the evaluation of mine safety performance in Australia.

1.5 Safety Performance in the Australian Mining Industry. The safety performance in the mining industry is usually measured in terms of the fatality injury frequency rate (FIFR) and the lost time injury frequency rate (LTIFR). These are lagging indicators and are used as base line indicators of safety performance throughout the mining industry. The FIFR is the number of fatal injuries per one million hours worked and the LTIFR is the number of lost time injuries per million hours worked. A lost time injury is one that prevents the person from attending his place of work on the next shift. Information has been sourced from The Minerals Council of Australia Annual Report, which has used data collected through the States/Territory and Mines Inspectorate. This data provides a comprehensive picture of the minerals industry safety performance. It can be observed that in 2005-2006 eleven fatalities were recorded by the Australian minerals industry as depicted in Figure 1.1. This is a significant increase compared to the seven fatalities recorded in earlier in both 1995-96 and 2001-02. During the 11 years covered by Figure 1.1 the industry has recorded 155 fatalities, at an average of over 14 deaths per year. However over the last five years the eleven fatalities recorded in 2005-06 is higher than the five-year average of just over 10. It can be observed from Figure 1.1 that the number of fatalities has varied considerably over the decade, ranging from seven in 1995-06 and 2001-02 to a high of 33 in 1996- 1997. Whilst the trend shows decreased fatal injuries over the last 11 years, over the last 5 years that downward trend has not continued. According to the Minerals Council, there is little evidence of a sustained improvement trend over the decade.

Figure 1.1 Fatal Injuries Australian Mines from 1995-96 to 2005-06

o ino o o C\J CM Year Range The following Table 1.5 shows the fatalities by state from 1995-96 to 2005-06. It should be noted that this table covers all mining activity including coal and metalliferous. However it is clear that the majority of fatalities have occurred in the most active mining states of WA, Queensland and NSW. In 2005-06 fatalities resulted from falls from height, explosives, fixed plant, rock falls and mobile equipment. It is interesting to note that in the most recent of the years, NSW is fatality free, which may be for the first time in its long mining history. Table 1.5 Fatalities by State Australian Mines from 1995-96 to 2005 06 1995- 1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 2004- 2005- 96 97 98 99 2000 01 02 03 04 05 06 WA 4 8 13 3 6 5 3 5 4 2 5 QLD 1 12 0 2 2 2 2 3 1 4 3 NSW 2 11 1 4 11 4 2 1 4 1 0 VIC 0 0 4 0 0 1 0 1 0 0 1 Tas 0 1 0 1 0 3 0 2 0 0 1 SA 0 0 1 0 0 0 0 0 3 2 1 NT 0 1 0 0 0 0 0 0 0 1 0 Total 7 33 19 10 19 15 7 12 12 10 11

Consideration of these fatalities on the basis of the Fatal Injury Frequency Rate (FIFR) shows them to be unsatisfactory.

According to the Minerals Council Report for 2005-06 the national FIFR was 0.04 as shown in Figure 1.2, which was the same as the previous year. It can be observed that the rates have fluctuated significantly from year to year and are now plateauing. While it is evident that the trend over this 1 lyear period is decreasing, the fact that on two occasions, in 1995-96 and 2001-02 was less than the latest two years suggests that there is certainly room for improvement and should be of concern to all in the industry.

A staff member of a safety organization (anonymity requested) stated to the author in 2008 that some fatalities on mine sites are not being recorded in some States because construction on site did not constitute a fatality in terms of reporting at the operation. This statement begs the question. Does the industry operate with the appropriate statistics in all States of Australia? Because, this would mean under reporting and as a consequence under reporting of important statistics. This issue will be discussed later in the thesis. Figure 1.2 Fatality Frequency Rate - Australian Mines - 1995-96 to 2005-06 (MCA 2006)

Year Range

Turning now to the other main indicator of safety performance, the Lost Time Injury Frequency Rate (LTIFR), according to the Minerals Council of Australia, Lost Time Injuries in 2005/6 have increased 8% to 1476 from 1373 the previous year. This is the first increase in lost time injuries in over a decade of continuous decreases figure 1.3. Figure 1.3 Lost Time Injuries - Australian Mines - from 1995-96 to 2005-06 (MCA).

5000

Year Range

The current lost time injuries for each sector of the mining industry is shown in figure 1.4. All sectors reported a decrease in lost time injuries except open cut metalliferous, which increased from 350 in 2004/6 to 399 in 2005/6, which is a 14% increase. It is significant to note that open cut metalliferous is only slightly better than underground coal, which suggests it must be a cause for considerable concern. Figure 1.4 Lost Time Injuries by Sector - Australian Mines - 2005-06

CO C/3 0) W O) CB CC CO 13 .> O o o o o c O o o o "c c CO § O 2 3 "B O T3 gc o 3 L>U< C C s O) 0) ^ a5 0) c Q. o O E E Q O O b E b 3 C/3

According to the Mineral Council during the past decade (1995/6 - 2005/6) the LTIFR has decreased consistently from year to year, though the rate of decrease is perceptively reducing, as might be expected asymptotically. Recent reports have noted that only incremental improvements had occurred and that rates may be levelling off. In 2005-06 a LTIFR of 5.4 was recorded which was lower than the previous year of 5.7 as shown in figure 5. Figure 1.5 Lost Time Injury Frequency Rate (LTIFR) - Australian Mines - from 1995-96 to 2005-06 (MCA).

25

O 20 c CD CD T 15

LL

00 o •I- C\J CO in cn o cp cp cp o o cp o CD OJ o -A CM CO 4 O) O) o o o o o CD CD O) o o o o o CD CM CVJ CM eg CvJ CD Year Range

The following three examples show how a falling LTIFR preceded a major organisational incident. In all three cases management were convinced on the basis of their LTIFR record that they were operating safe systems.

According to Reason (2005) ''The road to disaster is paved with falling or low LTIFR" who made the following significant observations;

• Westray mining disaster-Canada 1992 • 26 miners died. Company had just received an award for reducing LTIFR. • Moura mining disaster Queensland 1994 • 11 men died. Company had halved its LTIFR in the four years preceding the accident. • Longford gas plant explosion Victoria 1998 • Two died 8 injured. Safety effort had been directed at reducing LTIFR. Major hazards of unrepaired equipment not recognised. It is apparent from these three examples that when the LTIFR is reducing industry must not rest on its laurels since there is the potential for the danger of complacency. This means the industry must be more vigilant because the potential for a disaster or serious injury is ever present.

The earlier discussion on disasters in the coal mining industry, principally in Britain, has demonstrated that legislation developed over 150 or so years has greatly improved the safety of miners throughout the industry in Australia and elsewhere.

However, recent indicators of safety performance in Australia are sounding ominous warnings. Although the LTIFR is now plateauing, the fluctuating annual fatality numbers continue to cause concern. In fact the 11 fatalities recorded in 2005-06 is higher than the preceding five-year average of 10.4. The FIFR for the last two years has remained the same at 0.4.

1.6 Safety Performance in the International Mining Industry In Table 1.6 the Australian Fatality and Lost Time Injury Frequency Rates are compared with those in The United States of America, South Africa and the Province of Ontario in Canada. The information has been obtained from the Mineral Council of Australia (MCA) 2005-06 Report. According to this data the Australian mining industry compares very favourably with its South African counterpart. It can be observed from Table 1.6 that South Africa, as might be expected, has the highest FIFR of 0.28. This is not surprising when taking into consideration that its industry is heavily dominated by its underground gold operations, which are the deepest hot humid mines in the world. Some of these mines are approaching 4 kilometres deep with all the associated hazards of rock out bursts and ventilation issues. Other contributing factors to the increased FIFR are that South African mines are much more labour intensive, as well as the cultural and political environments being very different to those in Australia.

Of the groups listed, the USA underground coal sector is running second highest to South Africa with a FIFR of 0.24. This is very high compared to the Australian average over the last decade (1995/6 -2005/6) of 0.13. It is particularly alarming to observe the fatality rate in the USA when compared with the rate in South Africa of 0.28 especially considering the disadvantageous factors applying in South African mentioned above. This is even more surprising considering that the LTIFR in the USA underground coal mines of 17 is better than the Australian underground coal LTIFR of 19. This would suggest that there is no essential correlation or connection between FIFR and LTIFR. And therefore the fatality rate in the USA must be a cause for serious concern.

It can also be seen that in Ontario, Canada, • The underground metalliferous FIFR of 0.4 is much better that Australia's and compares favourably with the open cut coal sector in Australia. • The LTIFR of 4 is better than underground metalliferous and compares with open cut coal and metalliferous.

Table 1.6 International Comparisons of Fatality Incidence Frequency Rate and Lost Time Injury Frequency Rates for the year 2005-06. (MCA) 2005-06 Report.

SECTOR FIFR LTIFR Australia -Open cut Coal 0.04 4 Australia -Underground coal 0 19 Australia -Open cut metalliferous 0.02 4 Australia -Underground metalliferous 0.14 6 Australia - All Extractive 0.09 8 industries USA - underground coal 0.24 17 USA - underground metalliferous 0.11 11 South Africa - all mining 0.28 N/A Ontario, Canada underground metal 0.04 4 1.7 Recent Progress in Mine Safety Performance and Reporting in Australia. It can be seen from Table 1.7 that there is a wide variation in the safety performance of Australian States. New South Wales underground coal operations have the highest LTJFR of any state at 24. This is despite the fact that 2005-06 was the first year in over a decade, and probably very much longer, that is has been fatality free. This adds further credence to there being no correlation between the FIFR and the LTIFR. Queensland open cut coal and New South Wales open cut metalliferous had a significantly better performance when compared to the other States. Western Australia open cut coal was the highest at a LTIFR of 14 when compared to the other states in the open cut coal category.

Table 1.7 Comparison of LTIFR Safety Performance by State. (MCA) 2005-06 Report. state OC coal UG coal OC metal UG metal

WA 14 - 4 5 Qld 3 12 3 4 NSW 6 24 2 6

SA - - 8 5

TAS - - - 15

For a number of years the industry focus in terms of safety performance has been on lost time injuries and how they can be managed more effectively in terms of an individual's welfare and the issue of workers compensation. It has already been shown that lost time injuries rates are plateauing. Over the last few years other safety measures have been introduced such as disabling injuries rate and severity rate. In WA disabling injuries increased from 506 in 05/06 to 705 in 06/07 (MCA 2006). Coal suffered the highest serious injury rate of 13.5 compared to other industry sectors. It is interesting to note that there are now no underground coal mines operating in WA and therefore open cut coal has a higher serious injury rate than underground metalliferous mines. Workers compensation is currently paid for exposure to a number of health risks including silica, coal, asbestos, noise induced hearing loss, musculoskeletal disorders, diesel fumes, dermatitis, ergonomic back and fatigue disorders and skin diseases. ''The traditional mining-related exposures of concern - silica, coal and, to a lesser extent, asbestos - are generally well controlled, and the resulting traditional respiratory diseases most associated with mining are almost certainly becoming far less common."

''Using national compensation data for all miners in Australia, for eight years from July 2007, there was an average of 2,544 accepted claims each year by mining industry workers. Eighty three per cent of these claims were for injury. Of the remaining claims, only 10% were for diseases of the nervous system and sense organs (primarily noise induced hearing loss), 2% for disease of the musculoskeletal system and 2% for diseases of the digestive system." (Driscoll 2007).

In 2005/06, 802 workers compensation claims in Queensland coal mines were made costing $5.6m and 404 claims in metal mines costing $2.7m. Correspondingly, in NSW for 2005/06, 2057 workers compensation claims in coal mines were made at a cost of $ 15m and in metal mines the total claims cost was $1.7m. It has been estimated that the true cost of these work related illnesses and injuries is many times greater than these amounts. The additional costs would be mainly due to lost production time and equipment damage.

According to Billingham (2007) when discussing mine safety it was stated that following the 2006 annual briefing two fatal accidents had occurred and a total of four deaths during 2006-07.

Another alarming trend was that all statistical indicators had deteriorated in the reporting period 2006-07. Two of these accidents happened in world-class mines operated by BHP and Anglo Coal. Mobile equipment was involved in both accidents. Billingham went on to emphasise that although the general lag indicators for safety had plateaued following years of improvement, the fatality rate had continued to rise. "The inspectorate in Queensland is devoting resources to human factors research, which was a key aspect of each of the four fatalities over the past year. A recognised authority in this field from the United States has been engaged to assist the inspectorate to identify interventions that can be put in place to better handle the interaction between workers and the equipment and vehicles they use in mining environments". {Safety and Health Reports 1999-00 to 2006-07 2007).

It is interesting to note that in 2002 the Department of Mines and Energy stated the following, "Recent history in the mining industry in Queensland has shown that incidents and accidents have occurred as a result of unintentional errors or actions that do not recognise the personal risk present. Too often, the serious accidents are a result of conscious risk- taking, such as taking the easy way out, taking a short cut or not thinking about the risks in your workplace before starting work. It is not uncommon to find the victims knew the potential risk of accidents before the incident.

Our new legislation is based on risk management, the best legislation in the world will not prevent accidents if people are not made aware of what the hazards and their controls are, if they are too tired to undertake the task, if machinery is not fit for purpose, or if the culture of risk-taking is allowed to continue."

Human behaviour is therefore still a major component in many of the incidents and accidents, in the mining industry today. This point is made clear by Laurence (2003) "A body of evidence exists suggesting that many accidents are caused by mineworkers failing to follow procedures or rules''.

There has been considerable discussion over many years regarding the limitations of traditional reporting of health and safety data which emphasises the more negative and lag time indicators such as lost time injuries. More recently, concern has been raised about the accuracy and validity of reported data. Examples of this misreporting are, lost time injuries being reported as disabling or medical treatment injuries. Injuries leading to permanent disability are believed to be underreported which may in part be related to some cases not ending up as workers compensation claims. With the above mentioned issues in mind a review of the Queensland Mines and Quarries Annual Safety Performance and Health Report was commissioned.

The findings of this report were published in October 2007. (Parker & Cliff 2007). A summary of these findings indicated the following; • Over 50% of injuries that resulted in workers not being able to carry out their normal work on the next shift are not collected in any detail. This is due to reporting being limited to LTI and not including a Disabling Injury (DI) or a Return to Work Injury (RWI). • Collection of permanent disability injuries and illnesses is not adequate. There were some instances reported where workers with permanent disabilities received redundancy or retrenchment payment rather than Workers Compensation. A number of permanent disability cases were reported as DI or Medical Treatment Injury (MTI) and as such not reported as a LTI. • Some industry personnel who fill out Department of Mineral and Energy (DME) forms are inadequately trained in understanding the definitions and terms used. The current method of reporting individual mine performance may encourage the underreporting of incidents. • There is a perception in the industry that mines will be penalised by the DME for reporting too many incidents and the current practice of presenting awards to mines with no LTIs may encourage under reporting of incidents. • The focus on LTIs and the small number reported encourages underreporting. • The incident analysis tool Incident Cause Analysis Method (ICAM) is of dubious value due to the input format of the forms, limited training of data entry personnel and the use of other reporting systems, which are not transportable into ICAM format. • Some contractors and sub contractors were not reporting all accidents and incidents that they were involved in, due to safety targets being a condition of their contract. The safety performance of contractors is measured by reported injuries and high potential injuries and because contract payments are linked to safety performance, there is an incentive to not report injuries to the operator. • The incomplete capture of safety data for employees not employed by the operator of the mine. A concern has been expressed over a lack of reporting of injuries for some sub contractors and self-employed people. • Some persons on fixed term contracts who are injured at the time of the contract ending do not get their contracts renewed, but are not counted as losing employment due to injury. • There is concern within the stakeholders that sub contractors and self- employed persons were not adequately monitored.

The finding of this report further demonstrates that underreporting in the mining industry is a problem that must be addressed. The District President of the CFMEU, Andrew Vickers has argued that;

"the injury figures are wrong and distorted. People hurt at work were going back to light duties.. .management contracts were linked to performance indicators such as injury rates.. .there was evidence that injury rates were standing still at best but could be worse" ('Qld District tackles problems generated by the mining boom in our communities' 2006)

The above-mentioned issues regarding under reporting again reinforce the notion that the safety performance in the mining industry needs to be questioned particularly as current statistics may be heavily distorted due to the factors mentioned above.

The contribution of human factors to incidents and serious accidents in the mining industry is illustrated in Table 1.8. The table illustrates the fatal and significant incident reports over a three-year period where human behaviour and other factors can be identified. These reports are listed on the web pages of the Mines Inspectorate in Queensland, New South Wales and Western Australia.

These incidents have been caused by the following issues: • Poor communication • Not complying with specific rules and procedures • Lack of awareness of rules and procedures • Lack of clear instructions • Production being considered before safety • Inadequate training • Fatigue • Lack of appreciation of the consequences of individual and team actions • Lack of supervision Table 1.8 Information Derived from Significant Incident Reports in Queensland, New South Wales and Western Australia between 2004 & 07 (Sourced from Departmental web sites)

I.QUEENSLAND INCIDENT INCIDENT CAUSE A CONTINUOUS MINER A continuous miner operator was caught between a moving shuttle car OPERATOR WAS FATALLY and the side of the main roadway. Safety rules and procedures were not INJURED being followed and communications between the team members was deHcient. A WORKER WAS FATALLY The worlcer was walking along a haul road when he was struck from INJURED WHEN HE WAS behind by the loader. The worker should not have been on the haul RUN OVER BY A FRONT road; safety rules and procedures were not being followed. END LOADER A SENIOR MINING It appears that the deceased was carrying out an inspection when he ENGINEER WAS FOUND slipped over the edge, falling some 43m into water over 8m deep. The DECEASED AT THE mine had inadequate processes to systematically address the concerns BOTTOM OF A HIGHWALL of relatives for personnel who were absent following work on site. Safety procedures were found to be inadequate. COAL MINEWORKER A coal mine worker receives bums to his body when the water truck he RECEIVES BURNS TO 65% was driving down an access ramp overturned and burst into flames. OF HIS BODY Investigations by the Mines Inspectorate revealed poorly maintained brakes on the truck. Contracting company and a fitter are prosecuted. LOADER OPERATOR A loader operator receives fatal injuries when he was crushed by the cab RECEIVES FATAL of the front-end loader he was operating. The loader was being driven INJURIES. down an exploration track when it ran up a bank and fell over trapping operator under the cab. Safe operating procedures were found to be inadequate. Awareness and fatigue issues may have contributed to the incident. TRAINEE DIAMOND A trainee diamond driller received fatal injuries when working DRILLER FATALLY underground at a silver/lead/zinc mine. At the time of the incident he was INJURED working in a man basket attached to an integrated tool carrier when the basket fell to the ground. Safe operating procedures were inadequate for this operation. Safety rules not being followed. TRUCK DRIVER RECEIVES A truck driver was removing a wheel rim assembly when it gave way FATAL INJURIES under pressure due to a wear crack in the rim, which fatally injured the truck driver. The coroner recommended a review of the mine safety management plans to ensure that contractors are carrying their task in a safe manner, that the site senior executive be required to have an appropriate competency in order to establish and maintain the mine health and safety management system. TYRE HTTER RECEIVES A tyre fitter was removing the outer wheel of a dump truck when FATAL INJURIES compressed air from the inner wheel was released fatally injuring him. The coroner recommended that the company review the safety culture of the operation so that management have a better appreciation of safe work procedures. Non-compliant issues raised the question of effective supervision. The Inspectorate were asked to investigate how meaningful supervision can be delivered to workers associated with this types of operation. NEW SOUTH WALES INCIDENT INCIDENT CAUSE MINER FATALLY INJURED A miner was operating an underground loader by remote control he was IN LOADER INCIDENT positioned between the loader and the side wall. The loader appears to have moved towards him and he was pinned against a side wall resulting in fatal crush injuries. All mines utilising remote controlled mining equipment have been instructed to review their standards and procedures against the specifîc guidelines for using remote controlled equipment. Ensure that appropriate risk assessments are carried out and review the location of the operator whilst equipment is in remote control mode. WORKER FALLS A trade's person in an underground mine fell through the guardrail of an THROUGH GUARDRAIL elevated platform while cleaning the mine water screening plant. He fell 2.5 metres to a concrete floor sustaining serious injuries. He was not discovered until 3 hours after the fall. Mines to review their preventative maintenance systems and ensure corrosion effects are minimised. Appropriate procedures to be developed for persons working alone. OPERATOR CRUSHED IN An operator was crushed between the drill jumbo and the wall of the AN UNDERGROUND MINE drive. The operator sustained serious internal injuries resulting in him being paralysed below the waist. This incident raises a number of safety issues, which include risk assessment and job safety analysis, human error, training and safe work procedures, supervision and adherence to safety procedures and energy sources and release of energy. OPERATORS HANDS The operator of a crushing and screening plant sustained major hand INJURED IN A CONVEYOR injuries and amputation of two and a half fingers when his hands were caught under the head drum of a moving conveyor. The Inspectorate recommended that all employees are trained to isolate machinery before working on it, review isolation procedures, direct supervisors to enforce compliance with isolation procedures and apply risk management to crushing and screening plant design. ESCAPE FROM A truck driver sustained injuries when the vehicle he was driving escaped UNDERWATER TRUCK his control and rolled over a highwall into a water reservoir. The operator was taking a short cut at the time of the incident. This raised issues such as appropriate barriers, design and maintenance of haul roads, haul roads that are redundant should be barricaded off, operators must be trained and competent, seat belts must be fitted and worn and risk assessments and safe work procedures should be reviewed to ensure all potential hazards are identified and controlled. CONTRACTOR FATALLY A contractor was fatally injured while taking fluid samples from a INJURED BY HYDRAULIC hydraulic system used to power longwall machinery at an underground EQUIPMENT coal mine. The Inspectorate recommended that all mines should include the management of high pressure fluids in their safety management system, plan to manage risk of high pressure fluids, a hazard awareness programme, appropriate levels of competence for persons, a clear isolation policy, identification of high pressures, fit for purpose designed equipment and identifîcation of high pressure lines. SEAT BELTS MUST BE A number of mobile equipment incidents have occurred that have resulted WORN in serious incidents, including a fatality. Yet another example of behavioural issues where people do not follow the rules. Recommendations included the following, review operational risk assessments and safe work procedures, ensure appropriate seatbelt anchorage points are fitted, conduct tool box talks on the hazards of not wearing a seat belt and conduct regular work place inspections to ensure compliance. 3. WESTERN AUSTRALIA INCIDENT INCIDENT CAUSE MINER SUSTAINED FATAL A miner sustained fatal injuries from a fall of ground accident whilst INJURIES drilling blast holes in an underground stope. No ground supports were installed immediately above the airleg miner. Management did not ensure that ground control management plans are appropriate for all mining conditions and methods. They must ensure that the workforce follow these instructions by proper supervision. LOSS OF CONTROL OF Two incidents occurred at underground mines where the loss of SERVICE VEHICLES control injured the operators while travelling down a decline. The brakes of the vehicles had been poorly maintained and the operators had not been trained for the respective vehicles. EMERGENCY RESPONSE Two emergency response members during an exercise were struck MEMBERS STRUCK BY by a cylinder whilst descending an escape ladder way. The load was FALLING CYLINDER found to be poorly secured, the team members descended below a suspended load and they were not following the standard protocol for descending ladder ways. DRILLERS OFFSIDER A drillers offsider was fatally injured when he was struck by a "wear FATALLY INJURIED bend" which became detached at an exploration-drilling site. There was no safe work procedure in place for the task that was being carried out. The design of the wear bend and its attachments were not appropriate for high pressure. EXPLOSION OF A labourer was cutting up scrap steel with oxy-propane equipment FLAMMABLE when an old flammable liquid drum exploded causing serious bums CONTAINERS to the head chest and arms. There were no safe work procedures in place for the task that was being carried out and for the safe storage of drums at the site. TRUCK DRIVER FATALLY A truck driver was fatally injured when he was in the process of INJURED unloading tyres. A tyre fell from the truck and crushed him. Yet another case of safe work procedures being followed. The diseased must have been aware of the dangers associated with unloading large heavy tyres and yet he places himself in the danger zone. TRUCK DRIVER FATALLY A truck driver suffered fatal injuries in a mine when he lost control INJURED of the vehicle travelling down the main decline when he crashed into the side wall. Initial reports suggest that the driver was travelling too fast down the decline; if he had been using the appropriate gear the incident could have been avoided. Safe operating procedures must be in place and employees trained and supervised to ensure that they are utilised. PROCESS PLANT A plant operator was cleaning dirt from an operating conveyor when OPERATOR INJURED his hand became trapped between the idler and the belt causing a fractured forearm. The operator should not have been working on the conveyor whilst it was in motion. Safe operating procedures had not been followed. 1.8 Aims of the Research Programme Having reviewed the historical development of a mine safety ethos and summarised the recent and current safety performance of the Australian industry and the criteria used, it is appropriate to now describe the objectives of this research investigation.

The earlier discussion relating to the significant incident reporting revealed that people are being killed and seriously injured on mine sites and that the causes are due to human factors such as not complying with rules, procedures, and management failings.

The following is a summary of the research questions addressed in this thesis as well as the gaps in current knowledge and understanding. It is the author's contention that this research is important if the industry is to continue to improve its safety performance for the reasons listed: • Safety statistics have improved over the last decade, however that improvement has plateaued and over the last few years is trending upwards. This performance is unsatisfactory according to industry stakeholders; • The LTIF^ has declined over the last decade but has now plateaued and over the last few years is trending upwards; • The FIFR has also shown a decrease over the decade, but is now plateauing. The number of fatalities being recorded remains a concern and illustrates that mining remains a hazardous industry; • The high proportion of contractors involved in serious injuries and its implications for safety improvement.

The specific aims of this thesis are: • To analyse the current safety paradigm in the coal mining industry;

• To investigate what the current trends regarding lost time injuries, fatalities, severity of injuries and the high potential injuries are indicating, in terms of safety improvement; To investigate whether modem legislation and self-regulatory initiatives such as risk management and changed rosters has improved the safety performance in the coal mining industry;

To explore the effects that fatigue and awareness issues are having on mine safety performance;

To examine the trends in legislation and the differences of safety management for duty holders regarding experience and competency that is currently required in the industry;

To examine the issue of the growing number of contractors and the impact that they are having on safety performance and

To investigate the current philosophy regarding prosecution policies which include the issues of litigation and professional privilege and their impact on safety performance;

To investigate the problems of "disconnect" between company management systems and plans and the translation of such systems to the working level.

Li summary the major question addressed in this thesis "Is the safety performance improving in the Australian coal mining industry?" If not, then what can and should be done about it? CHAPTER 2

2 SAFETY PERFORMANCE AND LEGISLATION REVIEW IN QUEENSLAND AND NEW SOUTH WALES COAL MINES

The first chapter in this thesis has investigated the history of coal mining and how the evolution of legislation over the years has had a dramatic impact on improving mine safety. Also a general review of mine safety performance has been undertaken and international comparisons have been made. Comparisons of safety performance have also been made between the three mining states Queensland, New South Wales and Western Australia.

In order to further investigate safety performance this thesis will examine the coal mining safety performance in Queensland and New South Wales. This will involve analysing the Lost Time Injury Frequency Rate, High Potential Incidents, Medical Treatment Cases and Serious Bodily Injuries.

2.1 Queensland Coal Mine Safety Performance It can be observed from table 2.1 that the LTIFR has decreased from 7 to 3.1 in the open cut mines and from 27 to 12.6 in the underground mines. However over the last two years under review it may be observed that the LTIFR is increasing in both underground and open cut mines. Table 2.1 Lost Time Injury Frequency Rate in Queensland Open Cut and Underground Mines from 199-00 to 2006-07 Sources from the Queensland Mines and Quarries Safety and Health Reports 1999-00 to 2006-07 1999-00 2000-01 2001-02 2002-03 2003-04 2004-05 2005-06 2006-07 0/C 7 7 5 4 5 3.1 2.8 3.1 U/G 27 21 18 14 14 12 12.1 12.6

2.1.1 High Potential Incidents in Queensland Open Cut Coal Mines A "high potential incident" (HPI) at a coalmine is an event, or series of events, that causes or has the potential to cause a significant adverse effect on safety or health of a person.

According to the Queensland Mines and Quarries Safety and Health Report 2006-07 (2007) "The reporting of high potential injuries enables the industry to implement proactive strategies for managing identified risks - often before someone is injured". The reporting of HPIs is mandatory by legislation and the results of these incidents can prove costly in terms of human and commercial terms. It is therefore important to understand what constitutes a HPI. According to information sourced from the Coal Mining Safety and Health Regulation 2001 Schedule land 2, Serious Accidents and HPFs include the following: • A fu-e, • An ignition of gas, • Spontaneous combustion, • A ventilation failure, • An inrush, • A coal or rock outburst, • Damage or failure equipment used, • An unplanned movement, • A failure of explosion protected equipment, • An electric shock to a person. • A failure of electrical equipment if failure causes a hazard, • An unplanned ignition or explosion of a blasting agent, • A major failure of strata control,

According to the information from the Queensland Mines and Quarries Health and Safety Reports 1999-00 to 2006-07 the occurrence of High Potential Incidents (HPI) over the eight-year period in Queensland open cut mines can be observed from Fig 2.1. It can be seen that the HPI over this period have increased dramatically from 28 to 616.

Figure 2.1 High Potential Incidents in Queensland Open Cut Mines from 1999-00 to 2006-07. Sourced from Queensland Mines and Quarries Health and Safety Reports

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The most common incidents were from fires, which mainly involved vehicles. These fires, found around engine bays, turbo's and brakes, were often associated with bursting hydraulic hoses. Loss of control and unplanned movements were the next most common incident reported mainly due to brake failure. Many of the incidents involved mobile equipment where accidents were due to collisions, collisions while reversing and travelling in wet conditions. 2.1.2 High Potential Incidents in Underground Coal Mines The occurrence of high potential incidents in underground mines from 1999/2000 to 2006/2007 is shown in figure 22. It can be observed that the HPIs have increased from 40 in 1999/2000 to 215 in 2006-07. Electrical incidents were the most common type reported. Several of these incidents involved shuttle car cable operation. There were several incidents involving employees receiving electric shocks and several incidents involving roof falls and falling strata. As in the surface operations there were many instances of loss of control and unplanned movements.

Figure 2.2 High Potential Incidents in Qld Underground Mines from 1999-00 to 2006-07

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200

150 t Q. X 100

It may be observed from figure 2.3 that the total high potential incidents from open cut and underground operations from 1999/2000 to 2006-07 have increased from 68 to 831. Figure 23 High Potential Injuries from 1999-2000 and 2006-07 in Queensland Underground and Open Cut Mines. (Sourced from Queensland Mines and Quarries Health and Safety Reports)

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If one ignores the statistics for the first year when the reporting of HPIs was just being established Figure 2.3, the increase in High potential injuries from 118 in 2001-02 to 831 in 2006-07 is an increase of 713 over a seven-year period, which is a 604% increase. This rate of increase coupled with the fact that over the last two years the LTIFR is increasing demonstrates that the safety performance in the industry is not improving and therefore the potential for accidents and incidents based on this information is unacceptable to industry stakeholders.

2.13 Medical Treatment and Disabling Injury Cases Over the last three years the Queensland Department of Mines and Energy has been obtaining medical treatment case information and disabling injury statistics Table 2.2. Medical Treatment Case is an injury requiring treatment by a doctor, nurse or a person qualified to give first aid. A Disabling injury is a work related injury or disease resulting in a worker being unable to fully perform their regular job. (Either light duties or alternative duties are performed). Table 2.2 Medical Treatment and Disabling Injury Cases in Queensland Open Cut and Underground Mines from 2003-04 to 2006-07 2003-04 2004-05 2005-06 2006-07 Open Cut Medical Treatment 350 254 384 577 Disabling Injury 126 101 169 221 Underground Medical Treatment 440 238 374 555 Disabling Injury 194 154 236 199

The overall trend for both medical treatment and disabling injuries in the open cut from 03-04 to 06-07 are generally showing an increase, which correlates with the trend for HPIs. Over the same period the disabling injuries in the underground have decreased which may be due to reporting issues. This subject was referred to in chapter one of this thesis in a report by (Parker & Cliff 2007) which stated that over 50% of injuries that resulted in the worker not being able to carry out their normal work on the next shift are not collected in any detail. This is due to reporting being limited to LTI and not including a Disabling Injury or a return to work injury.

"According to the Ombudsmen's Report 2008 on Regulation of Mine Safety in Queensland ''Hundreds of serious injuries are not being reported in Queenslands booming mining industry, a top-level State Government review confirms ... The State Government has completed nine [unannounced mine safety] audits this year but their failure to systematically check figures provided by mining companies is criticised in the review."

One of the main reasons for the Ombudsman investigation was criticism in recent years in the media and academic forums about Queensland mine safety. This investigation considers whether the Queensland Mines hispectorate (QMI) is adequately performing its role. The investigation found that the QMI was not recording much of its informal compliance activity at mines, which means it has an incomplete picture of the performance of individual mines on safety and could lead to some safety concerns not being followed up. The report made 44 recommendations, which are intended to ensure that the QMI's compliance activity is supported by a robust administrative foundation. Other key recommendations include that the QMI: • Be given access to a broader range of compliance options • Ensure greater consistency in the compliance actions its inspectors take in similar situations • Take greater responsibility for the investigation of incidents at mines that result or could have resulted in serious injury, and • Implement better record keeping practices to ensure that vital safety information is not lost and that a more complete picture is presented of the QMI's compliance activity.

The Ombudsman's Report indicated that a substantial increase in funding would be required to implement some of the recommendations in his report. One option would be to fund the QMI through a direct levy on industry. However this would need to be carefully managed to avoid the process in itself giving rise to the perception of regulatory capture.

Subsequently the Queensland Government has announced a new annual tax on mining companies of $800 per employee to fund the Queensland Mining Inspectorate. This equates to in excess of $16m/annum. The CEO of the Queensland Resource Council has said ''that this would threaten perception of independence and impartiality."

The information presented in the Parker and Cliff's Report (2007) and the Ombudsman's Report (2008) support the main theme of this thesis, which is to challenge the current safety paradigm in the coal mining industry. 2.2 New South Wales Coal Mine Safety Performance The NSW Department of Primary Industries use different safety parameters than those in Queensland, for instance NSW do not report on High Potential Incidents. In order to make a fair comparison between Queensland and NSW safety data, statistics for Serious Bodily Injuries have been used. The Information has been obtained from the NSW Department of Primary Industries {Annual Reports 1999-00 to 2006-07 2007).

2.2.1 Lost Time Injury Frequency Rate and Serious Bodily Injuries The LTEFR and Serious Bodily Injuries in the Coal Mining Industry in NSW from 1999/2000 to 2006-2007 can be observed in Table 2.3, which shows that the LTIFR has reduced from 34 in 1999/00 to 14 in 2006-07, which is a reduction of 56%. However this reduction is plateauing. It may be observed that the serious bodily injuries recorded in 1999-00 are the same as those recorded in 2006-07, which is some seven years later. Over the eight years in question the serious injuries have remained almost static with no definite trend. However, over the last three years they have been increasing, which suggests that despite the fall in LTIFR, the industry continues to seriously injure people.

Table 23 Lost Time Injury Frequency Rate and Serious Bodily Injuries in NSW coal mines from 1999-00 to 2006-07 1999-2000 2000-01 2001-02 2002-03 2003-04 2004-05 2005-06 2006-07

LTIFR 34 33 30 23 22 18 15 14 SBI 37 34 34 32 40 32 36 37

In order to understand the significance of these injuries it is necessary to evaluate the seriousness of them. According to the - Coal Mines (General Regulation) 1999 - Clause 85 a serious bodily injury can be described as follows: • a fracture of the skull, jaw, spine, pelvis, arm, shoulder-blade, collar-bone, forearm, thigh, leg, knee-cap, ankle or ribs, • a dislocation of the shoulder, elbow, hip, knee, or spine, • an amputation of the hand or foot or of a substantial part of the hand or foot, • the serious impairment or loss of sight of an eye, • an internal haemorrhage receiving hospital treatment, • bums receiving treatment from a registered medical practitioner, • an injury involving injection of hydraulic fluid, • asphyxia.

According to the NSW Department of Primary Industries Annual Report 2006 the notifiable incidents increased from 273 in 2005-06 to 1010 in 2006-07. These reportable incidents may include those described for serious bodily injuries and an event, or series of events that can cause a significant adverse effect on the safety or health of a person, which is described in the Coal Mine Health and Safety Regulation 2006 item 55 and 56.

If one was just to observe the LTIFR which has shown a significant reduction in both Queensland and NSW over the last few years it could appear that the mining industry is improving its safety performance. "The LTIFR is valuable when high, but meaningless when low-more noise than signal. Tends to keep managements eye on the wrong ball-the person rather than the system". (Reason 2000)

This thesis has found that the number of fatalities, High Potential Injuries, Serious Bodily Injuries and Notifiable Incidents the industry is experiencing suggest that the industries safety performance is a cause for concem. A contributing factor may be due to the industry's rapid increasing output and as a consequence increasing employment numbers as shown in Table 2.4

23 Employment Numbers in Queensland and NSW It can be observed from table 2.4 that the total employment numbers in NSW and Queensland have increased by 79% from 1999-2000 to 2006-07. In NSW the employment numbers have increased from 11290 to 13060, which represents a 16% increase over the three years. In Queensland the employment numbers have increased from 16786 to 20639, which is an increase of 18% over the last three years. The increase in employment numbers may be causing some problems with regard to the rapid increase in HPIs in Queensland and to some extent with the high number of serious bodily injuries and the notifiable injuries in NSW. The average age of mine workers in NSW was 42 in 2006 and about the same in Queensland. This fact coupled with the growth of inexperienced people in the workforce suggests that the safety performance in the coal mining industry is not improving and is a cause for some concern since the industry is still seriously injuring mine workers. This concern is further substantiated when considering the rapid increase of HPIs in Queensland and the Notifiable injuries in NSW.

Table 2.4 Employment numbers in Queensland and NSW from 1999- 00 to 2006-07. Sourced from the Queensland Mines and Quarries and the NSW Department of Primary Industries Annual Reports

1999-2000 2004-05 2005-06 2006-07

QLD Surface 6477 13207 17081 16556 Underground 2694 3579 4319 4083 Total 9171 16786 21400 20639 NSW Surface 3968 5670 6117 6550 Underground 5615 5620 6541 6510 Total 9583 11290 12658 13060 Grand Total 18754 28076 34058 33599

2.4 Legislation in Queensland and New South Wales Safety in the Australian mining industry is governed by legislation, which is regulated by state, or territory government departments, which include the Department of Mines and Energy in Queensland the Department of Primary Industries in New South Wales and the Department of Consumer and Employment Protection in Western Australia. Within these departments, the Inspectorate who has specialist knowledge in safety is charged with administering mine safety legislation. Each state or Territory operates from its own set of rules and regulations.

A historical legislation review of Queensland and New South Wales is included in the thesis since it is necessary to understand the impact that legislation and the setting of rules have on the safety performance in the coal mining industry. Later on in this thesis the impact of the Robens Report will be discussed.

2.5 An Historical Overview of New South Wales Mining Legislation The history of the coal mining legislation in New South Wales follows the development of legislation in the United Kingdom after catastrophic disasters in the form of explosions, fires and roof falls which was mentioned in Chapter One of this thesis. This legislation was prescriptive in nature, which means that the duty holder is told precisely what measures to take. NSW was considered a more mature mining industry in the early 1900's, which closely followed UK legislation. Prescriptive legislation can be described as the exact steps to be adopted by individuals and organisations in order to comply, leaving little or no discretion for deviation (Reason 1997). Other developments in the history of New South Wales coal mining legislation from the mid 1800's are included (McLaughin 1995): • 1854: Mine plans and a requirement for the appointment of an examiner were introduced. • 1862: In order to improve the level of safety in mines an Act was passed in response from pressure from miners and the general public. • 1875: The New South Wales department of mines was established. • 1876: Minor amendments were made to the Act such as appointing coal mine inspectors to enforce the provisions of the Coal Mines Regulation Act (CMRA), and reports were filed from that time onwards. • 1890: Four hispectors were appointed to report on safety to the Examiner of Coal Mines. • 1896: Major amendments were made to the legislation and a new bill was enacted after the explosion at Bulli colliery in which 81 miners lost their lives. This significant change in legislation placed the responsibility for mine safety on the colliery manager. It also provided for certificates of competency and examinations for mining statutory officials. • 1897: The first Chief Inspector of Coal Mines was appointed to administer the CMRA and manage the operations of mines inspectors. • 1912: A revision of the Act consisting of a consolidation of amendments that had been made since 1896 was completed. • 1926: In response to the Mt. Mulligan disaster in 1921 in which 76 miners were killed and the 1932 Bellbird disaster in which 21 miners lost their lives the 1912 Act underwent a major revision. This involved additional regulations for ventilation, explosives, coal dust and the duties and powers of inspectors. • 1941: Following the Royal Commission on Safety and Health the 1912 Act underwent further revision, which up graded the rules for explosives, shot- firing, ventilation and the prohibition of naked lights in all mines. Electric safety lamps were introduced and owners were to supply personal protective equipment. • 1966: The Act was amended following the 1965 Goran Inquiry into the Bulli disaster. • 1979: Following the 1979 Goran Inquiry into the West Wallsend No: 2 explosion the Act was amended. • 1980: Further amendments followed the 1979 Appin explosion in which 14 miners were killed. • 1982: A major revision occurred when drafting of a new Coal Mines Regulation Act took place after the Robens Report on Safety and Health at Work was published in 1972. This report influenced the NSW government to adopt a new approach to industrial safety and health. This Act required the implementation of rules and schemes, which had to be approved by an inspector of mines.

The 1982 Coal Mines Regulation Act and The Occupational Health and Safety Act applies to all coal mines. If there is a conflict between the Occupational Health and Safety (OHS) Act and the Coal Mines Regulation Act the OHS Act will prevail. The Coal Mines Regulation Act is prescriptive but does contain some performance standards. The OHS Act is performance based. The Coal Mines Regulation Act places the primary responsibility for health and safety on the mine owner and the mine manager and the OHS Act places the primary responsibility on the employer.

2.6 The Regulatory Framework in New South Wales Coal Mines In Australia, specific legislation is applicable to each State or Territory. At the time of writing this thesis there is still no common mining legislation in Australia, which is why the National Mine Safety Programme is being developed which will be discussed later in the thesis.

The New South Wales coal mining industry regulatory framework consists of Acts of Parliament, regulations that are made under the Act, Conditions of Exemption or Approvals, Managers Rules and Schemes, Australian and International standards and codes of practice. The Coal Mine Regulation Act 1982 and the associated regulations are mainly prescriptive in format, specifying how certain hazards are to be controlled. The 2002 Act and associated regulations go some way towards a duty of care approach at the same time specifying management arrangements and duties. The procedures, which are prescribed in the Act, leave little choice for those duty holders bound by the Act in terms of compliance.

In New South Wales coal mines the regulations are inflexible and the only discretion available is a request to the Chief Inspector of Coal Mines for an exemption of a particular regulation. The 1982 Act and associated regulations attempted to redress the inflexibility issue by introducing Managers Rules and Schemes such as support of the roof and sides and transport. in A Historical Overview of Queensland Coal Mining Legislation Regulations for non-competitive sale of crown lands containing coal were introduced in 1865. Until 1887 coal lands were administered under the provisions of the crown lands acts. The New South Wales Registration and Inspection Act 1854 was nominally in force in Queensland. It is interesting to note that the New South Wales examiner never visited the Queensland coal mines ('Queensland State Archives: Brief Guide 13 '). • In 1865 regulations for non-competitive sale of crown lands containing coal were introduced. The first coal mining area developed under these regulations was at Burrum River. • In 1881 The Mines Regulation Act was introduced which provided for the supervision of coal mines and established an active Inspectorate of Mines. • In 1886 the Employers Liability Act extended the provision of workers compensation to miners. • In 1898 and 1968 major modifications to mining law were made when there was a shift in emphasis from the smaller miner to mining companies. • 1925: The Coal Mine Act 1925 was enacted to consolidate and amend laws with respect to prospecting and mining for coal and the regulation of coal mines. • 1930: The Mining Amendment Act was introduced which allowed Authorities to Prospect on Private Lands. • The Coal Mining Safety and Health Act 1999 was enacted in response to the Moura No 2 underground coal mine disaster of the 9^^ August 1994 which resulted the death of 11 miners. The government of the day committed themselves to the full implementation of the inquiry's recommendations, which was established to determine the nature and cause of the tragedy. • The Coal Mining Safety and Health Regulation 2001 were introduced which is necessary to translate the principles contained in the Act into practice.

The mining industry in Queensland has always been subjected to a separate Occupational Health and Safety (OHS) regulatory regime, enforced by an independent mines inspectorate. The Act is the principle legislation setting out the responsibility to control risk at an "acceptable level" through measures that are put in place at each mine. The regulation sets the performance requirement for risk control and contains prescriptive detailed requirements for critical processes, equipment, procedures and persons, where these are necessary.

2.8 The Robens Report Lord Robens chaired the British Committee of Inquiry in Safety and Health at Work, which was established in 1970 to review the provisions, made for occupational safety and health and to recommend any changes required (Robens 1972). The Committee's report, which was presented to Parliament in July 1972, became widely known as the "Robens Report". This report had far reaching effects beyond Britain on modem occupational safety and health legislation in a number of countries, including Australia.

The committee concluded that " The primary responsibility for doing something about the present levels of health and occupational accidents and disease lies with those who create the risks and those who work with them...Our present system encourages rather too much reliance on state regulation, and rather too little on personal responsibility and voluntary, self-generating effort. This imbalance must be redressed. "

In Australia different states have adopted somewhat different detailed approaches to the workplace arrangements required for health and safety. They all however subscribe to a similar broad pattern. As (Johnstone 1999) has written: 'A major development in OHS regulation in Australia since the 1970s has been the move away from detailed, technical specification or prescriptive standards, to a combination of general duties, supplemented by performance standards, process- based standards and documentation requirements in regulations and codes of practice made under the OHS statutes. The general duty provisions have all been introduced to ensure that the principal parties involved in all work processes are subjected to a range of interlocking and overlapping duties requiring them to do all that is reasonably practicable to ensure that work is carried out in a way that is safe and without risks to health.' One of the most important benefits of the Robens Report was the creation of safety representative and safety committees, which is discussed in more detail later in the thesis. It has been postulated by many safety professionals in the industry that safety representatives and the safety committees are very effective in improving health and safety performance then it is important to know what makes them effective. Walters and Frick (2000) in their extensive review of such evidence note that features promoting effectiveness include: • adequate training and information • opportunities to investigate and communicate with other workers • channels for dialogue with management on existing problems and planned changes

Where worker representatives are supported by trade unions directly or indirectly, they are more likely to be able to engage meaningfully and autonomously in the dialogue with employers, that is essential to self-regulation. It is an important requirement of this new approach to safety for workers and/or their representatives, to be involved in the direct participation and consultation of safety arrangements. British research reviewed in (Walters 1996) indicated that the effectiveness of joint arrangements in improving OHS is supported by: • legislative provisions for worker representation actively supported by regulatory inspectorates • management commitment both to better health and safety performance and participative arrangements coupled with the centrality of the provision for preventive OHS in strategies for ensuring the quality and efficiency of production • worker organisation at the workplace that prioritises OHS and integrates it in other aspects of representation on industrial relations • Support for workers' representation from trade unions outside workplaces, especially in the provision of information and training • consultation between worker health and safety representatives and the constituencies they represent • well-trained and informed representatives 2.9 The Impact on the Change of Legislation in Queensland when Compared with New South Wales From a historical perspective each Australian state has adopted the provisions of the century British Health and Safety Legislation which includes the 1878 Factories Act, and later the Coal Mines Act 1911. By 1970 each of the six states had an Occupational Health Safety (OHS) statute, which implemented the traditional British model of OHS regulation (National Research Centre For OHS regulation 2007).

This model required highly technical specification standards and procedures. State inspectorates with very broad inspection powers, which essentially relied on negotiated compliance, used informal enforcement methods. This was usually in the form of advice, education and persuasion. If this approach did not work the last resort was to use the criminal law for formal prosecution. The inspectors, particularly in the coal mining industry because they usually had to have similar qualifications and experience as the operating managers, were able to command respect within the industry. The advantage of this traditional approach was that the people operating the legislation knew exacdy what was expected of them and the OHS inspectorates were able to enforce the legislation relatively easily.

The main issues with this traditional approach were that it relied on a large number of detailed technical rules, which were very often difficult to understand, and the problems of keeping the legislation up to date were considerable. Standards were developed on an ad hoc basis in order to resolve problems that occurred at regular intervals. The rigidity of the standards certainly did not encourage employers to be innovative or to investigate more cost effective solutions. They also ignored the view that most hazards arise from the way work is organised and carried out. This traditional approach created a dependence on state regulation, with litde or no involvement in OHS from employees and unions.

In order to fully appreciate the changes that have taken place, particularly in the area of appointments and qualifications required of duty holders at underground and open cut mines in Queensland and NSW, the following issues will be examined: • The Reform of Australian Occupational Health and Safety Law; • Changes that have occurred in legislation in Queensland & NSW regarding the appointment and qualifications required for duty holders to operate at underground and open cut mines, which includes the inspectorate; • Comparison of the differences in requirements required between Queensland and NSW. • The National Mine Safety Framework.

Due to the lack of uniformity in Australian and in particular New South Wales and Queensland legislation, "The National Mine Safety Framework" will be examined as a way forward. The NSW inspectorate is actively pursuing a prosecution policy after a fatality. The effects of this policy will be discussed in some detail because of their adverse effects on relationships between management, unions and the inspectorate in NSW, which in turn is a problem for safety improvement along with other considerations, which will be discussed.

2.10 The Reform of Australian OHS Law The weakness of the traditional model coupled with economic and political developments in both Qld and NSW created a political environment whereby interest in the 1972 British Robens Report was stimulated. In essence this report concluded that safety and health in the UK needed a radical overhaul and, • there was too much law • law should be simplified • the balance between "prescriptive" and "goal setting" legislation needed to shift towards the latter • framework law should be supported by specific Regulation, Codes of practice and Guidance where necessary and appropriate. Voluntary standards would form the next tier of the scheme • the inspectorate should be reformed (Smith, T 1997)

This report also suggested a modification of the regulatory model based on two principle objectives, which responded to the weaknesses outlined in the traditional model. The first objective was to make the States role more efficient in the traditional regulatory system through the "creation of a more unified and integrated system'' (Robens 1972, Para 41) This unified system would bring together all OHS legislation under one statute which would contain "general duties" covering a range of parties affecting occupational workplace health and safety. This would include employees, employers, the self-employed, manufacturers, suppliers, and designers of plant and substances. The standards in the regulations and codes of practice would form part of the statutory general duties. The OHS inspectorates would be given new administrative powers to supplement prosecution. Corporate officers and corporate employers are liable under this new legislation for prosecution.

The second objective was the creation of "a more effective self-regulating system" (Robens 1972, Para 41). In the Robens report, self-regulation involves workers and management at workplace level, working together in order to achieve and improve upon, the occupational health and safety specified by the state. The most important element of the Robens model of self-regulation was that " there should be a statutory duty on every employer to consult with employees or their representatives at the workplace on measures for promoting safety and health at work, and to provide for the participation of employees in the development of such measures" (Robens 1972, Para 70).

In regard to the setting of standards in all Australian states, the occupational health and safety legislation has adopted the three tiered recommendations of the Robens Report: • Broad, overarching general duties, • Detailed provisions in the regulations, and • Codes of practice

Australian OHS provisions now allow for health and safety representatives and safety committees. However they are not consistent between the jurisdictions.

The Queensland mining industry followed by New South Wales have been the leaders in legislative reform, which has led to the necessary changes for promoting improvement. The Queensland and New South Wales legislations satisfy a considerable number of the characteristics of the Occupational Health and Safety legislation set out in the National Mine Safety Framework Implementation Plan.

"This plan provides for a nationally consistent legislative framework that protects the safety and health of mine employees and persons who may be affected by mining operations, and incorporates principles adopted in the International Labour Organisations Convention 176: Safety and Health in Mines" (Cunningham, Neil 2007). This subject will be discussed in more detail later on in the thesis.

Legislation in all states and territories in Australia need to be consistent in terms of adopting sound OHS law in order to achieve the best possible safety outcomes, that are necessary to improve safety for mine workers throughout the mining industry.

2.11 Changes that have occurred in Queensland Coal Mining Legislation As previously mentioned the current mining law in Queensland is governed by the following, • Coal Mining Safety and Health Act 1999. • Coal mine Safety and Health Regulation 2001. The Coal Mining Safety and Health Regulation 2001 is necessary to translate the principles of the Act into practice.

This Act was developed to ensure that modem safety management would focus on creating a concept of on site ownership of safety and health issues, brought about by the introduction of duty of care principles. The Moura Inquiry Report (Windridge et al. 1996) stated that: " The concept of 'duty of care' is sound and should be promulgated by any new legislation. It rightly puts onus on every person in the work environment to take reasonable care to ensure their own safety and health and not to endanger the safety and health of others. However, the concept does not naturally lead to the conclusion that all persons are (or can be) equally responsible for safety, even for their personal safety. Responsibility implies authority and those with the highest authority inevitably have the greatest responsibility, both to form rules and to ensure that they are complied with ".

One of the major changes in the new legislation is that operations must be carried out at an "acceptable level of risk". This means that operations must be carried out so that the level of risk is within acceptable limits and as low as reasonably achievable. In order to achieve an acceptable level of risk the act requires that management and operating systems must be put in place for each coal mine. If the level of risk is unacceptable to persons at a coal mine, the act requires that: • Persons be evacuated to a safe location; and • Action to be taken to reduce the risk to an acceptable level.

Having set the scene in term of Queensland current legislation it is now necessary to look at the qualifications requirements of duty holders to operate in open cut and underground mines. For example the new legislation states that in open cut mines the only person who needs to have a statutory qualification is the open cut examiner. The requirement to have a limited mine managers certificate is no longer required.

These duty holders will include all the management personnel required to operate open cut and underground mines, including the inspectorate. In order to fully appreciate the changes that have taken place over the last few years it will be necessary to first of all examine the requirements of The Queensland Coal Mining Act 1925.

2.12 Requirements of Duty Holders in Queensland Coal Mines After the commencement of the Coal Mining Act of 1925 the following changes were made for duty holders in Queensland Coal Mines: a) No person shall be appointed chief inspector of coal mines or an inspector (other than an electrical inspector or mechanical inspector) unless the person is the holder of a first class mine managers certificate of competency; b) No person shall be appointed an electrical inspector or mechanical inspector unless the person is the holder of: i. A degree in electrical engineering or mechanical engineering, as the case may be, conferred by the University of Queensland; or a. A degree, diploma or other qualification in electrical engineering, as the case may be, conferred by an educational body or institution which the Minister deems adequate. c) A person appointed mine manager at an underground mine employing more than 20 persons must be the holder of a first class certificate of competency. d) At an open cut mine with 25 employees a manager must be appointed who is the holder of a second class certificate of competency or a limited mine managers certificate.

A board of examiners is established to decide the competencies necessary for holders of certificates of competency. The board consists of a chairperson and at least 6 other members who must have a minimum of 10 years practical experience and at least 6 members must be engaged in the mining industry. The board of examiners, examine candidates for all or any of the following certificates and licences and, consequent upon such examination, may grant all or any of the same {Coal Mine Act 1925), a) First class mine managers certificate of competency; b) Second class mine managers certificate of competency; c) Limited mine managers certificate of competency; d) Deputies certificate; e) Open cut examiners certificate; f) Mine electricians certificate; g) Mine surveyor certificate.

The person appointed to assist the manager in the supervision and control of the underground works, who may be designated underground foreperson, undermanager, or overperson, shall, if more than 20 persons are ordinarily employed below ground, be the holder of a first class or second class certificate under the Act. It can be observed that in underground and open cut operations some seven statutory positions are required under the 1925 Act.

2.13 Current Legislation Requirements - Coal Mine Health and Safety Act 1999 In order to compare the current legislation requirements for duty holders (people with statutory responsibility) in open cut and underground operations this thesis will investigate the requirements of the Coal Mine Safety and Health Act 1999. The Act states that persons who are appointed to operate open cut and underground mines are required to have the following qualifications:

(a) Site Senior Executive (SSE): The site senior executive for a coal mine is the most senior officer employed by the coal mine operator for the coal mine who is located near the mine and has full responsibility for the mine. The site senior executive has the following obligations under the Coal Mine Safety and Health Act 1999: • To ensure that risk to persons from coal mining operations is at an acceptable level; • To ensure that the risk to persons from any plant or substance provided by the SSE for the performance of work by someone other than the SSE's coal mine workers is at an acceptable level; • To develop and implement a safety and health management system for the mine; • To develop, implement and maintain a management structure for the mine that helps ensure the safety and health of persons at the mine; • To train coal mine workers so that they are competent to perform their duties; • To provide for: i. Planning, organisation and control of operations; and ii. Carrying out work with technical competencies; and iii. Adequate supervision; and iv. Regular monitoring and assessment of the working environment, procedures, equipment and installations; and V. Appropriate inspection of each work place.

The site senior executive must develop and maintain a management structure for a coal mine in a way that allows development and implementation of the safety and health management system. The management structure must be documented and the responsibilities and competencies required for senior positions must be included {Coal Mine Health and Safety Act 1999).

(b) Underground mine manager: The coal mine operator or site senior executive must appoint a person with a first class certificate of competency to manage an underground coal mine.

(c) The underground mine manager: The underground mine manager must appoint a person holding a first or second class certificate of competency or a deputy's certificate of competency to be responsible for the control and management of underground activities when the manager is not in attendance at the mine.

(d) Ventilation officer: The site senior executive must appoint an appropriate person as ventilation officer for the mine. The person appointed must satisfy the following conditions: • The person has competencies recognised by the coal mining safety and health advisory council as appropriate for the duties and responsibilities of the position; • On appointment, the person is directly responsible for the implementation of the mine ventilation system and for the establishment of effective standards of ventilation for the mine.

(e) Deputy: The underground mine manager must appoint a person holding a first or second class certificate of competency or a deputies certificate of competency to have control of activities in one or more explosion risk zones. (f) Mechanical and Electrical: The underground mine manager must appoint a person or persons with appropriate competencies to control and manage the mechanical and electrical engineering activities of the mine.

(g) Electrical engineering manager: A person may be appointed electrical engineering manager only if the person has the recognised competencies for controlling and managing the mines electrical engineering activities.

(h) Open Cut examiner: The SSE must appoint a person holding an open cut examiners certificate of competency when mining activities are carried out in or around a surface excavation.

It may be observed from the abovementioned management structure that the only duty holders with statutory certificates are a mine manager and a deputy in underground operations and an open cut examiner in the open cut. The mechanical, electrical and ventilation personnel are appointed based on "appropriate competencies". The SSE at either an underground or open cut mine in Queensland with all of the above mentioned obligations must be able to carry out these duties without any qualifications and experience. He must be able to manage standards, control of operations, supervision, oversee technical competencies, monitor and carry out assessments in the working environment without the appropriate qualifications and experience to undertake the responsibilities of managing large complex underground and open cut operations. In an underground operation the person ultimately responsible for the safety of the operation must at least understand and have knowledge of the technology in order to address safety management issues.

2.14 Qualifications for Appointment as Inspector 2003 The chief executive of Queensland safety and health may appoint a person as an inspector only if the chief executive considers the person has (Coal Mining Safety and Health Act 1999 si26 P 68): a) A professional engineering qualification relevant to coal mining operations from an Australian university or an equivalent qualification; and b) Appropriate competencies, and adequate experience, at senior level in mining operations, to effectively perform inspector's functions under this Act.

2.14.1 Qualifications for Appointment as an Inspector May 2007 (Coal Mine Health and Safety Act 1999): 'The chief executive officer may appoint a person as an inspector only if the chief executive officer considers the person has appropriate competencies and adequate experience to effectively perform an inspector's function under this Act".

It may be observed that in May 2007 the law was changed in Queensland regarding the appointment of Inspectors. An inspector may be appointed if the chief executive officer considers the person to have the appropriate competencies and experience. The requirement to have an engineering qualification relevant to coal mining operations is no longer necessary.

Appropriate competencies and adequate experience at senior level is no longer required. It is no longer necessary to hold a first class certificate of competency in order to be appointed an inspector. This is mainly due to the fact that the inspectorate has been finding it difficult to attract appropriately qualified and experienced people because of the huge disparity in remuneration paid to industry when compared to the inspectorate. Also in recent times the philosophy of the inspectorate has changed to such an extent that many inspectors have resigned from the department. According to the Ombudsman Report on Regulation of Mine Safety in Queensland (2008), criticisms of the inspectorate include the following:

"Miners lives are at risk because of a shortage of safety inspectors sparked by high wages on offer in the private sector .. The head of Queenslands mine safety unit ... has told an industry conference in Brisbane that his department was understaffed and in a state of flux,...[A CFMEU official] said he believed the mining inspectorate was in crisis. The only thing they can reasonably respond to is fatalities ... they simply haven't got enough bodies on the ground to properly audit coal mines and that is most certainly going to have an impact on safety in the industry'. 2.14.2 Qualifications for appointment as Inspection Officer {Coal Mine Health and Safety Act 1999):

"The chief executive officer may appoint a person as an inspection officer only if the chief executive officer considers the person has appropriate competencies, or other adequate experience, to effectively perform an inspection officer's function under this Acr.

Due to the shortage of inspectors in Queensland over the last few years inspection officers have been appointed to assist the shortfall. These inspection officers now effectively have the same powers as inspectors. According to incumbents carrying out these roles the qualifications and experience required as a minimum is as follows;

a) A mining inspection officer would typically have a Deputy's certificate and experience of working as a deputy in an underground mine. b) A mechanical inspection officer would have completed an apprenticeship and worked as a fitter/ trades person in an underground mine. c) An electrical inspection officer would have completed an apprenticeship and worked as an electrician in an underground mine.

When considering the above mentioned issues regarding the appointment of hispectors and the fact that Inspection officers are carrying out the duties of Inspectors with deputy and trade qualifications and experience the Inspectorate in Queensland is being downgraded. This may ultimately have an effect on safety in the industry especially when considering the excellent working relationship that existed between the inspectorate and managers. According to the Queensland Ombudsman Report (2008):

''media and academic sources in Queensland and elsewhere have alleged in recent years that the Queensland Mining Inspectorate may not be adequately fulfilling its compliance roles under the Coal Mine Safety and Health Act 1999 (Coal ACT) and the Mining and Quarrying Safety and Health Act 1999 (Mining and Quarrying Act), and that mine safety standards may befalling as a result". 2.15 Requirements of Duty Holders in the New South Wales Coal Mining Industry Safety in the NSW coal mining industry for the purposes of comparing Queensland legislation is governed by the Coal Mine Health and Safety Act 2002, the Occupational Health and Safety Act 2000 and the Coal Mine Health and Safety Regulation 2006. The Coal Mine Health and Safety Act 2002 must be read in conjunction with the Occupational Health and Safety Act 2000. The Coal Mine Health and Safety Act 2002 applies to all places of work that are within a colliery holding or a coal exploration site, or the subject of a licence to mine coal under the Offshore Minerals Act 1999.

The objects of this act are to assist in securing the objects of the Occupational Health and Safety Act 2000 in relation to coal operations including the object of securing and promoting the health, safety and welfare of people at work at coal operations or related places.

In order to compare the differences between the duty holders in Queensland and NSW it is necessary to analyse the functions of the Coal Mine Health and Safety Regulation 2006-Reg. 162.

The 12 functions to which part 9 of the Coal Mine Safety and Health Act 2002 applies and evidence of competence to perform those functions is listed below.

1) Manager mining engineering at an open cut mine 2) Manager mining engineering at an underground mine 3) Manager of electrical engineering at an underground mine 4) Manager of mechanical engineering at an underground mine 5) Qualified electrical engineer 6) Mining supervisor 7) Qualified mechanical engineer 8) Electrical trades person 9) A person loading & detonation of explosives underground 10) A person who supervises the loading and detonation of explosives on the surface 11) A qualified ventilation engineer at an underground mine. 12) A qualified ventilation officer at an underground operation

Qualifications currently required for Inspectors in NSW (Coal Mine Health and Safety Act 2002-Section 146).

A person may be employed as an inspector only if the Minister considers that person has: a) A professional engineering qualification relevant to coal mining operations from an Australian university or any equivalent qualification, and b) Appropriate competencies, and adequate experience, in coal mining operations, to effectively perform the functions of an inspector.

The Minister may appoint a consultant as an investigator for the purpose of carrying out investigations under this Act, or to assist an investigator in carrying out such investigations.

2.16 Comparison of Levels of Competence Required for Duty Holders in Queensland and NSW The following Table 2.5 compares the current evidence of competence required for the different functions of management between New South Wales and Queensland Coal Mines. Table Comparisons of Levels of Competence Required Between Queensland and NSW. Specifíed function Specified evidence of competence NSW Qld Manager 0/C Certificate Not required Manager U/G Certificate Certificate Manager Electrical U/G and Certificate. Recognised Eng 0/C Competence competencies determined by Minister Manager U/G and Certificate. Appropriate Mechanical Eng 0/C Competence competencies determined by Minister Undermanager U/G Certificate Not required Deputy U/G Certificate Certificate Examiner 0/C Certificate Certificate Mining Supervisor U/G Certificate Not required

Mining Supervisor o/c Certificate Not required

Electrical trades U/G and Trades Certificate Appropriate person O/C competencies Mechanical trades U/G and Trades Certificate Appropriate person O/C competencies Shotfirer U/G Licence Recognised competencies Shotfirer O/C Licence Recognised Competencies Ventilation Eng U/G Diploma Recognised Competencies Ventilation officer U/G Certificate or Mine Competencies managers cert. recognised by the council. Inspector of Mines Certificate Appropriate competencies Inspection officer N/A Deputy or trades certificate

It can be observed from Table 2.5 that the only certificates of competency required in Queensland when compared with NSW are for the following: 1) Mine manager U/G 2) Deputy U/G 3) Open Cut Examiner In Queensland legislation there is no longer the requirement for a: a) Second class mine managers certificate of competency b) Limited mine managers certificate of competency c) Mine electricians certificate and d) Mine surveyor certificate

Therefore the main differences between the two Acts in NSW and Qld in terms of required qualifications are as follows: 1) In Queensland legislation the position of a statutory undermanager at an underground mine has been eliminated. This means that one very important level of management has been removed.

2) It is now possible in Queensland underground mines for a person without any statutory qualifications to supervise miners provided a deputy has examined the area in which the miners operate. It is claimed that supervisors or coordinators do not give instructions under the mines Safety Management System and therefore do not have any statutory duties.

3) A mine manager of a large complex open cut mine in Queensland under the current legislation can be managed by a person without any mining qualifications. There is no longer a requirement for a limited mine managers certificate.

4) There is no existence of a site senior executive in NSW legislation and as previously mentioned the SSE in Queensland does not have to have any mining qualifications to carry out the task. At least in an underground mine the mine manager has to have a first class certificate of competency.

5) In an open cut mine in Queensland there is no requirement for the mine manager or the SSE to have any formal mining qualifications or experience.

6) The open cut examiner is the only person required to have a statutory certificate of competency in an open cut mine. 7) An inspector in Queensland no longer requires a first class certificate of competency or any appropriate engineering qualifications in order to operate in Qld mines. It relies on the chief executive officer considering that the person has appropriate competencies.

8) In Queensland, Inspection officers of coal mines are now carrying out essentially the same duties as inspectors. The position of inspection officer does not exist in NSW.

One initiative that will help to address these differences in the legislation requirements between Queensland and New South Wales is the development of a National Mine Safety Framework, which will be discussed briefly in this thesis.

2.17 The National Mine Safety Framework As discussed earlier the lack of uniformity in Australian legislation has been a concern for some time within the mining industry. In 2005 the Ministerial Council established a tripartite group, with representatives from industry, workforce and State, Territory and Australian governments to guide the development and implementation of a national framework for mine safety. The National Mine Safety Framework was developed to deliver greater consistency in mine safety and health regulations across Australia. Most industry stakeholders agree that a consistent law across all States and Territories would benefit all mineworkers. The following statement substantiates this argument, which emanated from the Moura tragedy of 1994.

The Moura Inquiry (Windridge et al. 1996) stated: "The Kianga Inquiry of 1975 recommended that the Queensland and New South Wales coal mining legislation should be standardised. Progress in this direction over the subsequent twenty years appears to have been glacial. Learning and applying different legislation intended to manage the same hazards must be seen as unnecessarily be wasteful of the time and effort of key industry personnel. It is, moreover, a hazard source of itself with State and Federal Mutual Recognition Acts of 1992 now overruling any requirement for a statutory official appointed from New South Wales to demonstrate knowledge of the Queensland coal mining legislation, and vice versa. There is a need for common legislation, finally, to be progressed into existence and at Federal level if that is what it takes."

The National Mine Safety Framework is an initiative of the Ministerial Council on Minerals and Petroleum Resources and was initially developed by the Chief Inspectors of Mines, which was a subcommittee of the Ministerial Council. The Chief Inspectors are the most senior technical officers with regulatory responsibility for mining operations in the States and Northern territory of Australia.

There are seven strategies of the framework: • A consistent nationwide legislative framework; • Competency support; • Compliance support; • A consistently applied enforcement protocol; • Effective data collection, management and analysis; • Consistent approaches to consultation; and • A strategic approach to mine safety and health research and development.

At the time of writing this thesis, consultations are being undertaken Australia wide on three of the seven strategies namely, a consistent nation wide legislative framework, consistent and reliable data analysis and effective communication mechanisms.

2.18 Discussion In this chapter a detailed investigation has been undertaken of the safety performance in Queensland and NSW mines with particular reference to: • Lost time injuries, • High potential injuries, • Medical treatment cases, • Disabling injuries, • Serious bodily injuries, • Notifiable injuries.

Over the last decade LTI have been decreasing, however they are now plateauing and in Queensland over the last two years they have shown an increase for the first time in a decade. It has already been stated that HPI have increased by some 604 % in Queensland open cut and underground mines over the last seven years. It can be observed from table 2.6 that the HPIs have increased by 1100% in the open cut mines and 346% in underground mines. From 2003-04 the medical treatment cases have increased by 59% and 26 % in the open cut and underground mines respectively. Disabling injuries over the same time period have increased 75% in the open cut with only a small increase in the underground mines.

In NSW the serious bodily injuries have remained static from 2001 to 2006-07. However the notifiable injuries have increased by 370% from 2005-06 to 2006-07 figure 2.3, which indicates that miners are still being seriously injured.

The HPI both in open cut and underground operations in Queensland see Table 2.6 and Figure 2.4 suggest that the safety performance is not improving. This safety performance would almost certainly be exacerbated by the increase in employment numbers where experience and training are major issues that effect safety performance, which the industry must address. While it is true that the rate of reporting injuries has increased over the period it is unlikely that this alone accounts for the alarming increase in safety indicators.

According to the Queensland Ombudsman's Report (2008), hundreds of serious injuries are not being reported. This means the potential for further increases in safety statistics is high and therefore more miners are being injured. This safety analysis supports the view that safety is a major cause for concern and the safety criteria in most areas is showing an increase. Miners are being injured, to such an extent that all stakeholders in the industry must understand that community expectations are not being met and that safety performance is deteriorating. Table 2.6 Percentage Increase in the Safety Indicators QLD 2001 2003- 2006- Percentage 04 07 increase % HPI's 0/C 56 616 1100 U/G 62 215 346 Medical Treatment. Cases 0/C 350 557 59 U/G 440 555 26 Disabling injuries 0/C 126 221 75 U/G 194 199 3

NSW Serious Bodily 37 37 0 Injuries Notifiable Injuries 273 1010 370 Figure 2.4 Safety Indicators Over Captioned Period

Safety Indicators Increase Over Captioned Period 1200 • HPI's 0/C HPI's U/G 1000 -MTC's 0/C • MTC's U/G 800 • Disabling Injuries 0/0 • Disabling Injuries U/G CcD •g • Notifiable Injuries (NSW) co 600 400 200

0 2001 2004 - 2006 2007

An historical overview of the legislation in Queensland and New South Wales has been included in this chapter because it is necessary to understand the impact that this legislation has had on safety performance and the setting of rules in the coal mining industry. During the time of writing this thesis many of the stakeholders who had been consulted regarding safety performance are at a loss to explain why each of the major mining states of Queensland, New South Wales and Western Australia operate under completely different mining legislation. This is one of the major reasons for including the discussion on the newly formed "National Mine Safety Framework".

The different states have adopted different approaches to workplace health and safety arrangements; however they do all broadly follow a similar pattern and that is a move away from detailed technical specification or prescriptive standards, to a combination of general duties, performance standards, process based standards and documentation requirements in regulations and codes of practice made under OHS statutes.

These provisions have ensured that the parties involved in the work processes are subject to a range of duties, which requires them to do all that is reasonably practical to ensure that work is carried out in a way that is safe and without risk to health. One of the most important benefits to emerge from the Robens Report was the creation of safety representatives and safety committees which has contributed to many aspects of the improvements of past safety performance thus precipitating change in the safety culture of the industry. This safety culture is the subject of further subsequent discussion later on in this thesis.

In the new legislation in Queensland one of the major changes has been that operations must be carried out at an "acceptable level of risk" which means that management and operating systems must be put in place in order to achieve this objective. However under this system risks are kept at a level considered by experts to be 'acceptable'. According to the Queensland Ombudsman's (2008) Report

" We were informed that in many cases, experts can differ over the level to which risk in an activity can reasonably be reduced and that, in reality, a serious injury or death can still occur in a situation where mining experts agreed the risk was at an acceptable level."

New South Wales and Western Australia to a lesser extent have also moved to risk based systems. These risk-based systems will also be discussed later in this thesis.

The different requirements of duty holders in Queensland and NSW have been investigated. In Queensland open cut mines the only person required to have a statutory qualification is the open cut examiner. In underground mines the only two persons required to have a statutory qualification are the mine manager and deputy. The Queensland legislation has departed from common mining practice in term of essential qualifications and experience. It would appear that because there is a shortage of qualified experienced people in the industry the qualifications and experience of people has been downgraded in order to operate both underground and open cut mines.

This statement is substantiated by the comments made previously in connection with the Ombudsman's Report (2008) (see page 61) • Miners lives are at risk because of the shortage of inspectors • The Inspectorate is understaffed and in a state of flux • A CFMEU official stated that the inspectorate is in a crisis and that they can only respond to a fatality and do not have enough staff to conduct audits which will have an impact on safety in the industry. These findings may ultimately jeopardise the safety and health of our workforce.

The site senior executive at an underground or open cut mine is expected to achieve the management of standards, control of operations, supervision, oversee technical work, monitor and carry out assessments in the working environment without the appropriate qualifications and experience to undertake these responsibilities. It's not an appropriate defence to say that the S SE appoints persons with suitable competencies to carry out these tasks. In order for an SSE to control events at a mine, he or she first of all must understand the consequences involved in the often-complex decision-making process that takes place at a mine especially since he or she is the most senior person in the eyes of the law.

The Coroner (Hennessy 2007) after an inquest into the death of a truck driver in Queensland made the following finding: "the site senior executive is required to have a competency in order to establish and maintain the mine Occupational Health and Safety Management System".

The fact that NSW has not followed this direction would tend to demonstrate the inadequacy of the current Queensland approach.

Based on this research comparing Queensland and NSW legislation, the fact that a large complex open cut mine in Queensland can be managed by a person without any mining qualifications or mining experience cannot be in the best interest of safety improvement. Based on discussions over the years with stakeholders at Queensland Mining Council Meetings, the large mining companies have pushed for deregulation in certification because of the shortage of people with the appropriate qualifications and experience. This was evident in the removal of the limited mine managers qualification in order to manage open cut mines. The only person with a statutory qualification at an open cut mine is an open cut examiner. Due to the shortage of open cut examiners the inspections at mines are stretched to the limit. This means that the safety standards in mines are being equally stretched and may be deteriorating.

Since the Queensland legislation has eliminated the position of undermanager it is now possible, in underground mines, for miners to be supervised by persons who do not have any mining qualifications. Admittedly the area has to be inspected by a deputy. However can the industry really justify unqualified persons supervising the workforce simply because it is short of experienced qualified people. It is claimed that these supervisors or coordinators do not give instructions under the Mines Safety and Health Management System. This may possibly lead to increasing the potential for an accident or incident.

The position of undermanager has traditionally been the link between the mine deputy and the mine manager. Many mining personnel have found that they were able to achieve the level of the undermanager's qualifications, but were not academically able to obtain mine managers qualification. The position of undermanager was an excellent training ground for potential managers. Over the years this position has played a crucial role for the underground coal mining community. The mining industry in Queensland has lost this vital link between the Deputy and Manager and as a consequence, lost a vital safety management role in underground coal mines.

There are instances where an undermanager with only a second-class certificate of competency in the absence of the SSE has acted as the SSE at a large underground mine in Queensland. This is possible since there are undermanagers still operating in the industry from the old legislative system. Although there is currently no undermanager's qualification in Queensland there is in NSW. This means that the mine manager with a first class certificate of competency is subordinate to the person acting as the SSE who only has a second-class certificate. This illustrates how companies are able to manipulate the law in Queensland since there is no requirement for an SSE to have any qualifications. Over the last two years the turnover in staff within the Queensland inspectorate has been considerable. In discussions with these staff one of the main reasons for leaving was because they believed that the direction that the inspectorate was moving was not in the best interests of the safety performance in the industry. See previous comments in relation to the Ombudsman's report 2008 (see page 58). It has proved very difficult to recruit inspectors. One would have to assume that the inspectorate has been downgraded due the recent changes in legislation that have occurred which are listed below; • An inspector in Queensland no longer requires a first class certificate of competency or any mining engineering qualifications to meet the new criteria for an inspector. • There is now essentially no distinction between an inspector and an inspection officer; they are all now acting as inspectors.

Also as stated in the Ombudsman's Report 2008 the Queensland Mining Inspectorate may not be fulfilling its compliance roles under the Coal Mining Safety and Health Act 1999 and the Coal Mining safety and Health Regulation 2001 and that mining safety standards may be falling as a result.

It may be concluded that the inspectorate in Queensland will be continued to be downgraded until it operates in a similar fashion to the US model, whereby several inspectors go to a mine site and tick boxes, until eventually the inspectors have little or no knowledge of the operating procedures at a mine. In discussions with senior mining personnel the days of the mine manager being able to work in close harmony with the inspectorate to achieve the best outcome, will have long since gone, to the detriment of safety improvement in the coal mining industry.

In New South Wales, the legislation regarding the qualifications and experience of management positions and appointment of inspectors has remained essentially unchanged. However the adoption of risk management principles and hazard and effects management is closely aligned with that in Queensland. One would have to conclude that NSW have a much more robust stable inspectorate with which to confront the future challenges in the coal mining industry. Based on discussions with stakeholders it would appear that the NSW industry regarding certificated positions, has achieved the correct balance in which to enhance the safety programms with experienced and appropriately qualified people.

The arguments in favour of one set of national OHS laws for Australia are very clear. At present there are at least 11 separate statutory regimes applying throughout the country, each with its attendant regulations and codes of practice. The conventional arguments in favour of conformity are that it will lead to more equitable outcomes in that employees will be protected to the same standards where ever they work and that economic efficiency will be promoted because employers and employees, and other duty-holders will have only one set of laws in which to comply.

The lack of uniformity in the Australian OHS legislation needs urgent attention. For example, duty holders in the coal mining industry in Queensland operate with different Acts and Regulations at the same time working with the same hazards in both underground and open cut operations. There is a lack of uniformity when developing inspection, enforcement policies, and strategies, level of fines, infringement notices, and the considerable variation in health and safety representative provisions.

The formation of the National Mine Safety Framework is a very necessary worthwhile initiative, with three of the seven strategies being acted on currently namely the legislative framework, data analysis and consultation. The issue of federal and state mutual recognition acts of 1992 overruling any requirement for a statutory official appointed from NSW to demonstrate knowledge of Old mining law, and vice versa will take some considerable time to remedy. However, this issue should be one of the first on the agenda.

The Australian labour market is changing rapidly with unemployment at historic lows. The regulators need to develop standards, guidance material, enforcement, and inspection that address the need for labour hire, sub contracting and franchise arrangements. More flexibility is required regarding safety and health representatives, which are usually limited to employees and generally exclude contractors. The next chapter will investigate the mining safety environment.

CHAPTER 3

3 THE MINING SAFETY ENVIRONMENT

3.1 The Mining Safety Environment In order to examine the mining safety environment it is necessary to understand the culture on mine sites and the attitudes of mine workers regarding their behaviour especially towards safety. It is also necessary to investigate the effectiveness of risk management systems and Safety Management Systems with regards to safety improvement. This chapter will examine some coal mine disasters over the past four decades with particular emphasis on two of the most recent, which are Moura No2 and Gretley in Queensland and New South Wales respectively.

3.2 Safety Culture On Mine Sites In Chapter 2 different regulatory systems have been presented which incorporate prescriptive and performance based or enabling legislation. Up until the last two years it could be argued that regardless of the system adopted in the different States of Australia, reported injuries have decreased but are now plateauing. However, over the last two years they are increasing at the same time fatalities continue to occur. In order to improve the safety performance the industry is looking towards safety culture and changing attitudes and the behaviour of the workforce on mine sites. It has been argued that if safety in the industry is going to improve one of the first things that must be done is to change the safety culture of the industry and to implement a safety road map. However it is important to first of all understand what is meant by safety culture.

The term "culture" refers to a shared meaning system with certain observable behavioural consequences. Culture is defined as ''the collection of beliefs, norms, attitudes, roles and practices shared within a given social grouping or population " (Pidgeon 1991). Organisational culture is defined in terms of the beliefs and values of the organization, which act as a prescription for the way in which organisational members should work.

Safety "culture" can be thought of as a subset of organisational culture, where the beliefs and values specifically refer to matters of health and safety (Clarke 1999). Safety "culture" is defined as the set of beliefs, norms, attitudes, roles and social and technical practices that are concerned with minimising the exposure of employees, managers, customers, and members of the public to conditions considered dangerous or injurious. The importance of a safety culture lies in the link to safety outcomes such as incidents and accidents. A poor safety culture has been found to be a key determinant underlying accidents (Hidden 1989).

Creating and maintaining a safe, healthy and productive workplace through the involvement of employees, where no one is harmed, is ensuring occupational health and safety is fully integrated into all mine site activities. The safety operational initiatives should be to encourage all employees and contractors to think about their own safety and what they can do individually to deliver an injury free workforce. In this way occupational health and safety is built into the role of every employee and day-to-day operational activities.

In this same context The Advisory Committee of the Safety of Nuclear Installations Study Group in Britain (1999) proposed:

''The safety culture of an organisation is the product of individual and group values, attitudes, perceptions, competencies and patterns of behaviour that determine the commitment to, and the style and proficiency of, an organisation's health safety and management."

This applies equally to the coal mining industry in Australia. 3.2.1 Callide Mine Safety Culture Callide Mine is a good example of a mine that was in the forefront with regards to changing the culture by focusing on a team-based approach and a no blame culture. Back in the early nineties Callide Mine in central Queensland worked twelve months without incurring a single lost time injury and according to the Queensland Department of Resource Industries, this set a national record for any large operating mine in Australia (Parkin 1991). The mine set the LTIFR standard in the coalmining industry and was awarded the Shell Australia Chairman's Safety Award in 1991 and the Mineral Council of Australia's MINEX Highly Commended Award in 1997.

The Callide safety culture is recognised by all industry stakeholders as being a leading operation in the management of health and safety. The framework, which has been developed for managing safety and health, is the Shell's Principles of Enhanced Safety Management Programme, which is now encapsulated in the Health Safety and Environment Management System of the Royal Dutch Shell Group of Companies, 1985.

This requires all parts of the business to adopt a structured and disciplined approach to occupational health, safety and environment management with particular emphasis on hazard identification and risk management. The Health Safety and Environmental Management System elements are: Leadership and Commitment; Policy and Strategic Objectives; Organisation, Responsibilities, Resources, Standards and Documents; Hazards and Effects Management Process (HEMP); Short Term Planning; Policies and Procedures; Communication and Implementation; Monitoring and Corrective Action; Audit and Review These elements were developed as a result of major accidents such as the Piper Alpha oil rig explosion in 1988 and the Exxon Valdez oil spill in 1989, which led to increased awareness by industry and authorities that more effective management systems should be put in place to avoid major incidents. The Cullen Inquiry Report (1990) on the Piper Alpha accident recommended development of integrated safety management systems and safety cases based on a full formal safety assessment of each major risk. One of the first companies to address these issues was the Shell Group of Companies.

^^This system is essential to address the key HSE concerns - such as the high level of fatalities, deficiencies in asset integrity, substantial losses, and unnecessary exposure and risk. A HSE Management System, and especially HSE Cases for critical activities, establish appropriate controls for HSE hazards, including the essential HSE competencies for responsible staff and contractors. The result will be that every person is accountable for agreed standards and procedures in their area of responsibility. Our policy guidelines require HSE Management Systems in every operating company " (Jennings 1995)

A positive safety culture according to Santo (2000) who conducted a report on safety culture at Callide Coalfields requires the following focus: 1. Higher management commitment to safety 2. Open communication channels 3. A stable, experienced workforce 4. High quality housekeeping 5. A safety emphasis in training 6. Full-time safety personnel reporting directly to top management.

The four key components of Callide Coalfields safety culture is: • Visible management commitment to safety • Quality and quantity of communication • Workforce involvement • Housekeeping Each of the above is described below. 3.22 Visible Management Commitment Management actions as well as attitudes are a major factor in influencing the safety culture of any organization. Management commitment is expressed through a formal policy statement and includes management's attitudes and observed actions. Everyone in the organisation must also own this policy.

Management attitudes are very important for any successful attempt at improving safety in any organization. All serious incidents or potentially serious incidents have been treated as a major event and operations have ceased whilst corrective action has been taken and a detailed incident investigation has been carried out since the late 1980's.

In some instances the general manager has stopped all operations and conducted employee briefings on significant safety issues and incidents. The Shell Board Australia would summon Managers to the board meetings to discuss serious incidents and the actions that need to be taken in order to prevent a recurrence. This was again a strong demonstration of the importance of safety to the company.

Today employee injury and rehabilitation schemes are commonplace, however these schemes have been available to Callide employees since 1990. The perceptions of senior managers actions are influential in the development of a positive safety culture.

Leeming (1997) states, " that the major influences to the safety culture at any location are the attitudes and behaviour of management. The perceived attitudes and behaviour are more important than the actual attitudes and behaviour''.

At Callide Coalfields a positive safety culture is a way of doing business where management lead by example and enforce the rules at all times. Some signs of visible management commitment include: • Safety being first on all meeting agendas • Safety before production • Discipline being exercised fairly and consistently • Holding meetings and training sessions during production time 3.23 Quality and Quantity of Communication The quantity of communication that occurs between management and employees is hkely to significantly affect the amount of ownership the employees accept. There is a need to regulate how the attitudes are transmitted to ensure that management commitment is being accurately perceived (Clarke 1999).

Sites with a positive safety culture have effective forums of communications with the workforce. State of the company talks by senior management and regular toolbox talks by supervisors generate immediate feedback from employees. The more communication between management and the workforce the more ownership of safety will result. Lines of communication are kept open between employers and employees in order to foster a healthy work team environment.

3.2.4 Workforce involvement Employees are involved with the safety decision making process, as in the development of safe operating procedures, safety programmes, conduction of safety audits and being involved in the risks associated within their work group. The involvement of work groups will ensure that they will more readily accept ownership of any safety outcomes.

323 Housekeeping At Callide, housekeeping has a high priority since a clean tidy workplace makes for a safe and productive environment. Housekeeping inspections are conducted on a regular basis by the employees, supervisors and senior management. The Shell Group philosophy adopted by Callide became the accepted benchmark for other operations in Queensland. Callide Coalfields was the first mine to use a vehicle access committee to investigate accidents and incidents on the mine site. Following an accident whereby a person fractured his ankle when getting off a truck, an access committee was formed which consisted of members of the workforce from the different disciplines. This resulted in the development of the first set of inclined steps on dump trucks in coal mines. By the early 1990s this development was so successful that it was adopted by the industry and an industry access committee was formed to investigate accidents and incidents in Queensland.

33 Safety Roadmap Most mines are now developing a positive safety culture that is maturing as time goes on which follows a typical safety roadmap approach. The following safety roadmap shows that as the maturity of an organisation improves it becomes ever more necessary to concentrate on the behaviours of employees. It is also important for organisations to focus on legislation, compliance, procedures, equipment and management systems. The safety road map must become an integral part of the organisation and the industry must ensure that contractors are operating to the same road map in order to ensure consistency. Focus on compliance Legislation Standards Framework Safety Management Systems Targets & Goals Compliance Audits

Focus on procedures Lag Indicators Equipment & Management Procedures for Key Risks Systems Near Miss reporting Risk Management (catastrophic)

Focus on People Human Factors Visible Leadership Awareness Process Leading Indicators Behaviour Process

A well-documented approach that focuses on unsafe acts in the workplace is that of Behavioural Based Safety (BBS) which is the application of psychological research on behaviour applied to safety in order to reduce accidents and injuries in the workplace. BBS has been derived from behavioural learning principles conceived by behaviourists during the late nineteenth century and developed into an approach through integrating organisational development with quality and safety management (Parand & Foster 2006).

According to Koch, (2001) Pareto's law dictates that 80% of the consequences stem from 20% of the causes. Applied to accidents, this principle prescribes that at any given time 20% of the behaviours are responsible for 80% of the accidents. It is therefore logical to concentrate on the key safety behaviours and ensure that a no blame policy is adopted. In summing up the question of safety culture it is interesting to note the concluding remarks (Parkin & Pitzer 2000) at a Northern Territory Minerals Industry Safety Conference: • Safety is good business, our safety efforts must protect our most important asset - our people; • Think about safety all the time and build it into everything you do; • Its about individual behaviour, responsibility and accountability; • A strong safety performance will promote team work, build good moral, generate confidence and at the same time save costs; • The relentless pursuit of excellent safety performance is critical for success in this vital area.

3.4 Safety and Health Management Systems Safety management systems in the mining industry are a relatively new concept, which emanated from the outcomes of the Cullen Inquiry into the Piper Alpha disaster (Cullen 1990). They introduce a documented and structured way in which safety risks and hazards can be identified, quantified and controlled and if implemented properly can lead to continuous safety improvement.

It is well recognised in the mining industry that a good safety performance is good business in that it reflects excellent overall management. In order to produce a substantial improvement in the unacceptable high number of accidents and incidents in the mining industry, a more structured approach to safety management was required to take affect.

Reason (2000) stated that safety management systems must cope with the human and organisational risks as well as physical hazards. To do this effectively, they need to understand the nature of these risks: • Individual versus organisational accidents • Person verses system models • Defences, barriers & safeguards • Production verses protection problems • The variability paradox.

^^One cannot enforce the human condition but one can change the conditions under which they work'' (Reason 2000).

Every mining company must work with a safety management system in order to operate with a structured approach to safety. It is now a requirement in Queensland legislation that every mine must have a Safety and Health Management System (SHMS) in place that must provide for the basic elements of risk identification and assessment, hazard analysis, hazard management and control, reporting and recording relevant safety and health information and data. Each mine site must ensure that the SHMS that they adopt must ensure that "risk is managed so that the safety and health of persons who may be affected by the operation is at an acceptable level." One of the most comprehensive safety management systems that have been developed of recent years was by the Shell Group of Companies and was adopted by Shell Coal Australia.

3.4.1 The "Enhanced Safety Management System This system was named the "Enhanced Safety Management System" which has already been discussed earlier in this chapter. The basic philosophy is summed up by the following statement:

"It is the policy of Shell Companies to conduct their activities in such a way as to take foremost account of the health and safety of their employees and contractors, and to give proper regard to consultants of the environment. In implementing this policy companies must not only comply with the requirements of the relevant legislation but promote in an appropriate manner measures for the protection of Health, Safety and the Environment (HSE) for all who may be affected directly or indirectly by their activities.''

Analysis of accidents throughout the mining industry shows that by far, the majority of accidents causing injury are due to human behaviour - that is in effect saying that they are caused by unsafe practices. The main objective of any safety management system is to bring about a major improvement in safety performance that will be sustainable and ongoing.

Most mining companies today operate a safety and health management system similar to the Shell model " Enhanced Safety Management Programme" which must be regularly audited. This programme is regarded as the eleven commandments of any safety programme. • The key principles are as follows; • Visible Manage Commitment to Safety; • Sound HSE Policy; • HSE is a Line Management Responsibility; • Competent HSE Advisors; • High Well Understood HSE Standards; • Measurement of HSE Performance; • Realistic HSE Objectives and Targets; • Audits of HSE Standards and Practices; • Effective HSE Training; • Thorough Investigation and Follow Up of Injuries, accidents and Incidents and • Effective Motivation and Communication

The main consideration in producing an Occupation Health Safety Management System (OHSMS) is that they are easily understood by all concerned which includes management at all levels and indeed the workforce. They need to be flexible enough to allow management to manage the operations and hazards associated with each individual mine.

Each mine site taking into consideration their own individual hazards must prepare principle Hazard Management Plans. The intent of producing an OHSMS is to create a safer working environment at the workplace and to ensure that it does not sit on the shelf gathering dust. The most important aspect of generating a Safety Management Plan is the process that is undertaken to achieve the fmal outcome. 3.42 Communication and Consultation The most essential factors necessary in producing a Safety Management Plan (SMP) are communication and consultation. Communication in its simplest form " is the transfer of meaning, which is evidenced by a message passing from sender to receiver. The mechanism or channel used to send the message will have an impact on how the receiver interprets the message. The design of the mechanism may convey one way or two way, synchronous or asynchronous, individual or group communication that is further supported by the type of media involved. " (Leveritt 2005)

Consultation can be defined as the 'Hhe partnership principle of involving all those individuals with an interest in coming up with effective solutions to safety issues, which lead to acceptance and ownership. "

The SMP incorporates the mine policy and procedures, training manuals, safe work, procedures, records and various forms and the hazard management plans. The supporting documentation consists of the Act and Regulations; Australian standards, codes of practice and industry guidelines.

The involvement of the workforce in the development of the SMP and in particular the principle hazards plan is crucial for the successful implementation of the plan. In order for the process to be successful it is crucial to have effective communication and consultation between the management and the workforce. The communication has to be a two way process, with employees having the right to question outcomes of any decision taken by management that effects their workplace.

This has proved difficult especially with regard to contractors who are a significant part of the workforce at most operations today. One of the main challenges facing the industry is the number of persons entering and moving within the industry. According to Forbes and Wilson (2005)

^'The industry has a large percentage of the workforce being transient compared to the workforce of several years ago where mines had long term employees and a relatively stable and experienced people. The challenge this offers for any safety management system is how should we communicate and implement the system for all to comprehend and to comply with, especially those people that move from site to site on a regular basis. "

3.43 Methods of Communication Traditional communication mechanisms such as memos, meetings, team briefings and notice boards, which often use a mix of hard copy and electronic formats to get the message across are now used extensively. Other approaches to formal communication include the use of email, internet, videos, virtual meetings and focus groups.

Informal communication such as conversations on the job are often used to get the message across and are very effective with small groups of people. It has been proven many times that the best way to get the message across is communication between the supervisor and employee. This means that the supervisors must be trained in methods of the communication process. Most mines use the following types of communication, which obviously depends on the message, being conveyed: • Safety information which includes accidents and incidents; • Verbal communication • Non verbal communication • Electronic communication • Meetings • Stop work meetings

35 A Positive Safety and Health Management System Consolidated Rutile Limited (CRL) is a good example of a relatively small company who developed a sustainable safety management plan, which identified the following issues that they needed to focus attention on: • people and behaviours; • injury management; • hazard identification; • risk management and control; • contractor management; • incident reporting and accident investigation; • document structure and control and • accessibility to the information, and fitness for work.

According to Carey (2005), ''There has been a significant shift in the culture and behaviours at all levels of the workforce. The major focus on risk assessment processes, consultation, involvement and communication has had a significant positive impact on the way CRL is viewed internally and externally. "

Safe work procedures are developed with the workforce and one of the major advantages of this procedure is that the workgroup undertaking the task is actually involved in the process of developing their own procedure. This ensures that the task which is to be carried out is not only carried out in a safer manner but is usually done much more efficiently as a result of worker involvement in the process. The task of documenting these procedures is generally left to supervisors, however they must be signed off by the individuals involved with the SWP.

Risk management will be discussed later in this thesis, however having the workforce involved in this process means that they can then take ownership of the outcomes of the development of hazard plans and SWP. With this in mind all employees then have a responsibility to report any hazards that they have identified but also to take corrective action to rectify the hazard if at all possible.

3.6 Issues with Safety Management Systems The implementation of safety management systems has not been without some negative comments even though these systems are now enshrined in legislation. One of the most important deficiencies is the amount of paper work generated during an audit process, which can have a negative effect on the achievement of safer and productive workforce. Another negative is that the process weakens the input of employees because of updating and other issues. The link between the OHSMS and improvement is questioned because of the different types of systems put in place and the different environments in which they operate.

A good example of the opposing arguments to successful safety management system according to Forbes and Wilson (2005):

"We are required under the Act to make available for inspection by mine workers employed at the mine, a copy of the safety and health management system. I suggest that this is also not achieved, as most mines are spread over a large area and the work area usually is some distance from the main office or training centre. So many employees would not actually have the ability to inspect or review the SHMS if seeking information. It therefore just becomes another system that sits in the site library or Safety Managers office collecting dust. Even if it was readily available for employees, it is usually such a large document that anyone reading it would not have the time available to them during the shift. It is also generally written in such a manner that it is difficult for them to understand or locate the information they require. "

One of the major problems with SMS is their complexity because there are many elements involved with the system. It is therefore obvious that the system can quickly become out of date. This fact was highlighted in the findings after the 1998 Longford Gas Plant explosion when a lack of current operating procedures and necessary knowledge were acknowledged as contributory factors to the explosion. It is an accepted fact that written procedures should not only be readily available to operators but should be written such that they are easily understood. One of the biggest problems is a lack of understanding by the workforce of the key elements due to the complexity of some SMS and the limited communication by management.

According to Johnstone (1999)when reviewing SMS found that in many cases safety improvements had not been forthcoming and mineworkers saw the system as 'a bit of a joke, something to keep the guys happy in corporate and not something we actually do'

"Our safe working procedures tend to be a hotch potch of ideas. They are not readable and the guys can't comprehend them at all. Its lots of paper and lots of people don't know what's in the procedures, and no one wants to be looking at 5 or 6 pages of a bland Jocwm^wi." [Professional Staff]

" Workers have to be Philadelphia lawyers, they're too complex. I've got blokes underground who can't read and others who have difficulty in reading basic literature " [Foreman]

In order to ensure that Safety and Health Management Systems deliver the required results it is important to adopt the following lessons: 1. Make sure that foundations are well prepared. The focus should be on any pre- existing problems, which will ensure programme credibility and enhance acceptance and therefore workforce commitment. 2. When monitoring programme effectiveness the focus should be on the areas that need improvement and then following up and dealing with any issues. 3. When setting up standards and procedures it is important to keep it simple. I 4. Having a SHMS in place is only a starting point it is therefore very important to follow up on all the issues requiring attention. 5. Managers and supervisors should never accept that no news is good news. They need to ask the difficult questions of the workforce and lead from the front.

According to Forbes and Wilson (2005), the main challenge facing the industry is the number of people entering and moving within the industry. A large percentage of the workforce is transient compared to the workforce of several years ago when mines had long-term employees who were relatively stable and experienced. This problem is further exacerbated when one considers the large numbers of contractors now employed in the industry. The challenge for any safety management system is ''how do we communicate and implement the system." for all to comprehend and comply with, especially those that move from site to site on a regular basis. This would suggest that these people could be overlooked ''therefore relying on their own understanding and experiences or judgement to get them through, with little or no knowledge of the mines requirements "

At Goonyella Riverside mine after a serious injury in 2001 the mine was closed for a two weeks period in order for HPM/Helvory contractors to conduct a major examination of their safety systems. This was because of a number of serious and reportable incidents which had occurred over the previous six months and which had resulted in serious injury to personnel and damage to equipment. The mine was shut down until senior management could satisfy the mine management and the inspectorate that they could manage the operation to the standard expected and required to prevent incidents and injury.

In order to address these issues a process of reviews were conducted by one-on-one communication with all site employees. The outcome of the reviews was as follows: • Little focus on procedures and processes; supervision was not being involved in any of the decision processes to do with the crews or work flow, • Management focus had been totally on production, • The SMS had not been communicated to the workforce who had little knowledge of its content and a poor understanding of its purpose and the document was not readily available, • Risk management was non existent and no training had been conducted with the workforce, • The supervision had little or no understanding of their responsibilities.

The issues mentioned at Goonyella Riverside were similar to those that existed at Baralaba mine in 2006 when after a serious incident concerning mobile equipment the mine owners agreed to close the mine down for two weeks in order to implement a basic management system. This illustrates the difficulties that small mines have when trying to implement appropriate basic safety management systems. This is despite the fact that Baralaba is owned by a large company like Peabody who should have provided the resources to better implement these management systems from the start of operations. In the matter of an inquest into the cause and circumstances surrounding the death of a truck driver the coroner, Hennessy (2007), made the following findings:

''That coal mine operators critically review the ejfectiveness and implementation of their mine safety and health management system as they are obliged to under the Coal Mine safety and Health Act 1999. It is recommended that particular attention be paid to how the mine system controls the activities of contractors and ensures they are carrying out their task in a safe manner."

In summary, Safety and Health Management Systems in Queensland must be implemented before a mine starts producing coal. Some of the main issues are that there are too many different standards, which makes them very difficult to manage (Brady 2005). Non-standardization leads to confusion especially for contractors and service providers. Systems audits should be conducted rather than compliance audits and all mineworkers need to be trained since they do not understand their obligations under the SHMS.

3.7 Risk Management in the Mining Industry Following the Piper Alpha disaster the Cullen Report published in 1990 recognized that the offshore industry had a prescriptive approach where inspectors policed the platforms for adherence. A more effective approach would involve the platform deriving its own OH&S Plan, which would be reviewed by government and audited by inspectors. This then prompted universal change in Risk Management practice.

The current legislation in Queensland and New South Wales is part prescriptive and part self-regulating. In response to this approach the mining industry has now developed tools such as risk management strategies, safety management systems, safety management plans, principle hazard management plans and safe work procedures. The following discussion will elaborate on a general introduction of risk management principles and some examples of positive and negative outcomes. 3.7.1 Risk Management Systems Risk management according to Joy (1999) is " the systematic application of management policies, procedures and practices to the tasks of identifying, analysing, treating and monitoring risk."

Most mines adopt the following basic risk management system (Figure 3.1).

Figure 3.1 A Basic Risk Management System

Identify the Hazard

Monitor Performance

Decide to Decide to Decide to Eliminate Mitigate Tolerate

In both Queensland and New South Wales a risk assessment must be carried out before the introduction of a new piece of machinery or a new method of work. The main drivers for risk management in the mining industry today are as follows: • The poor safety performance in the industry; mineworkers are still being seriously injured, • Regulatory change, • Need to reduce uncertainty in major projects and • The need to minimize cost exposure. Human error is well recognized as a factor to be considered during the risk assessment and management process. However in light of a study carried out by the Minerals Industry Safety and Health Centre consideration of human error on the risk management process should be given an even higher priority and more detailed consideration especially during the monitoring of the effectiveness of controls.

"Rather than being the main instigators of an accident, operators tend to be inheritors of 'pathogens' created by poor design, incorrect installations, faulty maintenance, inadequate procedures and management decisions and the like. The operator's part is usually that of adding the final garnish to the lethal brew that has been cooking. In short: unsafe acts in the 'frontline' stem in large measure from bad decisions made by rear echelons" (Reason 1989).

As one mining safety regulator pointed out, ''mining itself is an industry where hazards are large, risks are inherent and change is continual. Therefore successful management of risks associated with mining consequently requires a systematic approach."

This was the view of the Warden's Court Report (Windridge et al. 1996) on the 1994 Moura Mine Disaster, which recommended that mines be required to put in place Mine Safety Management Plans relating to key risk areas and that these plans should be based on detailed risk/hazard analysis.

A good example of introducing a risk assessment processes to improve the safety performance can be demonstrated at Crinum Mine which is regarded as having one of the best safety and operating standards in the Australian underground coal mining industry. Effective communication is a priority between miners, supervisors and management. There is a high degree of commitment to risk management and safety management plans. One of the main reasons for this commitment is that the mineworkers appreciate the fact that their experience and knowledge have contributed to the plan. One of the most important tools which they use at Crinum is the 'take 5 programme' which is used extensively in the mining industry, the process has five steps "Stop, Think, Identify, Plan and Proceed." The Take 5 Process is explained in the following Table 3.1. Table 3.1 The Take Five Process

1.ST0P Do I understand the task? Is a documented procedure, JSA or work instruction available for this task 2. THINK Is there a current change to process, procedure or design? Am I trained, competent and authorised to do the task? 3. IDENTIFY What hazards are associated with performing this task? What controls will I implement to reduce the risk of 4. PLAN conducting the task to as low as reasonably possible If the implemented controls reduce all residual risks to Low: Proceed with the task 5. PROCEED If the implemented controls DO NOT reduce all residua risks to Low: STOP and perform a JSA.

A standard risk analysis matrix is used in order to determine the risk category. The risk can then be categorised into intolerable; efforts must be made reduce the risk further or tolerable as shown in Figure 3.1 below: Figure 3.2 A Risk Management Matrix

MANAGING RISKS

A level of risk that is so high as to require significant and urgent actions to INTOLERABLE

Efforts must be made to reduce the risk further (As Low As Reasonably

TOLERABLE A level of risk that is low but will

Where a job safety analysis (JSA) or a higher-level risk assessment has been carried out and all the residual risks are ALARP, then it is okay to proceed with the task.

3.8 Industry Concerns Regarding Risk Management PhUosophy Many safety practitioners in the industry have expressed concern to the author that the risk management approach only really satisfies the requirements of legislation and allows management to do some "window dressing". Whenever people visit mine sites these days mine management and operators seem to be spending a large amount of time doing risk assessments. The risk assessment approach tends to take away the ability of work groups to get on with carrying out the task safely. Also the fact that some miners cannot read and some have difficulty understanding or comprehending a document would question the use of this philosophy. Gone are the days when miners could use their initiative or think for themselves to solve a problem. They are forced to use the system; in other words the miner becomes a robot. Another problem with the risk assessments methodology is that it can be manipulated. It is the author's experience that management can exert pressure on participants in a risk assessment in order to achieve a particular result. In other words the whole process can be manipulated towards an outcome that suits management.

According to the Minerals Industry Safety and Health Centre (2005) in the final report on underlying causes of fatalities and significant injuries the shortcomings in the risk assessment process resulted in: • A lack of human error forgiveness in equipment and process operations. As human error is unavoidable in the longer term improving the tolerance of the presence of human error offers the opportunity to reduce the level of harm to people in the minerals industry. • Lack of protection barriers to protect against human error • A short-fall in maintenance strategies and implementation • A lack of behaviour monitoring which, if strengthened, would reduce either the level of unsafe acts (Human Errors) or enable specific defences against the acts.

The Construction, Forestry, Mining and Energy Union (CFMEU) in its submission to the 2005 Mine Safety Review stated that " staff conducting risk assessments at site level are not adequately trained to perform the task, nor take into account the full nature of risks". The CFMEU then went on to express a negative attitude to risk based regulation and reliance on OH&S management systems and wishes to retain prescriptive regulation.

Further the CFMEU and the Australian Workers Union are apprehensive about the new risk based approach. They consider that a stronger regulatory (i.e. prescriptive) framework will ensure improvements in the safety performance of the industry. They fear that the risk will not necessarily be assessed and managed adequately, and that the necessary enforcement to ensure that it is, may be deficient. 3.9 The Impact That Disasters Have Had On The Australian Mining Industry In order to understand the mining safety environment from a different perspective the author will examine the Australian coal mining disasters over the past four decades shown in Table 3.2

Table 3.2 Analysis of Australian Coal Mine Disasters involving 4 or more mining fatalities from 1965 to 1996 Mine Year Mineral Fatalities Cause Bull! 1965 Coal 4 Fire Wyee 1966 Coal 5 Roof Fall Box Flat 1972 Coal 17 Explosion Kianga 1976 Coal 13 Explosion Appin 1979 Coal 14 Explosion Moura No 4 1986 Coal 12 Explosion Moura No 2 1994 Coal 11 Explosion Gretley 1996 Coal 4 Inrush Total 80

The above Table 3.2 shows that from 1965 to 1996 eighty miners have suffered fatalities in the Australian coal mining industry. It can be observed that of the 80 fatalities, 67 were the result of explosions, which means that over this time period 84% of fatalities were due to underground explosions.

The following is an analysis of mines that have suffered explosions and the impact these tragic accidents have had on the coal mining industry. • Box Rat - Eighteen men were fatally injured when a major explosion occurred during the process of fighting an underground fire. The impact of this disaster was that new mine rescue protocols were introduced. • Kianga - Thirteen men died following an underground explosion after an outbreak of spontaneous combustion. This disaster resulted in significant changes to legislation; the establishment of an autonomous safety in mines research organisation (SIMTARS); and the requirement of mines to have available a means of analysing air samples. • Appin - A gas explosion occurred during a pre-planned ventilation change, resulting in the death of fourteen employees. The NSW Department of Mineral Resources said they would implement all the recommendations of the judicial inquiry. These included new regulations, improved gas management and monitoring and the employment of a ventilation officer. • Moura No 4 - Twelve men were fatally injured due to an underground explosion attributed to an ignition caused by a flame safety lamp. This disaster resulted in the prohibition of flame safety lamps; the founding of a committee to establish minimum training requirements for coal mines; and major changes that impacted on emergency egress.

In order to understand what lessons can be learned from these disasters the author will critically analyse the latest mining disasters at Moura No2 and Gretley. The author has chosen Moura No2 and Gretley because they are the latest disasters to occur in Australia and the outcomes of both have had a significant impact on safety improvement in the Australian mining industry.

It can be observed from the following analysis into both disasters that management at all levels have been found guilty of failures. These failures include: organisational failure, communication failure, lack of knowledge about hazards, failure to recognize warning signs and a lack of appropriate training.

3.10 Moura No 2 Mine In the twenty-two years from 1972 to 1994 some 53 miners have lost their lives in four separate disasters due to underground explosions at Box Flat and Moura. Given this tragic loss of life, it was inevitable that the inquiry into the Moura No 2 disaster would be the focus of considerable public attention and concern. In August 1994 eleven miners died at Moura no 2 mine as a result of an underground explosion caused by spontaneous combustion. According to the Wardens Inquiry (Windridge et al. 1996) into the accident, the contributing causes to the first explosion were identified as a number of failures in responses, approaches or systems at the mine. These were: • Failure to prevent the development of a heating within the 512 panel; • Failure to acknowledge the presence of the heating; • Failure to effectively communicate and capture and evaluate numerous tell- tale signs over an extended period; and • Failure to treat the heating or to identify the potential impact of sealing with the panel consequently passing into the explosive range due to the methane gas accumulating in the panel. • Failure to withdraw persons from the mine while the potential existed for an explosion.

When analysing these failures (Hopkins 1999) it can be deduced that they can be classified as organisational failures, which are summarized below: • The system for communication in the management organisation at the mine was totally inadequate. • The communication between corporate and mine site was inadequate especially with regard to warning signs. • The production figures were better communicated than the system for communicating safety information. • The feedback mechanism for those people reporting warnings or hazards was non-existent. • There was a misplaced reliance on oral communication and personal experience and a tendency to ignore written reports. • There was a culture at the mine that unless warning signs were confirmed they could be ignored. • There was a culture of denial at the mine site. • When warning signs were detected no specific actions were required. • The company's auditing process was found to be completely inadequate. In summing up this state of affairs regarding organisational failure the Moura Report stated: "It is the opinion of the Inquiry that events at Moura surrounding assumptions as to the state of knowledge of the night shift on the August, and the safety of those at the mine, represent a passage of management neglect and non decision which must never be repeated in the coal mining industry. Mine workers place their trust in management and have the right to expect management to take responsible decisions in respect to their safety. They also have the right to expect management to keep them informed on any matter likely to affect their safety and welfare."

It is regrettable that the air of caution, arising out of uncertainty, which was exhibited at the mine in order to bring forward the sealing of the 512 Panel did not extend to the general safety and welfare of the workforce and, in particular, to informing and keeping persons out of the mine for a time subsequent to that sealing.

Communications at Moura were deficient in many respects, and it has been outlined earlier in this chapter that safety at the coalface depends on effective communication. The communication at any place of work depends on the transfer of information both oral and written. The transfer of information must be structured in such a way as to ensure that the appropriate message is effectively communicated and not reliant on the overlapping of a shift system, which was demonstrated at Moura where at weekends no overlap was achieved. The Moura disaster occurred because vital information was rendered ineffective, by both the inadequate information processing system and by a culture that neutralized it. Reason's theory of latent failures, which is very applicable to Moura states:

"latent failures, arising mainly in the managerial and organisational spheres, combine adversely with local triggering events (weather, location etc) and with the active failures of individuals at the sharp end (errors and procedural violations), (Reason 2000).

The latent failures identified at Moura were the organisational problems listed eariier, especially the problems with communication. The triggering event being the heating and the failures of individual managers to acknowledge that a heating might be occurring especially on the night of the explosion. It is the responsibility of organisations to manage the risk in what is termed organisational accidents (Reason 1990). However, when analysing the tragic events at Moura No 2 human behaviour is very much a part of the failures that have been enunciated. Reason argues

"that human error can never be eradicated and that it is the responsibility of the organisation, senior managers and supervisors to put effective safety management systems, barriers and defences in place to buffer our basic and somewhat defective, cognitive behaviour."

The system for managing catastrophic risk was totally inadequate at Moura. The panel where the explosion occurred had been designed so that extraction would be completed within three months, which is well inside the coal's incubation period of six months. A gas monitoring system had been installed to alarm for spontaneous combustion. There was no action plan and no effective system in place to effectively manage and control events.

The Moura Inquiry made 24 recommendations, which encompass sixteen-subject areas, which were aimed at preventing the occurrence of a similar incident. The inquiry also made comment on many other key areas, which needed investigation and improvement in order to ensure the safety of those employed in the industry. Following the release of the report of the Wardens Inquiry the Minister for Mines made a commitment to implement all the recommendations. An Implementation Committee was established to oversee the development and implementation of the recommendations. The Chief Inspector of Coal Mines then established five Task Groups in order to review the recommendations and report back their findings. 3.10.1 Task Groups Review and Recommendations Task Group 1 was responsible for developing guidelines for a Spontaneous Combustion Management Plan and Mine safety Management Plans for the key risks of: Ventilation Spontaneous Combustion Gas Management Methane Drainage Emergency Evacuation Strata Control

Task Group 2 was responsible for developing guidelines for the protocols for governing the Withdrawal of Persons, Re-entry, Conduct of Emergency Procedures and exercises, and notification and approval prior to sealing a part of a mine.

Task Group 3 was responsible for the development of protocols for governing the training of coalmine workers in hazard awareness, spontaneous combustion, risk management, communication and emergency procedures. Competency requirements for statutory functions governing refresher training would need to demonstrate their fitness to retain their certificates of competency on a regular basis. Refresher training was to be conducted every five years.

Task Group 4 focused on the identification and selection of Self Rescue Breathing Apparatus which would effectively address the use and alternatives to the Filter Type self rescuer and guidelines for industry covering life support for escape and Emergency Escape Facilities.

Task Group 5 focused on the Design and Installation and Maintenance of Seals and Ventilation Control Devices including the provision for the rapid sealing of a mine when conditions warrant such action. The identification and selection of effective inertisation systems and protocols for use in Queensland mines. The inquiry also made comments regarding the possible implementation of the concept "of duty of care" which is sound and should be included in any new legislation. It rightly puts the onus of every person in the work environment to take reasonable care to ensure their own safety and health and not to endanger the safety and health of others. Mine management has the responsibility to form rules and to ensure that they are complied with. Although the inquiry was not opposed to the introduction of self-regulation it stipulated that any self-regulation should be established within a framework of legislation that prescribes minimum requirements in respect to safety. It also suggested that high probability and low consequence matters could be dealt with self- regulation and low probability and high consequence matters should remain the subject of prescriptive legislation. The inquiry also said that there was a need for common legislation in both NSW and Queensland in order to facilitate a common level of the knowledge of legislation in both states in order to ensure if nothing else consistency.

All the recommendations from the Inquiry have been implemented except one, which was for the development of a mines rescue escape vehicle. This project is now in the development stage and has been the recipient of three separate ACARP projects. A prototype is expected to be developed in 2009.

3.11 Gretley Mine In 1996 at Gretley mine, miners inadvertently broke through into flooded old workings of an old abandoned mine and four miners died in the inrush of water. Several years earlier Gretley mine management had obtained mine plans from the Department of Mineral Resources. Unfortunately those plans were incorrect, indicating that that the old workings were 100 meters further away than they actually were. The surveyor and the mine manager at the time of the tragedy assumed that the plans from the department were accurate. Some two years later the mine had a new surveyor and a new manager, and both individuals assumed that the plans were accurate, relying on the judgments of their predecessors. According to (Hopkins 2005), the faulty maps were produced by a departmental draftsman for another purpose in 1980. The drafting error made before the Gretley mine began operations, culminated sixteen years later in disaster.

A nine-month judicial inquiry followed and the findings showed "widespread and serious shortcomings" at every level of management at the Newcastle Wallsend Coal Company.

These included the: • Failure to act on reports made by the mine deputy on three separate occasions on the considerable amount of water at the coalface. • Not undertaking a risk analysis even though management was aware of numerous abandoned mines in the area. • Failure to check the accuracy of mining plans used by the company to determine the location of deserted mines in the area. The mine surveyor did not investigate the position of the old mine • Failure by management to inform the miners of the vital information on the deputy's reports and that they were working towards old workings. The miners should have been told that they were working towards an old mine filled with water. • Failing to carry out advanced drilling or to sink bores to determine the whereabouts of the deserted Young Wallsend mine.

It is a sad reflection that during the inquiry management admitted that if it had undertaken forward drilling or investigated the reported presence of water, the disaster would have been avoided. It is interesting to note that three out of the four deaths were contract workers. The findings were also critical of the Government Department of Mineral Resources for issuing inaccurate maps and failing to investigate the position of the old mine.

The Gretley judicial inquiry ran for nine months and made 43 recommendations. According to the NSW Government response to the report the findings provide a clear reminder that responsibility for safety lies with industry and includes: • intelligent, objective and perceptive planning. • management-worker commitment,

• monitoring of safety concerns,

• dedicated training and

• regular reviews.

A summary of the 43 recommendations included research on mine plans, storage of records, prevention of inrush, mining approvals process, colliery abandonment plans, investigations, and prosecutions.

Justice Staunton the presiding judge at the inquiry as well as making 43 recommendations referred the evidence to the Crown Solicitor to determine if the company and the managerial staff should be prosecuted under the Occupational Health and Safety Act. The subject of prosecutions has had a huge impact on the way safety is managed and therefore will be discussed in some detail later in this thesis.

3.12 Discussion This chapter has sought to demonstrate that one of the most important safety initiatives for success in the existing mining regulatory environment is an effective safety culture and the vital role that communication plays at all levels in the organisation and the involvement of the workforce. This chapter has analysed the safety culture on mine sites and how a good effective safety culture can not only improve safety on mine sites but can also make big improvements on productivity at the same time. It has been shown that a good safety culture will improve the following of compliance with rules and regulations on mine sites.

The workforce appreciate good leadership; they need to know exactly where they stand on all the issues that effect their day to day work environment. They need to be able to observe the commitment of management to safety and open communication channels where information flows not only top to bottom but bottom to top. They need to observe leadership by example. The workforce needs to be part of the solution to effective safety management. They need to be able to observe the attitudes and behaviour of management. Examples of good safety culture on mine sites have demonstrated how an effective safety culture can impact on safety performance by promoting teamwork, building good morale and therefore creating an appropriate safety environment.

Since legislation is moving from the prescriptive to a more risk based philosophy a more structured approach to safety management is required to take effect. The discussion on safety management systems has demonstrated how a documented structured approach in which safety risks and hazards can be identified, quantified and controlled if implemented properly can lead to continuous safety improvement.

Also identified is a recent analysis of incidents throughout the mining industry whereby the majority of incidents causing injury are due to human error or unsafe practices. Therefore attention to human error should go a long way to improving safety on the mine site. The key elements of safety management systems have been discussed and shown how, if implemented, can appropriately improve safety performance. It has also been demonstrated how effective communication and consultation with the workforce can influence the positive outcomes of a safety management system, which help to create a partnership leading to acceptance and indeed ownership of the system. Examples of the implementation of SMS have been demonstrated at different mine sites.

Although SMS are enshrined in legislation the discussion gives a few examples of the difficulties encountered when implementing these systems. It has been shown that the most important deficiencies are the amount of paperwork generated during an audit process and the fact that this process weakens the input of employees because of updating all the elements. It has been suggested that the SMS are so cumbersome that they become another system that sits on in the site library or safety manager's office collecting dust. The size of the document has the potential to limit availability to the workforce and that it is usually written in such a manner that it is difficult for employees to understand or locate the information they require. One of the biggest problems is the lack of understanding by the workforce of the key elements due to its complexity and in some cases the limited communication by management. It has been demonstrated that some employees are unable to read and others have difficulty in reading basic literature. This is further exacerbated by the large number of contractors who are now employed in the industry and who move from site to site. This would suggest that some employees would have to rely on their own understanding and experiences of safety systems to get them through with little or no knowledge of the mines requirements.

The discussion shows two examples of mines being closed in order to improve the safety performance; it is not unreasonable to suggest that there are many more instances. After the death of a truck driver the coroner was scathing in her comments regarding the controls and activities in place to ensure that contractors are carrying out their task in a safe manner (Hennessy 2007) .('Qld District tackles problems generated by the mining boom in our communities' 2006)

Safety and Health Management Systems (SHMS) are an important part of the way forward, however in order to improve the implementation they need to be less complex and the elements need to be standardized across the industry. System audits should be conducted rather than compliance audits. Most importantly, mine workers need to be trained in order to understand their obligations under the SHMS.

Risk management has been discussed in some detail and an example of a risk assessment process has been detailed. The problems with the risk management philosophy have been discussed in detail. The main issues with the risk assessment methodology is that it takes away the ability of miners to think for themselves in order to complete a task. They are forced to use the system causing the miner to become like a robot, which may have serious consequences for safety improvement. In some cases it encourages supervisors to abdicate responsibility, they just rely on the system.

Risk assessments can be manipulated towards the outcome that suits management.

The discussion has shown that the CFMEU considers that staff are not properly trained to conduct risk assessments nor take into account the full nature of the risks. They would prefer a stronger regulatory framework (i.e. prescriptive), which will ensure improvements in safety performance of the industry.

There is always room for improvement in educating mine workers, in planning for safety, communication and constant vigilance in what is a hazardous and ever changing environment.

The next chapter will deal with the problems associated with hours of work and fatigue issues in the mining industry.

CHAPTER 4

4 HOURS OF WORK AND FATIGUE MANAGEMENT

4.1 Hours of Work and Fatigue Management This chapter will review the literature regarding work hours and fatigue management with a view to understanding the implications of these issues for safety improvement in the coal mining industry. Since the implementation of the Howard Government industrial relations laws, which were introduced in 1996, there has been a move away from the traditional 8-hour shift to the 12-hour shift.

This has allowed companies to move to new rosters, which were originally rejected by union members because of the longer working hours. However mine workers soon saw the advantages in these rosters in that they could provide longer breaks from work. Examples of a 12 hour roster are working four days on and four days off, or seven days on and seven days off which means with holidays the mineworker works less than six months per annum. On the days off mine workers are able to travel long distances, which has enabled a majority of mine workers particularly in Queensland to live preferably in coastal communities. A statement made by Andrew Vickers of the CFMEU was that they are:

Aware of people travelling by car from mines in Central Queensland to as far away as the Hunter Valley in New South Wales, the Gold Coast, Sunshine Coast, Townsville and Cairns ('Qld District tackles problems generated by the mining boom in our communities' 2006).

Although the miners admit to fatigue working these long shifts, because of the life style considerations that these rosters provide for their families they would be very reluctant to move away from these shift arrangements. Recent mine expansions have led to miners working in areas where accommodation is hmited which has led to more traffic on the roads and with 12 hour shifts it means that most of these workers are on the roads at peak morning and afternoon periods. With hot seat change-overs this means that some rosters have shift lengths of 12.5 to 13 hours. The transportation of heavy mine equipment, fuel and oils to mining areas is not only a hazard in its own right but is a hazard to persons travelling to and from work. This increase in traffic volume and the consequential accelerated deterioration of the road system are hazards that drivers must face travelling to and from work.

The above-mentioned long working hours and fatigue associated with them is at the forefront of industry's attention following a double fatality on Queensland roads in 2005. This incident is currently the subject of a coronial inquiry and it is expected that the findings will have a significant impact on the way these related issues are dealt with in the future. These issues will be discussed later in this thesis.

This chapter will review the research literature regarding long working hours and fatigue to assess their impact on the health and safety of miners.

4.2 Recent Research Research has shown that shift arrangements can have significant consequences for health and safety of mine workers. Long working hours are associated with adverse health outcomes such as heart disease; sleep disorders, gastrointestinal disorders, psychological illness and fertility problems {Digging Deeper Report - Hours of Work and Fatigue Management 2007).

According to a study which was conducted for Japanese men workers (Liu & Tanaka 2002) a dose-response relationship between hours of work and the risk of non-fatal acute myocardial infarction (heart attack) was found. The longer the hours of work, the higher the risk of heart attack. Working more than 60 hours per week nearly doubled the risk of a heart attack. The highest risk was found to be the number of days per week where workers had less than 5 hours sleep. Two or more days per week with less than 5 hours sleep increased the risk of heart attack by three and a half times.

The abovementioned data may even underestimate the risks associated with extended working hours (Newcombe 2007). Newcombe suggests that excessive working hours may in fact be influencing such health factors as body mass index, hypertension and high cholesterol levels.

Some studies have suggested that stress in workplaces is exacerbated when working long hours. According to Maruyama & Morimoto (1996) who compared managers working at similar organisational levels, it was found that those who worked more than 10 hours per day were more than two and a half times likely to experience high job stress than those who worked less than nine hours per day. For those mines that operate outside the standard working hours of nine to five, fatigue has been found to be a major hazard. Most mines operate seven days per week and the shifts worked have duration of between 9 and 12 hours and in many cases sometimes even longer with overtime. These working time arrangements are associated with an increased risk of fatigue related errors and awareness issues compared to working day time hours.

Reference will be made to the Digging Deeper Report, which was commissioned by the NSW Mine Safety Advisory Council and published in November 2007. This report is probably one of the most comprehensive that has been undertaken in the NSW or Queensland Mining Industry. During the research some 53 mine sites were visited, 583 people were interviewed and 1667 people completed questionnaires.

The consequences of sleep deprivation and fatigue reported in the Digging Deeper Report, are extensive and impact on a range of mood and performance variables. Some examples include: reduced concentration, impaired attention, poor judgement of own performance, inability to assess problems and determine solutions, impaired decision making, slower reaction times, poor hand eye co-ordination, poor communication skills, impaired short term memory, mood swings, loss of situational awareness and increased lethargy. (Dinges et al. 1997; Harrison & Home 2000; Lamond & Dawson 1999).

Ill The above-mentioned impairments have huge consequences for the quality and standards of work performance, but more importantly the risk of incidents, which may inevitably lead to serious injury.

It is clear from the above discussion that a minimum amount of sleep is required to maintain a baseline waking function. Recent research has indicated that individuals who obtain less than six hours sleep per night for a series of consecutive nights will exhibit cognitive and physical performance impairment (Dinges 1995).

43 Cognitive Psychomotor Performance and Decrement Associated with Sustained Wakefulness (SW) and Alcohol Intoxication. Since the industrial revolution shiftwork has become an increasingly common work practice. Research studies over the last twenty years have clearly identified shiftwork as an occupational health and safety risk factor (Akerstedt 1995). Reduced opportunity for sleep and reduced sleep quality are generally considered to be major risk factors associated with shiftwork related accidents (Akerstedt 1995; Leger 1994; Milter et al. 1988). Not surprisingly, the combination of these factors leads to increased fatigue, lowered levels of alertness and impaired performance on a variety of cognitive psychomotor performance tasks (Harrington 1978).

Experimental studies have shown that sustained wakefulness (SW) impairs several components of performance including hand-eye coordination, decision making, memory, cognitive, visual search performance and speed and accuracy of responding (Babkoff et al. 1988; Fiorica et al. 1968; Linde & Bergstrom 1992). In addition to cognitive factors, affective components of behaviour such as motivation and mood are altered as the duration of SW increases (Babkoff et al. 1988; Bohle, P. & Tilley 1993).

From the studies cited above it is clear that there is a consensus that cognitive psychomotor performance is impaired by sleep disruption and extended wakefulness associated with shift work (Akerstedt 1995). This performance impairment is associated with an increased risk of accident (Dinges 1995).

Policy makers in western industrialised countries have generally not legislated to manage and control fatigue in a manner commensurate with the statistical risk associated with it. However this is in stark contrast to alcohol-related performance impairment, where policy makers have prescribed work and or the operation of equipment under the influence of alcohol.

Given that the effects of SW are qualitatively similar to the effects of moderate alcohol intoxication (Klein et al. 1970), it is difficult to understand why fatigue- related performance impairment has not been subject to similar levels of regulatory intervention.

4.4 Fatigue Related Issues Fatigue is a state of impaired physical and/or mental performance and lowered alertness arising as a result of inadequate restorative sleep. Other mediators of fatigue are time of day and length of time awake.

Some of the worst accidents in the past 30 years have identified fatigue as a major contributing factor to the incident. Fatigue contributes to accidents by impairing performance and at the extreme end of the scale by causing people to fall asleep. In the UK it is estimated by the department of transport that at least 20% of fatal road accidents on UK motorways are the result of drivers falling asleep at the wheel. In the USA driver sleepiness is estimated to have contributed to 57% of fatal accidents involving trucks (IPIECA 2007).

The circadian rhythm is an important determinant when trying to solve the shift rotation issues and with most mines including underground mines working up to twelve hour shifts it is very important part of the process. It is defined as: Human beings are programmed to sleep during the night hours and to be active during the day. The sleep/wake cycle is called the circadian rhythm. The term circadian comes from two Latin words, circa - about, and diem - a day. Thus circadian rhythms refer to a physiological functions that cycle over a day. Examples are the sleep/wake cycle, alertness and performance, body temperature, production of hormones like melatonin and Cortisol and heart rate. These rhythms are generated by a clock in our brains, which controls their timing. Circadian rhythms do not generally adjust easily to shiftwork (Baker & Ferguson 2004).

This work by Baker & Ferguson was commissioned by the Minerals Council of Australia to assist people in the mining industry to assess existing proposed working time arrangements, and identify fatigue related issues and concerns.

Sleep deprivation and fatigue are largely dependant on working time arrangements. In order to develop working time arrangements that aid sleep, health, well-being, work design, and fatigue it is important to obtain detailed information on the interaction between human physiology and the working time arrangement.

Rosters in the Mining Industry Hours of work arrangements in the mining industry require careful management. There are many factors that have been identified as contributing to potentially adverse impacts. These require special attention but only when the site-specific factors are included. The importance of site-specific factors reinforces the need for site management and workers to exercise their duty of care and not rely on generic guidelines or regulations.

There are many different types of roster being employed in the mining industry to day, which predominantly has 12 hours shifts. These rosters allow mine workers to live in major centres and coastal communities. These rosters provide for up to seven consecutive days off which allows miners to commute long distances. For those who drive (which would be the majority) it exacerbates the issue of fatigue especially at the end of a shift sequence when that individual is keen to get home. If one considers underground employees especially those doing hard operational work, the problem is further exacerbated. Underground miners in particular admit to finding the twelve- hour shift difficult; however the life style considerations overrule the safety and work issues at the expense of potential accidents and incidents.

A study of the relationship between hours of work and accidents and incidents in the Australian mining industry suggested that it was not possible to compare different rosters to see if one roster pattern had a lower incidence rate than another because there appears to be no uniform definition or application of definitions in reporting incidents between mines. It was not possible to assess the incident rates during overtime hours worked as overtime hours were not tracked in sufficient detail. The issue of contractors further exacerbated the problem especially short-term contractors who are very difficult to keep track of (Cliff 2006).

The 2003 review of the Western Australia mine safety legislation described the nature of the mining industry in that state, in terms that are equally applicable to Queensland and NSW: "The mining environment, operations and culture are significantly different from industry generally. Mines are often located in distant and sometimes remote geographic locations.

Mines themselves are often very dusty, noisy and dirty places to work. The work can be highly repetitive, and sometimes physically demanding but not always mentally or intellectually stimulating or challenging. In most modern mines, shift arrangements mean that employees work extensive periods and many do not get regular or perhaps even adequate rest breaks". 45.1 Shift Pattern Characteristics According to the Digging Deeper Report (2007) the following specific characteristics of shift patterns that are know to influence fatigue are:

• Sleep opportunity: An example of sleep opportunity is as follows; if an individual is working a 12-hour shift and the commute time is 30 minutes each way then the sleep opportunity time is approximately 11 hours. In this period time will be spent engaging in personal, family, social and leisure activities.

• Consecutive night shifts: A sleep debt can be accrued over a period of consecutive night shifts due to the quality and quantity of sleep obtained during daytime hours. The risk of an accident increases with each consecutive night shift worked. According to (Folkard & Tucker 2003) compared to the first night shift the risk is increased by 17% on the third night shift and 36% on the fourth.

• Start Times: If people start before 6 am they have to truncate their sleep period in the early morning hours. Due to the 'forbidden zone' for sleep in the early evening hours (Lavie 1986) it is very difficult to go to sleep earlier than normal in order to compensate for early starts. Early starts can lead to clock watching and may also require people to drive to work in the lowest point in their bodies alertness rhythms, in the early hours of the morning.

• Shift length: If people are working long shifts it reduces the time for sleep as sleep is sacrificed in favour of other non work related activities in order to maintain some normality for shift workers. The shorter the sleep opportunity the less sleep will be obtained. Research has indicated that the risk of accidents occurring increases significantly from the hour of work (Folkard & Tucker 2003) Prior wake impacts on alertness and performance. A shift length of 12 hours will be associated with a prior wake of at least 13 hours and possibly longer depending on the travel time and therefore the time of arising from sleep. • Direction of shift rotation: It is a well known fact that forward rotating shifts day, afternoon and night are a better match for the bodies natural rhythms and as a consequence result in less sleep disturbance (Knauth 1997).

There are a few devices for measuring and monitoring fatigue and some of these devices are currently being tested in the mining industry. However these devices do not prevent fatigue and therefore cannot be used as a preventive strategy. The strategies that will be discussed later on in this thesis will concentrate on fatigue management.

Fatigue and Awareness Issues In underground operations in Queensland from 2002/03 to 2004/05 on average 60% of High Potential Incidents were due to awareness issues (Qld Department of Mines and Energy Safety Statistics, 2005). In Open Cut operations during the same period on average 41% of High Potential Injuries were due to awareness issues.

It is interesting to note that awareness in underground operations scores 60% and in the open cut 41%. It is therefore reasonable to assume that one of the major causes of awareness is attributable to fatigue (weariness from exertion). It can be concluded that these high levels of awareness issues in both the underground and open cut operations are a significant contributor to incidents at work.

However the issue of the "twelve hour shift" and shift rosters needs to be examined particularly in view of the large number of awareness incidents, which are occurring in both underground and open cut operations. Alertness of the workforce is also a factor, research has shown that risk rises after a nine-hour shift and exponentially after twelve hours (Akerstedt 1995). 453 Vehicle Crashes On The Way To and From Coal Mines These issues were investigating by a report called "Crashes on the way to and from Coal Mines in NSW" by N Mabbott, D Cornwall, B Lloyd, and A Koszelak (2005) for the Coal Services Health & Safety Trust 2005.

In January 2005 approximately 9760 coal miners worked in NSW. A total of 219 vehicle crashes were recorded in the 7.5-year period of data supplied. Of these, four were fatal. Therefore there were 215 injury crashes, or 28.6 per annum. This represents approximately 0.3% of NSW coal miners being injured and 0.005% being fatally injured in a motor vehicle crash per year on the way to or from work.

This research has indicated that approximately 29.2 coal miners will be involved in a crash and be injured and 0.5 drivers will be killed on the way to and from work in any one-year.

Similar research was undertaken by Milia and Smith in Queensland (2004). The report was entitled "The Underlying Causes and Incidence of Driver Fatigue in Shiftwork and Non-Shift Work Population". The report investigated driver fatigue as an issue for miners travelling to and from work in Queensland.

4.6 Research Findings of Fatigue and Shift Work in NSW and Queensland. The major findings of both the NSW and Queensland reports have been compared, with the Queensland research in italics. • Mean age for all workers was 40 years old • NSW - Mean age was between 39 and 40 years.

• Falling asleep at the wheel was reported in 13% of shift workers when driving to night shift. Also 13% of workers driving to day shift fell asleep over the last year studied. Workers reported higher sleepiness levels and higher impairment levels when driving home from night shift work than day workers. NSW - 2.7% of crash injured drivers fell asleep at the wheel causing the crash. A further 9.8% of miners fell asleep on the way to work and 21.9% fell asleep on the way home from work.

• In the previous 12 months ten drivers reported incidents driving to work and twenty-four drivers reported incidents driving home from work. Common to all groups were running on to the shoulder or off the road and crossing the centre line. NSW - 12.3% of crash injured drivers lost control due to inattention. This included running off the road and over the centre line. 9.8% of incidents on the way to work and 10.2% of incidents on the way home from work, were due to another vehicle (usually opposing direction) crossing the centre line.

• The results have suggested that driving too early in the day, driving long distances and working long daily shifts contribute to increased driver fatigue. NSW - A high number of crashes and incidents occurred early in the morning between 0400 hours and 0900 hours. A further high peak of crashes appeared between lunchtime and 2000 hours. This may be influenced by drivers driving to and from 8-10 hour shifts through post lunch circadian low point. The more recent incidents over the past year 2004 indicate that 12-hour shifts patterns are moving the afternoon incidents to a later time slot. It should be noted that 12hour shifts in Qld are the norm.

• 23% of drive in drive out workers reported falling asleep on the long drive home. Some of these workers left home at 0300 to drive directly to the working shift (up to 230km), while others left as early as 0200 hours the day before and drove up to 1300km. Interviewed drivers were driving long distances after a number of consecutive night shifts (up to 12 consecutive shifts) and some drove up to 600km without a break from driving. NSW - Unable to ascertain how long some of the journeys were, however it is likely that there is a mix of townships within 50km.

Some survey respondents suggested a break or a nap before driving and the use of buses would alleviate the problem. There were differences between the methodologies of the two research projects, however there is enough evidence to support that coal miners are suffering the effects of driver fatigue on the way to work and more so on the way home. This is further emphasised in Queensland where 12-hour shifts are the norm. These results have led to many crashes and a high level of incidents in both New South Wales and Queensland.

The long drives, early start times and long shifts practiced in the Queensland study promote fatigued drivers. The New South Wales study indicates that driver fatigue appears to be present when 8-10 hour shifts were in place. Now that 12 hours are the norm it is certainly the case.

These studies have sought to express the impairment associated with fatigue with its equivalent level of alcohol intoxication, thus being able to provide an index of comparable impairment.

4.7 A Study Conducted by the Sleep Research Centre in South Australia Data from two studies conducted by the Centre for Sleep Research, SA 1998 supports the idea that Sustained Wakefulness (SW) may carry a risk comparable with moderate alcohol intoxication since approximately 50% of shift workers on eight hour shift patterns typically spend at least 24 hours awake on the first night shift in a roster (Knauth et al. 1980).

The highest level of impairment observed in this study (0.096% BAL) would occur at the end of a typical night shift (i.e. 0600-0900 hours) and would frequently coincide with a trip home for many shift workers.

The results from these two studies support the proposition that performance impairment and the risks associated with SW are significant and are similar to those observed for moderate alcohol intoxication in social drinkers. The current literature indicates that controlling the causes of fatigue is not just a question of working hours; it's about the time available for adequate sleep recovery. In general a good threshold for hours of sleep recovery are as follows: • The aim should be for people to have between seven and eight hours of sleep each night. • Less than six hours sleep over a few nights will result in impairment. • Sixteen hours of wakefulness in most cases will result in impaired performance. • The length of waking hours should not exceed the total amount of sleep in the previous 48 hours. • The loss of one night's sleep requires more than one nine-hour sleep to recover. Controls are necessary for assessment of fatigue related risk in the work environment. Further controls must be based on organisational and personal factors such as shift design, working hours, work design, quality and amount of rest prior to and after a work period, activities outside of work and other factors including sleep issues.

4.8 Hours of Work According to the Digging Deeper Report (2007) the weekly hours of work in the NSW mining industry are high when compared to the mining industry as a whole. This is illustrated in the Table 4.1 below and clearly shows that people in the NSW mining industry are working long hours compared to the Australian mining industry as a whole. Table 4.1 Average Hours of Work in the NSW Coal Mining Industry NSW Mining Industry Australian Mining Mean (hours per week) Industry- Mean (hours per week) Employed full time 50 46

Comparing statistics across national boundaries is not always reliable due to working hours and definitions, however the following gives some comparative data. The USA mining industry in July 2007 worked 47.3 hours on average, which is over two hours less than the NSW mining industry. In 2006 the highest average in Europe was in Austria at 44.3, which is considerably lower than the NSW mining industry.

A standard international definition has been developed for working over 48 hours per week. On that basis, the International Labour Organisation Report, Working Time Around The World, gives comparative statistics for twenty countries from 2000-2005. When analysing these statistics it was found that Peru had the highest percentage of employees working long hours with 51% of employees working more than 48 hours per week. The NSW mining industry is well in excess of this figure with 53% of employees working more than 48hours per week. It can be assumed that the situation in Queensland based on the current information available would be similar to that in NSW if not worse.

The Digging Deeper Study survey found significant differences between the hours worked by different occupations. It can be observed from Table 4.2 that under managers and managers worked the longest hours, as one would expect with the administrative employees working the shortest hours. The data shows that generally, managers, supervisors, engineers and other professionals usually work longer hours than miners, tradespeople, equipment operators and labourers in the coal mining industry. Table 4.2 Hours Worked in Different Occupations in the NSW Coal Mining Industry

Activity Average Hrs per week Undermanager and other managers 54 OHS manager/officer 52 Engineer 52 Deputy and other supervisors 52 Other professionals 51 Miners 49 Trade persons 49 Equipment operators and labourers 49 Administrative employees 44

These long hours were reinforced by interviewees from staff groups during the survey who reported that they were fatigued as a result of their hours of work and shift arrangements:

We work 12 and a half night shifts - you only need bad concentration for a couple of seconds for something bad to happen. Fatigue is a really big problem. Twelve and a half hour day shifts are not too bad, night shift is dreadful. I don't know how truck drivers and digger drivers manage it (coal employee).

Excessive hours worked causes fatigue and needs to be looked at for people's safety

(coal employee). We've had lots of incidents; a truck ran off the road, lots of incidents falling asleep. Lots of people fall asleep and don't report it. You see marks, so you know what's happened. The consequences depend on who notices. If there's damage to the vehicle you have to report it, but otherwise people are too scared to speak up about it (coal operator). 4.9 Fatigue Risk Factors According to respondents of the survey there is a significant difference of fatigue depending on the shift being worked. The night shift was reported to cause the biggest problems regarding work performance and fatigue levels. The findings that both night shift and afternoon shift have negative effects on work performance, alertness and ability to concentrate would suggest that the current shift arrangements are not adequately managing the risks associated with shift work.

The data shows that of those who work night shift: Nearly one quarter have problems with work performance; One third have problems with fatigue; Nearly one third have problems with alertness; and Nearly one third have problems with their ability to concentrate.

The outcomes of these responses suggest that for the employees working these shifts coupled with the long hours that they are working, would indicate that there are substantial ramifications for health and safety in the industry.

The roster risk factors at mine sites were found to be attributable to; The number and length of breaks during the shift; Starting times especially before 6am; Seasonal changes in roster pattern; Commute times, some exceeded an hour each way; Fly In Fly Out and Drive In and Drive Out rosters; and Financial incentives.

Based on these criteria rosters could be assessed for low, medium and high risk, which is illustrated in Table 4.3. It may be observed from this table that most rosters in the coal mining industry were in the medium risk category. Table 43 Roster Risk Parameters Sector High risk Medium risk Low risk Coal 4 10 3

4.10 Industry Issues with Hours of Work and Fatigue Very few sites in NSW could provide evidence of a systematic risk management approach to hours of work and fatigue:

Wi^ have a draft fatigue policy ready to go to the OHS committee (coal, OHS manager). {Digging Deeper Report - Hours of Work and Fatigue Management 2007)

Some shift supervisors work 14 hours on site and then have to commute one hour to and from work. This reduces their sleep opportunity well beyond the safe limits.

The NSW mining industry is usually located near residential centres, however commuting times and extending shift times considerably limit sleeping opportunity:

We have people who travel to Cessnock so, on top of 12 hour shifts, with shower and travel they can be away from home for 14.5 hours (coal manager) (Digging Deeper Report)

Another example of miners working long hours where fatigue issues are causing safety and health problems is to be found in Queensland. The wealth that has been generated from the mining boom in Central Queensland has been the centre of media and public attention. According to the Queensland's CFMEU President the boom is creating some serious social consequences for people in the industry and the communities in which they live. This rapid expansion, coupled with compressed work schedules, has caused a dramatic increase in road usage in areas not designed to handle the volumes of traffic that these roads have to handle. Andrew Vickers: ""This has seen Central Queensland highways turning into killing fields and it is ordinary people who are paying the price for this through loss of life and injuries'" (Smith, B 2007).

Vickers also made comment that employers are moving away from providing proper accommodation in the mining centres, which has resulted in some cases with workers sleeping in cars and under bridges.

Companies are attempting to provide single person accommodation for employees and because of limited affordable housing in mining communities more families have relocated to the nearby major centres like Rockhampton, Mackay and Yeppoon. This issue has been further exacerbated with all companies moving from eight to twelve hour shifts. This means that most mine workers commute to these centres after completing a roster sequence. The CFMEU (Andrew Vickers) view on this approach was as follows: "Employers can't say in 2007 we are going to put a mine in Central Queensland and we'll provide you with single person accommodation we don't care where you live where your family is and you get yourself to and from work the best way you can its not our responsibility. Its their responsibility (Smith, B 2007).

This sharp increase in the number of workers on the highways driving to and from work has proved to be a major safety issue. Police figures show that the Central Queensland region accounted for sixty percent of all fatigue related road crashes in the state in 2006 and the traffic on the Capricorn highway the gateway to the mining region had increased by 30% in the same period.

In August 2007 an international conference in Queensland was told that not enough drivers know about the dangers of fatigue and its deadly impact on driving. This conference followed a double fatality and another accident in Central Queensland in 2005, which may have been attributable to fatigue and at the time of writing is at the centre of a Coronial Inquest being held in Rockhampton. The inquest is trying to ascertain if fatigue played a major role after it was revealed that the mineworker had been awake for 17 hours when he attempted to drive the 250-kilometre journey home to Yeppoon. The CFMEU made the following statement regarding fatigue: People will have to accept the fact that they're going to have to sleep before they can take off on a long journey, for example after concluding a 12-hour night shift. It's simply intolerable that people would work for 12 hours straight and then starts off on a 10 or a 15-hour road trip. It's ludicrous. (Smith, B 2007)

4.11 Industry Response to Long Work Hours and Fatigue This section of the thesis will investigate the industry response to long working hours and the impact of fatigue management. Some examples of fatigue management plans will be evaluated to understand the problems associated with mineworkers working these long hours.

4.11.1 Fitness for Work The legislation in Queensland stipulates Fitness for Work in the coal mines safety and health management system to provide for controlling risks at work associated with: • Excessive consumption of alcohol; • Other physical or psychological impairment e.g. stress; • The improper use of drugs; and • Personal fatigue.

A cross section of the workforce must be involved in developing a programme for fatigue with fitness provisions agreed by the majority of the workforce that will be affected by it. This programme must provide for the following: • An education programme; • An employee assistance programme; • The maximum hours for a working shift; • The number and rest breaks in a shift; and • The maximum number of hours to be worked in a week or roster cycle.

Operations can design a fatigue management plan, which will enable all stakeholders to work towards minimising the risks of fatigue. The management of fatigue requires the following: • A Policy - which outlines the approach, commitment and accountability for all stakeholders and an audit process. • A Training programme in order that people can identify the signs and symptoms of fatigue. • A programme for Tracking Incidents and near misses. • Medical and Well Being Support that includes diagnosis of sleep disorders.

Countermeasures that can be put in place to minimise incidents and crashes on the way to and from work are as follows: • A working party to be established to investigate and initiate the feasibility of the recommendations from the reports in NSW & Qld • All coal mines should implement means to ensure that all staff can adequately manage the current roster designs that are in place. • All coalmines should undertake fatigue management training of all staff and management. • A health programme should be put in place, either through the mines or the NSW or QLD governments. • All mines should investigate opportunities for utilising buses as an alternative means of transport. If not practicable, car-pooling should be encouraged. • Further investigation of traffic volumes should be conducted through the working party.

4.11.2 Response to Fatigue Issues by Industry Mining companies in both Queensland and New South Wales have started to implement fatigue management plans. The Industry is still coming to terms with complexity of fatigue and shift arrangements related management issues. The larger mining companies are coming to terms with these issues much better than the smaller companies. However one of the biggest problems that they all face is that of consistency across the industry.

It has been mentioned earlier in this chapter that certainly in Queensland the current coronial inquiry regarding fatigue is focusing the industry's attention on the issue. In response to the issues associated with fatigue the Queensland Resource Council members have supported the formation of a Road Accident Action Group in collaboration with emergency service providers and community representatives to promote road safety in the Bowen Basin.

4.113 Fatigue Management Plans In order to gain an appreciation of fatigue management plans some examples in Queensland and NSW will be evaluated. Most fatigue management standards are to provide a framework for managing and understanding fatigue and minimising and controlling the risks associated with fatigue in the workplace.

A good example can be found at Coal and Allied in NSW (2007) where the fatigue management standard must ensure that: • Individuals are fit for work; • Companies meet their safety obligations to employees, contractors and the community; • Hazards are minimised and risks associated with fatigue are managed; • Appropriate decisions are made in relation to hours of work and shift rosters; • Ongoing assessment and monitoring of fatigue risks; • Education and training to help manage fatigue and related risks is provided. It has already been shown that hours of work in the coal mining industry are high by Australian and International standards. This has ensured that any fatigue management standard stipulates hours of work. The Coal and Allied example in Table 4.4 is typical of what currently constitutes rules for hours of work across the industry. Table 4.4 Rules for Hours of Work Work hours (24 hours) Rules Up to 14 hours hidividual assesses fitness for work 14 to 16 hours Formal risk assessment Working beyond 14 hours need approval Fitness assessed before going home More than 16 hours No individual to work more than 16 hours in a 24 hour period Total hours of work Total hours should not exceed an average of sixty hours per week over a four week period Controls must be in place to ensure that individuals are not working excessive hours in any seven day period Fatigue controls must be in place for any roster that employees work Break between consecutive shifts A minimum break of 10 hours Risk assessment required if individual is required to return to work prior to completion of a 10 hour break Call back No more than one call back in a 24 hour period

4.11.4 Management of Fatigue This management fatigue policy consists of the following: Employees must self manage their own fatigue; they have to take the first steps if they consider that they have a problem. They must discuss with their leader and if necessary allowed to have a fatigue break or be allocated to other duties. The Leaders are responsible for ensuring that fatigue is managed in their particular work group taking into account fatigue breaks and if an employee is constantly suffering from fatigue and unable to fulfil the requirements of their role then counselling or discipline is appropriate. Education and training is provided to employees and supervisors in order to ensure that they can make decisions regarding roster design and work arrangements. They must understand the factors, which contribute to fatigue, their responsibihties in relation to fatigue management and be able to develop strategies for managing personal and operational fatigue. On commencement of employment all employees are provided with information on fatigue management education.

Risk assessments must be carried out: When planning tasks and carrying out work; Prior to implementing a new shift roster or making changes to existing rosters; Prior to approving any extension to working above 14 hours.

The risk factors which must be considered and which effect the person are things like commuting times, length of shifts, sufficient time off, rest breaks, personal factors, heavy physical work, and recent shift history. Risk factors, which affect the work, are type of work being carried out, is the work physically or mentally demanding, fatigue environmental factors, level of supervision required and the shift involved day or night. The fatigue management plan must be monitored, reviewed and audited annually.

Most shift rosters in the industry are based on the following parameters see Figure 4.1. Figure 4.1 Roster Safety and Health Considerations

The general guidelines used by industry when designing working arrangements related to fatigue management are simple rosters, direction of shift rotation, start times, blocks of shifts, appropriate breaks, travel time, sleep opportunities, night work and rostered hours.

4.115 Management of Fatigue at Gregory Crinum Mine Another example of how fatigue is managed is at Billiton Mitsubishi Alliance (BMA) mines in central Queensland. According to the BMA fatigue policy at Gregory Crinum mine, in order to manage shiftwork and reduce the effects of fatigue responsibility lies with both the employer and the employee. In an attempt to manage fatigue two sleep pods are being tried out at the mine to allow employees to take short naps during shift work to reduce fatigue and increase alertness.

The philosophy is that if employees become fatigued on the job then a power nap can really help ('Power naps combat fatigue' 2007). A defined procedure using self - assessment is used to determine if a controlled nap is required. If employees are sleepy when they finish a shift they are encouraged not to drive home, but to get someone else to drive them home. 4.12 Road Safety Alliance Programme The previously mentioned safety road programme has been developed in conjunction with Queensland Police, Department of Main Roads and Queensland Transport. This programme is called the Mining Industry Road Safety Alliance (MIRSA), which implements, develops and coordinates road safety initiatives and delivers agreed safety outcomes. MIRSA is involved in road safety activities to address the 'fatal four'-Drink Driving, Speeding, Failure to wear seat belts and Driving While tired with particular focus on the Peak Downs Highway and adjacent corridors.

A broad range of activities has been initiated through MIRSA to raise awareness of the consequences of risk taking behaviours on regional highways that include; • Fatigue education; • Infrastructure projects; • Wide loads; • Rental vehicles; • Roadside billboards; • Young drivers; • Safety campaigns; and • A MIRSA website.

4.13 Discussion This chapter has dealt with hours of work, shift rosters and fatigue management. It has demonstrated that these issues are amongst the most important safety concerns facing the mining industry to day. Research has shown that shift arrangements and rosters can have significant consequences for the health and safety of mineworkers. These working time arrangements increase the risk of fatigue related errors and awareness issues when compared to working day time hours. One of the most significant reasons for miners suffering the effects of awareness and fatigue issues is the move away from the traditional eight-hour to a twelve-hour shift and four days and seven day rosters. It has been outlined in the text how the industrial relation laws of the Howard Government have encouraged companies to move to these longer working hours for productivity reasons. Although initially rejected by the employees they have now been overwhelmingly accepted because of life style considerations. These roster arrangements now allow mining families to live in coastal and major centre communities. The Ci^EU response to these longer working hours was that self regulation of work hours has been the approach in mining since 1996 and has seen the greatest increase in hours in that period.

The increasing use of contractors, of 12-hour shifts, of compressed rosters and the use of fatigue management policies' are major contributors. (CFMEU 2004)

This of course has been at the expense of safety fatigue considerations throughout the mining industry. Mining is still a dangerous occupation and we expect miners to undertake their tasks suffering the effects of fatigue. It has been shown that shift work reduces the opportunity for sleep and that reduced sleep quality is generally considered to be a major risk factor associated with shiftwork related accidents. Given that the effects of fatigue are similar to the effects of moderate alcohol consumption it is difficult to understand why fatigue performance impairment has not been subjected to similar levels of intervention. These new rosters have increased the traffic on the highways to such an extent that at shift change times traffic congestion is proving to be a major safety concern.

It has been shown that 60% of the high potential incidents in underground operations and 41% in open cut operations in Queensland are attributable to awareness from fatigue issues and since the rate of HPIs is increasing at a rapid rate it is a real concern for safety in the coal mining industry. The reports on vehicle crashes and the underlying cause and incidence of driver fatigue and shiftwork have demonstrated that miners are still working 12 hour shifts and driving in some cases long distances home when in fact they are suffering from the effects of fatigue. If this level of driving impairment was related to alcohol consumption they would not be legally allowed to drive. The highest level of sustained wakefulness or fatigue impairment observed was at the end of the first night shift and was in excess of the legal limit for alcohol consumption. According to the Digging Deeper Report (DDR) (2007) the following comments were made: I am really tired. If I said I couldn't keep up the hours, I wouldn't be doing this job for very long (coal supervisor)

They'll stand up here and say - if you're tired, not fit, go home, don't come in. But then they'll write you up for not coming in (coal operator)

This chapter has highlighted that the NSW coal mining industry is working long hours compared to the rest of the mining industry in Australia. On the basis of the International Labour Organisation Report, which compares statistics for twenty countries around the world 53% of NSW, employees are working more than 48 Hours per week, which is well in excess of Peru, which was the highest at 51%. These long hours were reinforced by employees during the survey conducted by the DDR. It can be assumed that based on the available information Queensland would be working similar hours to those in NSW.

Managers, which include Undermanager's, Engineers, Deputies and Supervisors, are working long hours between 54 and 51 hours per week. These hours are most probably understated due to the fact that overtime is not tracked and therefore not reported. These hours are of concern to the safe working of mine operations and will almost certainly have negative consequences for safety performance.

If employees become fatigued on the job employers are now encouraging employees to power nap. They are able to have a short sleep provided that they carry out a defined procedure using self-assessment with a supervisor involved. According to the DDR:

Napping has the ability to be abused - 7 don't need to get a good sleep at home because I can sleep at work' (coal OHS manager). Some supervisors reported that they actively discouraged napping and considered that it was abusing the system. According to the DDR, (2007) a recent fatigue related incident at one site in NSW resulted in the dismissal of the individual for failure to control non-work related risk factors. This issue resulted in the employees at this site saying that they would be less likely to report fatigue issues: One bloke drove into a windrow. He doesn't work here any more. They preach to people, pull the truck over and stop, but its noted against you in a little book. Its seen as you are not managing well (coal operator)

It has been outlined in this chapter that there have been some concerning reports of perceptions that those employees reporting fatigue risked disciplinarily action. While ever this is the case it will be impossible for the industry to satisfactorily address fatigue. A 'no blame' approach to incident reporting and investigation must also extend to fatigue issues.

Quite a few operations are using rotation of tasks as a fatigue control. This initiative has proved to be reasonable effective in some cases however due to the rapid expansion of the industry this has become increasingly difficult to implement. According to a CFMEU industry safety advisor; Rotation of tasks has been recently raised as a fatigue control when used in regard to extended shifts, but with current skill shortages this is becoming increasingly difficult to implement (Dalliston 2008).

The industry now accepts that fatigue is a major cause for concern regarding the safety of mineworkers and companies are now in the process of implementing fatigue management plans. The implementation of these plans varies considerably across the industry with the larger companies leading the way. Most fatigue management plans rely on the individual response to fatigue, however most individuals will have a diverse response to fatigue issues. So rather than just focusing on the individual causes, it's important to focus on the work related causes. In order to effectively address fatigue management it is important to complete appropriate risk assessments that concentrate on work hours and sleep opportunity. However since fatigue is such a major safety issue in the industry it would make much more sense to go back to the eight or nine-hour shift pattern and so avoid the issue of sleeping on the job.

The next chapter considers the problems associated with prosecution policies and their impact on the industry. CHAPTER 5

5 ACHIEVING COMPLIANCE THROUGH PROSECUTION

5.1 Achieving Compliance Through Prosecution The function of prosecution in achieving compliance with OHS legislation is a highly contentious issue in the mining industry. This is particularly so in New South Wales following the Gretley disaster where the Department of Primary Industries (DPI) has developed a new found enthusiasm for prosecution especially after a fatality. It decided to prosecute not just companies but also individual mine managers and other statutory holders.

The Departments prosecution policy (Mineral Resources (NSW) 1999), and the approach of the Investigation Unit charged with investigating serious incidents and fatalities, has precipitated a seething dispute between the New South Wales Mineral Council and major mining companies on the one hand, and the mine safety regulator and the trade unions on the other (Cunningham, Neil. 2007).

The companies believe that prosecution is counter - productive and inhibits appropriate safety investigation, moves away from a no blame culture, encourages a defensive rather than a proactive approach to OHS and drives away potential mine managers at a time of critical labour shortage.

''One of the most effective means of achieving sustained improvement in health and safety culture is to inculcate health and safety values and attitudes in future leaders and managers when they are in their youth. Unfortunately, one negative effect of the current 'automatic' prosecution policy of Work Cover / Minerals Resources is to discourage the young from entering mine management. Increasing numbers of future mining industry professionals are electing whilst they are still at university not to enter into mine management" (Calvin 2005). The introduction of the Occupational Health and Safety Amendment (Workplace Deaths) Act 2005 (NSW), introducing a higher penalty regime for workplace fatalities involving recklessness or intent, has added fuel to the fire. However on the other side of the debate the unions welcome these developments; they have been seeking prosecutions for some considerable time because they believe that the DPI has not been effectively applying the compliance policy and welcome the push to bring corporate law-breakers to account. The unions would like to see the regulator expand the use of prosecution to a far wider range of circumstances.

In Queensland and Western Australia the prosecution policies are not as strict and are not enforced to the same degree as they are in NSW, however signs are now emerging that the traditional 'advise and persuade' approach is in rapid recession. In consequence, many companies are watching anxiously, fearing that the new found enthusiasm for prosecution in NSW will infect their own states (Cunningham, Neil. 2007). On the other hand the mining unions urge that this is exactly what is needed to achieve improved OHS outcomes.

5.2 Prosecution Policies In the Moura Inquiry recommendations no mention was made of any charges being brought against BHP and its management, even though the company sent men underground in a highly dangerous situation. The mining union did not pursue legal action either.

In the Gretley case two companies and three managerial staff were prosecuted which was the first time in the history of coal mining in Australia where companies and staff had been prosecuted. In this case the inspectorate, urged by the unions, vigorously perused prosecution. The shift in policy has caused huge disquiet and controversy in the industry especially in management ranks. The subject of the difference between the two philosophies regarding prosecution at Moura and Gretley will be discussed later. 53 Prosecution for Offences in Occupational Health and Safety In New South Wales the inspectorate are actively pursuing a prosecution policy following a fatality. The following statement emphasizes the futility of the current prosecution policy.

It is fundamental that the criminal law must be administered in an appropriate fashion. The legislature has chosen to emphasise the importance of occupational health and safety matters by creating absolute offences. If the prosecution of offences is undertaken in an arbitrary, capricious and irresponsible fashion, the laws themselves are brought into disrepute for reasons that are obvious. This is especially so in the area of occupational health and safety prosecutions where it is the custom of the prosecutor to seek a moiety of the penalty, that is payment of one half of any amount imposed by way of a penalty" - Newcastle Wallsend Coal Company Pty Ltd v Inspector McMartin (2006) NSWIRComm 339, per Marks J. (Cunningham, Neil. 2007).

It would seem that there are two sides of disagreement regarding the highly contentious NSW prosecution policy. On one side is the NSW Mineral Council, which represents the mining companies, and on the other side are the inspectorate and the mining unions.

5.4 The NSW Mineral Council Position on Prosecution Policy The NSWMC argues that prosecution is counter productive, inhibits thorough safety investigation, which stimulates a defensive rather than a proactive safety culture.

"The automatic prosecution policies are now impacting negatively on the objective of reaching zero harm" (Calvin 2006). The reasons for this are as follows: • The lessons from serious incidents and accidents are not being used to prevent a recurrence of the incident or accident until many years after, because of legal privilege and the other considerations related to the pending charges. It creates a climate of distrust between the parties, which is in complete opposition to finding out what happened, why did it happen and what can be done to prevent a recurrence. • This policy does not encourage near miss reporting simply because the findings could be used against the company in possible future prosecutions. • Since recent prosecutions have not only targeted the companies concerned but individual duty holders it has become a major disincentive for young people to consider a management role in the mining industry. • It moves away from the no blame culture, which the industry must have if the safety of the mining industry is to continually improve.

This attitude promotes a defensive culture where the respective parties are encouraged to seek client privilege. To understand what "Client legal privilege" means in terms of finding out the facts regarding an incident or accident the following statement explains the situation:

" Documents produced for the purpose of obtaining legal advice or in the anticipation of possible prosecution may be subject to client legal privilege. This means there is a basis to say those documents do not need to be produced to the inspector or to a court or a tribunal'' (Humphrys, 2001)

Companies are advised by the legal profession to be very careful about generating reports about the incident or accident. Employees are encouraged not to write written documents in relation to accidents without the prior approval of the manager, because they may be damaging to the companies legal position and the legal position of its directors, managers and employees.

The prosecuting authority must prove its case beyond reasonable doubt. It is not for any company or individual facing prosecution to help prove the case against them. It is the inspector's responsibility to carry out the investigation.

Some companies will volunteer all relevant information and provide the inspector all the information the company has in its possession. Other companies may not wish to co-operate at all. In Queensland more and more companies ensure proper communication and co-operation with an inspector while at the same time managing the legal process and taking steps to protect the company's legal position of its directors, managers and employees.

5.5 The Unions Position on Prosecution Policy The mining unions agree with the developments regarding prosecution because they believe that they act as a deterrent to company law breaking and are actively encouraging the inspectorate to further expand the use of prosecution to a much wider set of circumstances. The mining unions are of the view that this prosecution policy is required in order to improve OHS in the industry. The enthusiasm for prosecution in NSW has become infectious because there are definite moves in Queensland to travel down the same path with pressure being put on inspectors to enforce prosecutions.

5.6 Trust Between Management and the Mines Inspectorate Mine operators and industry associations widely report that trust between themselves and the mining inspectorate is at an all time low (Wran & McClelland 2005). Managers in NSW who have the most contact with the inspectorate have indicated that prior to the prosecution policy being introduced the relationship between management and the inspectorate was very helpful and constructive. It is now strained and difficult. This about change is due entirely to the prosecution policy. Previously, management and the inspectorate have worked together to achieve a common goal, which was that of zero harm. The relationship has broken down and mistrust between the parties has destroyed the constructive interactions regarding compliance and improving compliance outcomes. Instead of working together to achieve a common goal the parties are working against each other. Put another way:

^e have a greater chance of efficient and effective regulation if we have a regulatory culture where (regulators and regulated) actually listen to each other and respect the concerns of the other; we have a lesser chance of cost-effective regulation if these two constituencies see their mission as to destroy the other, taking it in turn to win battles without either side winning the war (Braithwaite 1993). The industry needs to encourage open reporting, investigation and the creation of a safety culture that is just. Reason's ''just culture" emphasises that " valid feed back on the local and organisational factors promoting errors and incidents is far more important to safety than assigning blame to individuals" (Reason 1997,1998).

A small proportion of unsafe acts are egregious, and warrant sanctions, so what is needed is not a blanket amnesty on all unsafe acts but a just culture which generates " an atmosphere of trust in which people are encouraged, even rewarded, for providing essential information- but in which they are also clear about where the line must be drawn between acceptable and unacceptable behaviour" (Reason 1997, 1998).

British Airways Flight Crew Order 608 suggests that disciplinary action should only be taken against an employee where they have taken action or risks, which, in the company's opinion, no reasonably prudent employee with his/her training and experience would have taken (Reason 1997,1998).

5.7 Gretley Prosecutions Two years after the judicial inquiry into the 1996 Gretley disaster the NSW Government started the process of prosecuting the Newcastle Wallsend Coal Company, and its parent company Oakbridge Pty Ltd and several of its managerial staff. In 2004 at the NSW Industrial Relations Commission Justice Patricia Staunton handed down her judgment which found the companies and three of its managerial staff guilty of safety breaches under the Occupational Health and Safety Act.

The decision to prosecute senior officers of the company was not only a departure from previous practice in the mining sector but amounted to a new development in the direction of prosecutions under the Occupational Health and Safety Act 1983 .The ability to prosecute company officers has been present for a number of years and had mostly been used for officers of small companies who were directly involved in safety breaches. The Gretley proceedings represented a new move into prosecuting those involved in the overall management of a large company (Foster 2008). It can be assumed that it was this aspect of the proceedings, which led to a public outcry, by elements of the community supporting the interests of business owners and managers.

According to Smith (2005) Justice Staunton rejected the company's defences, finding that while the companies were entitled to rely on the Department of Mineral Resources (DMR) information as being accurate, this did not excuse them from their obligations to ensure a safe system of work. She said that two of the plans provided by DMR were seriously deficient in purporting to depict old workings in a way that one could be confident of their accuracy, and companies should have taken the step of ascertaining their accuracy. Justice Staunton also rejected the defence of the two surveyors, finding that they were concerned in the management of the corporation as well as the mine managers. She found that they had not established that they weren't in a position to infiuence the conduct of the companies, nor had they used due diligence to prevent the companies contravention of the act.

According to Mining Australia 2004 the outcome of the Gretley Inquiry was that mining convictions were imposed on the company and managerial staff, which is the first time in Australia where a company and managerial staff has been convicted for safety miss-management. Penalties were imposed on the operating company, owning company, first mine manager, second mine manager and the mine surveyor (Hopkins 2005). The penalties imposed on the various defendants were as follows; Operation company $730,000 Owning company $730,000 First mine manager $30,000 Second mine manager $42,000 Mine Surveyor $30,000

Penalties were not imposed on the Department of Mineral Resources (DMR). However according to the QC representing the dead miners families (Mining Australia 2004), both the mining company and the DME could have been convicted for being the "direct causes of the disaster." A formal investigation had found that the DME approved maps, which indicated that the abandoned mine was a 100m from where the miners broke through into the old workings, and ultimately perished.

The question that the recommendation regarding prosecutions poses is that if the companies and management are to be prosecuted then why not the Department of Mineral Resources? This was shown to be the case when Justice Staunton recommended that the evidence of his inquiry be referred to the Crown Solicitor to determine whether Newcastle Wallsend Coal should be prosecuted for offences under the Occupational Health and Safety Act. There was no suggestion of criminal charges for causing the deaths and no mention of the Department of Mineral Resources. According to CFMEU president:

" It's the first time in the 200 year history of the NSW coal industry that anyone has been convicted for the loss of life despite more than 3000 miners being killed in the States coal mines'" (Maher 2004).

It is interesting to note that the second tribunal mentioned earlier was not completed until August 2004 nearly eight years after the incident and over six years after the first tribunal was completed. The CFMEU criticized the Government for not prosecuting the DMR and have stated that there is a lack of regulatory protection for the growing number of contract workers within the mining industry (Mining Australia 2004). Industry studies indicate a connection between a lack of safety in coalmines and the growth of contract employees in the coal mining industry. According to the CFMEU, contractors are favoured by mining companies over full time employees because they are cheaper and many contract workers are non-union orientated. Also safety standards for contractors were lower than full time company employees since they receive much less training and induction for safe operating.

The new owner of Gretley is Xstrata, which is a Swiss conglomerate mining company who were responsible for paying the $1.6 million fine, and have subsequently challenged the validity of the Health and Safety Laws that provided for the Gretley criminal convictions. This action was seen as being very provocative by mining unions. The victim's families asked the company to drop its challenge to the validity of the Health and Safety laws that provided for the Gretley criminal convictions. The Miners Union General President said that Xstrata's challenge has provoked enormous resentment among rank and file mineworkers.

"Our members demand the right to the fiill protection of the law when they go to work. Mining companies have to accept that if their negligence results in death or injury to workers then they will be held to account. Our members cannot be expected to work in the most dangerous industry in the world without the full protection of the law" (Maher 2005). hi December 2006 a Full bench of the NSW Industrial relations Commission overturned the previous conviction by a single Judge, Staunton J, that the surveyor at the Gretley mine was "concerned in the management of the Corporation" and therefore guilty of an offence under the Occupational Health and Safety Act 1983. The decision re-affirmed the guilt of the two mine managers and the two companies concerned in the management of the colliery (Foster 2008).

However the penalty imposed on the mine manager who had not been actively involved in the company at the time of the inrush was effectively overturned. The court applied the provisions of the law not to enter a criminal conviction against that mine manager. One reason for this was the "justifiable sense of grievance" experienced where one of those parties responsible for the incident (here, the NSW department which had provided misleading maps) had not been prosecuted. However Justice Marks disagreed with other members of the full bench regarding the sentences that should have been imposed and went on to make some comments which were subsequently widely reported in the media and which were highly critical of the prosecution process. He said "more than prosecution... amounting to persecution'' (Foster 2008).

From the discussion on the analysis of Moura No2 and Gretley disasters it has been demonstrated that they have similar management failures. This thesis will now investigate the different types of inquiry used for both of these disasters since the outcomes of these inquires have had a profound impact on safety in the coal mining industry both in Queensland and New South Wales.

5.8 Moura No 2 Inquiry Process It is appropriate to first consider how the Moura No2 disaster inquiry was undertaken. The investigation into the accident was conducted by a Warden's Court of Inquiry. In conjunction with the Mining Inquiry, a Coronial Inquiry was conducted by the Mining Warden in his capacity as Coroner. The Wardens inquiry was governed by the following legislation, {Coal Mine Act 1925) S74: 1. Unless otherwise determined by the Minister, in every case of accident causing death or serious bodily injury, an inquiry into the nature and cause of such an accident shall be held before the warden and four persons having practical knowledge and skill in the mining industry selected by the warden and having no connection with the coal mine where the accident occurred. 2. In every case of an accident causing death or serious bodily injury, the warden shall at least 4 days before such an inquiry is held, send notice of time and place of holding the inquiry to all appropriate parties. 3. The warden shall forward to the Attorney- General the notes of evidence taken at such inquiry and in the opinion of the persons having practical knowledge and skill in the mining industry (who shall record their findings as to the nature and cause of the accident, and make such recommendations as appear to them necessary for the prevention of similar accidents), and the warden's report as to the nature and cause of such accident, and shall forward a copy of same to the Minister. The warden shall announce the findings at the conclusion of the inquiry. 4. The evidence taken at the inquiry held under this section may, if the Minister thinks fit, be submitted to a Board of Examiners; and if it appears to such a Board from such evidence that the accident was caused directly or indirectly by the non observance by the holder of any certificate, licence, or permit under this Act of any of the provisions of this Act, or by reason of the holder's negligence, such Board may require the holder to show cause why his or her certificate, licence, or permit should not be suspended, cancelled, or otherwise dealt with. 5. Every person so required to show cause shall, when called upon, appear before the warden, who shall hold a further inquiry into the conduct of such person. 6. If such a person fails to appear, or such Board finds after such further inquiry that the person has been guilty of any offence against this Act or of any negligence or misconduct, such Board may disqualify the person by cancelling or suspending the person's certificate, licence, or permit, or, if such certificate or licence was granted by an authority outside the state, by cancelling or suspending the approval thereof for such period as such board thinks fit; and during the period of disqualification the person so disqualified shall be deemed not to hold a certificate, licence, or permit. For all the purposes of an inquiry under this Act, the warden shall have the power of a warden's court.

Pursuant to section 74 of the Coal mining Act 1925, an inquiry into the nature and cause of the accident was convened at Gladstone before the Mining Warden and four persons having practical knowledge and skills in the mining industry who were not connected with the coal mine where the accident occurred.

The inquiry sat for thirteen weeks and heard evidence from sixty-six witnesses who were examined as indicated in the following inquiry structure. A total of three hundred exhibits which included plans; reports, graphs and letters were tendered. The transcript from the evidence comprised 5200 pages.

The Warden's Inquiry Structure is as follows: • The structure is similar to Coronial Proceedings, • The process is inquisitorial as opposed to adversarial. All witnesses were asked detailed and searching questions, • Appearances o Council Assisting, o Council for the Parties, • The questions asked by the council assisting were of an investigative nature. Whereas the questions asked by the Council for the respective parties was of a protective nature. • Each witness was examined under oath, • Expert witnesses gave evidence at the inquiry, • Evidence in Chief, o Was determined by the questions asked by the Council Assisting, o Statements made in court during the proceedings and the report compiled by the four panel members. • Cross examination by all the parties, • Examination by the panel members, • Examination arising from questions from the above mentioned people.

At the time of the inquiry, the inquiry process was fragile because the Act did not provide for continuity of the inquiry should any one or more of the panel be unable to continue their role. The Act was subsequently amended to accommodate this deficiency.

5.9 Gretley Inquiry Process In NSW the incident or accident is investigated by a court process, which is held before a Judge. According to the Coal Mine Regulation Act s95 the Court process is as follows: • The Minister may direct a court to hold an investigation for ascertaining the causes and circumstances of an accident or determining the effects of a practice. The Report to the Minister must state the causes and circumstances; or the findings relative to practice; and add any observations, which the court thinks right to make. Where show cause actions or appeals are involved Assessors must be appointed to assist the Judge. In other actions they must be determined by the rules of the court. The Assessors have the power to advise but not to adjudicate, they are not required to make findings or recommendations.

5.10 Differences Between the Moura No 2 and Gretley Inquiries The differences between the Moura and Gretley Inquiries is shown in Table 5.1. This table illustrates the essential differences in procedure between inquiries held in Queensland and New South Wales.

Table 5.1 Differences between the Moura No 2 and Gretley Inquiries. Moura Gretley Unless the minister otherwise If Minister Directs determines Before a Magistrate (Warden) Before a district Court Judge Panel required to make findings and Panel advisory only recommendations

Possible for subsequent proceedings No subsequent proceedings except before a Board of Examiners (BOB) appeal to a higher court

Constrained jurisdiction Broad jurisdiction

The main difference between the two Inquiries is that in the case of the Moura Inquiry the purpose was to determine the "nature and cause" of the accident and for the panel to make findings and recommendations. Prosecutions were not sought, which allowed a free flow of information between all parties that enabled the Warden to complete the findings and produce a report that contained recommendations. These recommendations have dramatically changed the way safety is managed in both Queensland and New South Wales. The Moura panel assisting the warden consisted of individuals with extensive experience in coal mining, who after examining all the evidence and the witnesses were able to make sound recommendations based their findings. The findings and recommendations were produced one and a half years after the accident happened, see Table 5.2.

The Gretley Inquiry on the other hand with a totally different approach which involved prosecutions and took over eight years to finalise (Table 5.2). The total length of time to complete this inquiry was seven years longer than the Moura hiquiry. The reason for this significant length of time as previously stated was due to the prosecution of companies, managers and other duty holders. This process encourages all parties to use legal privilege and thus prevent vital information that would help to prevent accidents from coming out.

One of the reasons for this is that it's a judicial process where a Judge hears evidence where the prospect of a prosecution can limit the free flow of information due to legal privilege. The Judge can have individuals with experience in mining to assist him however those individuals are not allowed to make recommendations, that is the responsibility of the court. This process takes too long to get the final outcome of an investigation and legal privilege is the main reason. This aspect will be discussed in more detail and demonstrate how the Queensland Warden Court system is much more efficient in dealing with the outcomes of investigations and making recommendations to prevent a recurrence. Table 5.2 The Time Taken to Complete the Moura and Gretley Inquiries Accident Date of Date of Time to Complete Accident Findings hivestigation Moura August 1994 January 1996 1.5 years Gretley November 1996 August 2004 7.75 years November 1996 Final Decision 8.5 years May 2005

Having established the differences between the two inquiries and the time taken to complete them, the thesis will now investigate the following outcomes in order to make comparisons in the terms of time taken to complete them. The reason for this approach is that the quicker the outcome of a case, the quicker the lessons are learned in order to prevent a recurrence: • Outcomes from the Queensland Wardens Court from November 1998 to March 2001; • Prosecutions in NSW from August 1995 to April 2007; • Findings of the Coroners Court in Queensland from December 2002 to March 2007.

5.11 Outcomes of the Queensland Wardens Court from November 1998 to March 2001 The outcomes of the Wardens Court will be examined between November 1998 and the last case in March 2001. The purpose of the Wardens Court was to determine the nature and cause of the accident without the fear of prosecution. It may be observed from Table 5.3 that it took between 3 to 12 months to complete an investigation and the average time taken to complete the thirteen investigations was six and a half months. Therefore the lessons learned and the recommendations were available for all parties in the industry some six and half months compared to eight and a half years at the Gretley Inquiry. Table 53 Outcomes of the Queensland Wardens Court from November 1998 to March 2001 Date of Injury Type Location of Date of Time Taken Accident Accident Findings Months 22 March 2000 Serious Injury Goonyella 8 March 2001 12 Riverside Mine 30 August 2000 Fatal Cook Colliery 1 March 2001 6 26 May 2000 Fatal Oaky No 1 mine 9 November 5 2000 15 March 2000 Fatal Jellinbah mine 24 August 2000 5 22 May 1999 Serious Injury Laleham U/G 24 February 11 Mine 2000 20 January 1999 Serious Injury Oaky No 1 Mine 29 October 1999 8 4 May 1997 Fatal Blackwater O/C 3 December 6 1997 5 November Fatal Laleham U/G 3 September 10 1996 Mine 1997 19 September Fatal Oaky No 1 Mine 27 March 1997 6 1996 31 December Fatal Moura O/C 12 April 1994 4 1993 19 December Fatal Goonyella 30 April 1992 4 1991 Riverside Mine 18 August 1988 Fatal Collinsville No 15 November 3 2 Mine 1988 6.67 Average

5.12 Prosecutions in NSW from August 1995 to April 2007 In response to the Mine Safety Review in 1997 and the Gretley Inquiry the New South Wales Government established the NSW Department of Primary Industries Investigation Unit in order to improve mine safety and promote changes to safety culture in the mining industry. The Unit has the power to investigate accidents and incidents in any part of the NSW mining industry. It has the power to determine the nature and cause and circumstances surrounding an accident or incident and can investigate matters on site off site including equipment suppliers, manufacturers and other people relevant to the accident and it can recommend prosecution if appropriate. The unit is separate from the inspectorate and reports to the Director-General on all matters relating to the investigation. The Inspectorate report the occurrence of serious accidents and incidents to the Investigations Unit (www.dpi.nsw.gov.au/primefacts).

The Investigations Unit has from August 1995 to April 2007 documented fifty-three decisions and there have been 38 successful prosecutions resulting in conviction. Of these decisions 73% of the prosecutions involved a fatality. About 20% involved serious bodily injuries and 7% dangerous occurrence.

In order to obtain a comparison between the time taken to complete an investigation under the Queensland Wardens Court system and conduct investigations with prosecution in NSW coal mines it is necessary to examine Table 5.4. It may be observed that from August 1995 to April 2007 thirteen coal mines were involved in prosecutions. The time taken to complete these investigations ranges from 3 to 6.8 years and the average time taken to conduct each investigation is over four and a half years. Table 5.4 Prosecutions in NSW Coal Mines from August 1995 to April 2007 Date of Injury Type Location of Date of Time Taken Accident Accident Findings In Years January 1996 Serious Bodily Coal Cliff August 1999 3.5 Injury Colliery April 1996 Fatal Berrima Jan 2001 4.75 Colliery January 1997 Fatal Dartbrook November 6.8 Colliery 2003 November Fatal United November 6 1997 Colliery 2003 July 1998 Fatal Awaba November 6.3 Colliery 2004 May 1999 Dangerous Wyee Colliery May 2006 6 Occurrence July 1999 Fatal Cooranbong Nov 2003 4.3 Colliery July 1999 Serious Bodily United March 2005 5.66 Injuries Colliery July 1999 Fatal Tahmoor September 3.1 Colliery 2003 August 1999 Fatal Cumnock No 1 June 2004 4.8 Colliery February 2003 Dangerous Glennies Creek June 2006 3.33 Occurrence Colliery November Fatal Kayuga Mine February 2007 3.2 2003 May 2004 Fatal Mount Thorley April 2007 3 4.67 Average If it takes over four and a half years to complete an investigation the lessons learned are too late to prevent a recurrence of similar occurrences. An example is the may 2004 explosion at BHP Billiton's Boodarie Hot Briquette Iron Plant at Port Headland Western Australia, killing the shutdown coordinator and seriously injuring two other employees (Moore 2006). • Making public the results of inquiries into Piper Alpha and the Longford disaster in Victoria helped improve safety procedures; • Two years after the accident no lessons to the public have emerged on how safety can be improved; • The delay is due to the dual effects of legal privilege and legal process.

In discussion with industry personnel it has been said that that some law companies are advising their clients to use lawyers to undertake incident investigations to use "legal privilege" to protect any information gleaned. In June 2006 BHP pleaded guilty for failing to provide for a safe working environment and was fined $ 200,000 and had to pay $58,000 in costs. Because BHP pleaded guilty it ensured that information gleaned from investigations into the Boodarie explosion never made it to the open court and therefore did not become public knowledge. Safety Institute of Australia President Gavin Waugh suggested that the Boodarie incident highlighted a lack of transparency in WA.

Janine Freeman of Unions WA said companies should not be allowed to hide behind the law to avoid their occupational safety and health responsibilities.

Companies should not be adopting a blame culture and if companies hide behind legal privilege then they undermine the effectiveness of safety in the workplace and should not be used for restricting access to accident reports. "Actions to conceal information through manipulating process always leads to mistrust and a backlash which inevitable results in more prescription''

The death at Boodarie was one of three, which occurred at BHPB facilities within weeks of each other. In response the WA Government set up an independent inquiry headed by barrister Mark Ritter who issued BHPB with 21 recommendations to improve safety at Boodarie. The Ritter report will be the subject of further discussion later in this thesis.

Dr Andrew Hopkins who wrote the Lessons from Longford Gas Explosion was asked by BHPB to conduct an investigation into the Boodarie incident. When BHPB were approached regarding this investigation and the impact of the lessons learned they said that the Hopkins Report was produced under legal privilege and therefore not available.

5.13 Findings of the Coroners Court in Queensland from December 2002 to March 2007 In March 2001 the Wardens Court in Queensland was abandoned and replaced with a Coroner's Court. The prosecution philosophies of NSW are gradually being adopted in Queensland. In order to make a comparison of the Warden's Court and the Coroner's Court in terms of time taken to complete an investigation Table 5.5 has been compiled.

This table shows the findings of the Court between December 2002 and March 2007. It can be observed from Table 5.5 that the length of time taken to complete the investigations ranges from one to three and a half years and the average for the 10 investigations is well over two years. This is due to legal process and prosecution initiatives, which means that it's over two years after the accident before the court can make recommendations, which will allow lessons to be learned in order to prevent a recurrence. Table 53 5 Findings of the Coroners Court in Queensland from December 2002 to March 2007 Date of Injury Location of Date of Time Taken Accident Type Accident Findings In Years March 2007 Fatal Moranbah Ongoing North Mine February Serious Broadmeadow February 2 2006 Injury Mine 2008 December Fatal Cannington Ongoing 2006 Mine February Fatal Century Mine May 2006 2.25 2004 July 2004 Serious Goonyella January 2008 3.5 Injury Riverside Mine August 2004 Fatal Highway July 2005 1 Reward Mine October Fatal Mayne River February 2.3 2004 Mine 2007 November Fatal Mount Norma December 2 2004 Mine 2006 August 2005 Fatal Foxleigh March 2007 1.7 September Fatal Dawson Mine December 2.25 2005 2007 October Fatal Rockhampton/ November 3 2005 Yeppoon HAV 2008 December Fatal Highway November 2 2002 Reward Mine 2004 2.2 Average

According to (Braithwaite 2002) in British pits it was found that companies "not only thoroughly involve everyone concerned after a serious accident to reach consensual agreement on what must be done to prevent reoccurrence but also did this after 'near accidents' as well as discussing safety audits results with workers even when there was no near accident"

He concludes; After mine disasters, so long as there has been an open and public dialogue amongst all those affected, the families of the miners cared for, and a credible plan to prevent recurrence put in place, criminal punishment served little purpose. The process of the public inquiry and helping the families of the miners for whom they were responsible seemed such a potent general deterrent that a criminal trial could be a gratuitous and might corrupt the restorative justice process that I found in so many of the thirty-nine disaster investigations I studied. (Braithwaite

2002).

5.14 Issues with the Prosecution Policies In Australia up until the Gretley prosecutions there was a free flow of information between all parties and information was shared. That has now changed because of legal process and privilege. A good example of this deterioration is demonstrated in this example:

In January 2003 a contractor was crushed by a fall of equipment at Kayuga Mine in NSW. The company was prosecuted for failing to ensure that employees of Muswellbrook Crane services working at the site were provided with or maintained a safe system of work, and for not carrying out a proper evaluation of the risks associated with the task. At the time of the incident only two company employees and 250 contractors were on site. Some of the company systems for managing contractors were not in operation at the time of the incident and there was also a failure to conduct a proper risk assessment of the work to be performed. Muswellbrook Crane Service was prosecuted for failing to identify and assess the risks involved.

During a personal discussion with a senior safety person connected with the incident, who has requested anonymity, expressed concern at how the company investigation process was carried out. At the investigation the following organisation representatives were present: • Mines Inspectorate • Mines Investigation Unit • Union / Employees • Contracting Company • Kayuga Management

Each of the above mentioned personnel had legal representation. At the investigation no one would talk to each other because of legal privilege and the question of finding out what happened, why did it happen and what can be done to prevent a recurrence was a non-event. The company did not share their findings with the investigation unit. The aforementioned safety person connected with the incident was extremely frustrated by the whole process.

The company did its own investigation and a report was produced, however it was not available to company employees in order for them to learn the lessons from the incident and so help prevent a reoccurrence. No one was allowed to discuss the incident and the report was locked away. The reason given for this approach was that it had been done to protect the company. This was because the company lawyers needed to protect the company. It is called legal privilege.

5.15 The NSW Investigation Unit In NSW the inspectorate have the power to call in the Investigation Unit (lU) to investigate High Potential Incidents. Companies have started to investigate their HPI in order to learn the lessons from these incidents. However as soon as the lU gets involved the information is locked up because of the issues of legal process and privilege. This process also extends to audits made by the companies. Most quality management systems have at the very basic level three components: • Plan • Check • Act Therefore if consideration is given to the three basic things we do to learn the lessons from any incident: 1. Inspect 2. Audit - subject to legal privilege 3. Investigate - subject to legal privilege.

When conducting audits and investigations which are subject to legal privilege, how is it possible to gain the root causes of accidents and incidents when companies are advised to withhold information that would not allow lessons to be learned because of legal privilege?

The whole essence of any safety investigation is finding out what happened why did it happen and what is to be done to prevent a recurrence. This approach is being jeopardised due to legal process and privilege, this is demonstrated in the following disturbing incident, which occurred recently.

On the 17'^ of January 2008 an employee of a contractor was killed underground at BHP Billiton Cannington Mine, which is south east of Mount Isa. The Minister for Mines, Geoff Wilson, said that: "My Department has advised me that mines investigators were prevented from accessing the scene of the fatal incident and speaking to witnesses and other employees for a full 24 hours after the incident occurred" {Minister demands answers on investigation delay 2008).

He went on to say that after meeting with BHP Billiton he remained concerned that there was an unacceptable delay in vital information being provided to the mines inspectorate. He also said that it is the mining company's responsibility to ensure that investigators have enough information to do their work, finding out what happened, why did it happen and how similar incidents can be avoided in the future. In this case, that didn't happen. The Ministers final comment was:

"There is no excuse when those in control of a mine site fail to provide the basic particulars of a fatal incident at the mine for more than 24 hours". 5.16 Discussion The mining industry has made some significant improvements in safety performance due to the companies, unions and the inspectorate working together to achieve a common goal of safety improvement and thus zero harm. Since the Gretley prosecutions this working harmonious relationship has deteriorated to the detriment of safety improvement in the mining industry.

The lessons from incidents are not being learned due to the fear of being prosecuted, which creates a climate of distrust between the parties. Companies are encouraged to seek client privilege and near miss reporting is being affected because the findings could be used against the company in future prosecutions. Audits and high potential incidents are also subject to prosecutions, which lead to lock up of vital information in order to prevent recurrence. More importantly it promotes a defensive culture and moves away from one of the most important parts of any safety improvement programme that of a no blame culture.

The conviction of companies and managers sends a message that, where the lives of many workers are at high risk from known hazards, companies need to be very careful in planning and executing work, and to be mindful of the consequences if they do not. According to Cunningham (2007), achieving a balanced approach to prosecution is not easy. On one side the evidence suggests the extreme 'advise and persuade' policy that Queensland and Western Australia inspectorates have favoured will possibly fail to send appropriate signals to the recalcitrant. On the other side the tough prosecution policy that New South Wales has applied to fatalities will also fail in preventative terms. The Cretley decision demonstrating the vengeful prosecution against those who neither intended harm nor were reckless in their behaviour is considered unjust, and this has caused the law to lose its legitimacy in the eyes of duty holders.

The CFMEU have been critical of the NSW Covemment for not prosecuting the DMR in the Cretley inquiry and stated there is a lack of regulatory protection for the growing number of contract workers within the mining industry. They expressed concern that the safety standards for contractors was lower than full time employees since they receive much less training and induction for safe operating. Since contract workers now make up a large percentage of the workforce this is a major problem facing the industry.

The differences in the philosophy adopted at the Moura and Gretley inquiries have

been discussed in some detail, which have highlighted the impact these outcomes

have had on the mining industry. The main differences are:

• In the case of Moura the purpose was to determine the nature and cause and

for the panel to make findings and recommendations.

• hi the Gretley hiquiry the purpose was to find the cause of death and ascertain

the case for prosecutions.

It can be observed from the text that the Moura Inquiry was completed and the report published within one and a half years after the accident. However the Gretley Inquiry took eight and a half years to complete and in the process changed the industry safety culture throughout the mining industry.

A comparison of the time taken for the investigations in the Wardens Court in Queensland from November 1998 to 2001, the Prosecutions in NSW from August 1995 to April 2007 and the Coroners Court in Qld from December 2002 to March 2007 is shown in Table 5.6. It can be observed that the average time taken for the Wardens Court was just over six and a half months compared to over four and a half years in NSW and over 2 years in the Coroners Court in Queensland.

One would have to conclude that the Wardens Court is not only more efficient in its process, but because there is no fear of prosecutions, it is able to find out what happened, why it happened and what needs to be done to prevent a recurrence without the fear of the legal process and legal privilege. Instead of information being locked up, the Warden's Court outcomes allows for free flow of information where lessons can be learned and trust between all parties can be restored. Table 5.6 Comparison of the Time Taken to Conduct Inquiries Wardens Court in Nov 1998 to Average Time 6.67 Months Qld March 2001 Taken for the Inquiry Prosecutions in Aug. 1995 to April ii 4.67 years NSW 2007 Coroners Court in December 2002 to ii 2.2 years Qld March 2007

The NSW Mineral Council made the following comments in its submission to the review of the OHS Act 2000 (Williams 2005) regarding the prosecution of the mine manager who had recently been found guilty by the Full bench of the Industrial relations Court despite the Court finding that: • He took up his position just months before the collapse of the roof of a mine he was managing; • He had limited opportunity to become completely familiar with the mine and its operations; • He carried out underground assessments and did not notice anything untoward in respect of the state of the roof; • He attended conscientiously and diligently to all his safety responsibilities in the period before the incident; • He found nothing in the reporting system that alerted him to a risk arising from the instability of the roof; and • He was not involved in the critical planning stages where decisions were made about assessment procedures.

The mine manager would be subjected to the possibility of a term of up to two years imprisonment if he had had a prior conviction. Mine managers are now simply unwilling to place themselves 'in the firing line' where prosecutions can occur for acts or omissions outside their control and in spite of their best efforts. This issue was discussed in the introduction to this chapter (Galvin 2005). The Prime Minister John Howard called on State Premiers to support him in reforming occupational health and safety laws that apply to the mining industry. The Prime Minister declared that the existing laws are imbalanced and unfairly target mine managers. State laws are inhibiting productivity by effectively scaring off prospective senior staff and that the laws need to be overhauled to reflect a "sharing of the burden" (Howard 2006).

With regard to offences involving recklessness being treated as a criminal offence it is interesting to note the following comment contained in the Robens report: "We recommend that criminal proceedings should, as a matter of policy, be instituted only for infringement of a type where the imposition of exemplary punishment would he generally expected and supported by the public. We mean by this, offences of flagrant, wilful or reckless nature which either have or could have resulted in serious injury" (Robens 1972).

It January 2008 BHP Billiton (BHPB), one of the largest mining companies in the world prevented mine investigators from accessing the scene of a fatal accident and speaking to witnesses and other employees for a full 24 hours after the incident occurred. The Minister for Mines in Queensland had to call a meeting with BHPB in order for them to cooperate. He said after the meeting, that he remained concerned that there was an unacceptable delay in vital information being provided to the mines inspectorate. This is a classic example of "Disconnect" between what corporate management want and what is achieved at the mine site.

It is a well-known fact that in the event of a fatal accident the Chief Executive Officer or his immediate subordinate is one of first persons to know about a fatality. One can only assume that the company acted in this way to protect the company due to the fear of litigation. This kind of behaviour has no known precedent in Australia. One month after this incident the company in February 2008 settled out of court to the tune of $300,000 after two workers were seriously injured at the Goonyella Riverside mine. The company had been charged with neglecting its duty of care obligations under Queensland's Coal Mine Health and Safety Act 1999. BHP has incurred two fatalities in WA and one in Qld in 2008. In preventing these fatalities there is a need to have open honest dialogue instead of protecting the company's interest for fear of prosecution.

To conclude this chapter it must be stated that if prosecution policies continue, valuable information which could help prevent accidents and incidents will be lost to the detriment of attracting mining engineers into mine management positions and improving safety in the Australian mining industry. One way of preventing this from happening would be for the industry to adopt the no blame culture and move to a system like the Wardens Court in Queensland where there was a free flow of information without the fear of prosecutions. The findings and recommendations are completed in a much shorter time frame which means that the lessons learned are available more quickly than the current outcomes in both Queensland and New South Wales with a consequent positive outcome for safety improvement.

In respect for the need for prosecutions, where they might arise, it seems that above recommendation from the Robens Report makes eminent good sense.

The next chapter will discuss the issues of "disconnect" and its effects on safety management systems and how it affects safety performance. "Disconnect" is an issue that arises directly from matters discussed in this chapter and is of considerable concern to the industry because of its potential impact on safety performance.

CHAPTER 6

6 THE "DISCONNECT" OF SAFETY MANAGEMENT SYSTEMS.

6.1 The "Disconnect" of Safety Management Systems This chapter investigates the literature regarding the issues of 'disconnect', which has been the cause of some considerable concern with stakeholders regarding Safety Management Systems and their impact on safety improvement in the mining community. The 'disconnect' of safety management occurs when what is planned to be done, in the documented OHS management system and what is actually achieved at the work place differ. It is also described as the difference between what corporate officers want and direct should happen and what actually happens on the coalface.

This concern regarding the apparent 'disconnect' between company management systems, plans and the translation of such systems and plans to the working level and their effective implementation will be considered in some detail. The following documentation will be analysed because of the impact it has had on safety performance in the Australian Mining Industry: • The Ministerial Ritter Report {Ministerial Inquiry: Occupational health and Safety Systems and Practices of BHP Billiton Iron Ore and Boodarie Iron Sites in Western Australia and other matters 2004) into mine safety practices at BHP Billiton Iron Ore and Boodarie Iron (BHPBIO) Sites in WA and;

• The Wran Mine Safety Review and its Implications (Wran & McClelland 2005). 6.2 The Impact of Disconnect associated with Safety Management Systems in Western Australia In order to come to terms with the issue of 'disconnect' the inquiry into the fatalities at BHPBIO will be examined in some detail. In response to three fatalities at BHPBIO sites in May 2004 the Minister for State Development in WA set up a Ministerial Inquiry headed by Mark Ritter into the occupational health and safety systems and practices of BHPBIO sites and related matters. The purpose for this inquiry was to ensure that the Minister was fully informed as to the occupational health and safety systems and practices, with a view to determining what action may be necessary in order to improve OHS safety performance at BHPBIO sites and across industry generally.

This Inquiry was reliant upon co-operation of all the participants and in the region of 200 entities (both government and private) and individuals have contributed to the Inquiry by providing written and oral submissions and participating in meetings and private and confidential interviews.

Western Australia is one of the world's major iron ore producers and in 2003 it produced 17% of the worlds iron ore. It also achieved a new export record of 172Mt valued at $5.2 billion in 2003.

BHPBIO operate six open cut mines in the Pilbara region, five of which are operated by contract mining companies, and Boodarie Iron operates the iron ore plant in Port Hedland, which produces iron ore briquettes. The total workforce employed for these operations is 5,831, which includes 3,625 contractors which means that contractors make up 62% of the workforce. Approximately 80% of the workforce at BHPBIO are engaged under individual contracts of employment. Of this, 45% are engaged under common law contracts and 35% under Australian Workplace Agreements (AWA's). Management and administration are employed under common law contracts and those employees who are employed under AWA's are employees who would otherwise be traditionally covered by award classifications. Approximately 20% of employees are employed under union collective arrangements or award classifications. 6.2.1 Employee Workplace Agreements There are differing contractual arrangements between each of the contract miners and the workforce who work at the mine sites not operated by BHPIO. However the decision by BHPBIO to offer employees workplace agreements which were introduced in 1999 as a means of improving business efficiency and productivity caused some major issues for health and safety which culminated in litigation in the Federal Court. BHPBIO were successful in winning the right to implement AWA's. The decision did not mention that there were possible implications for OHS arising out of changing workforce relations and the industrial conflict, which may occur, which is exactly what happened. The Ritter Inquiry made the following comment:

It is sufficient to say at this stage that the Inquiry is of the view that the introduction of workplace arrangements has led to issues between management and the workforce with implications for the implementation of occupational health and safety systems and that this has not been adequately addressed by BHPBIO.

This subject will be discussed later when trying to communicate the corporate visions, policies and standards in this thesis because of the industrial disputation and its effect on safety improvement. In a safety feed back survey in which the total number of responses received was over 2400, according to the Ritter Inquiry 30% of recipients believed that the business does not put safety before production

622 Corporate Visions Policies and Standards When trying to communicate the corporate visions, policies and standards to the workforce the President of BHPBIO likened the process to a body of water that cascades down a waterfall and for successful implementation, needs to carry people and information with it and reach and be "lapped up" by the sites further down the body of water. If the health and safety systems are not taken up by the sites, then there is an element of 'spillage'. The 'spillage', which occurs, will have an impact upon the understanding and implementation of safety policies, visions and standards at sites and if there is a substantial amount of spillage it will substantially undermine the effectiveness of the systems. This spillage is another way of describing the "disconnect" of safety management systems.

The inquiry conducted 154 confidential interviews, which were conducted on a voluntary basis. Some employees were fearful of repercussions if it was known that they had been interviewed by the inquiry. At a few of the contractor operated mines no one came forward for an interview despite the fact that they lived in Newman where they would have ample opportunity to attend. The Inquiry spent three days interviewing people at the Yandi mine, which proved to be an intensive exercise, due to the number of people that wished to be interviewed. In excess of 30 people were interviewed and almost all of them were concerned about the occupational health and safety systems and practices at the mine.

6.23 Mt Whaleback Mine The Mt Whaleback is operated by BHPBIO and is their oldest mine and therefore it is the mine in which BHPBIO can most directly influence the implementation of OHS systems and practices. In the most recent audit in 2004, this mine achieved the best score of any BHPBIO operation. As mentioned previously this mine has changed from having an award-based workforce to one that has the majority of its workforce being none-award employees. " It is apparent from discussions the Inquiry has had with BHPBIO management and award employees at Newman, that there are some elements of distrust, rather than trust between some of the management and some of the award workforce".

Management changes to OHS are treated with suspicion by some award employees. On the management side objections to changes in OHS are treated with suspicion by some elements of management because of the union's industrial relations campaign opposing individual contracts. There was concern expressed regarding the role of trade unions and the impact this industrial situation was having on worker involvement in safety management systems. In regard to relationships between industrial relations and OHS reform Bohle et al. (2000) said: might be suggested that participatory mechanisms avoided by OHS laws and the shifting focus of industrial relations provide opportunities for innovative workplace reform that enhance productivity and employees health and wellbeing. However this requires real commitment and planning by all parties. It also requires a regulatory framework that encourages trust by ensuring genuinely representative negotiations, the maintenance of minimum standards and notions of equity. Without these prerequisites there is a real danger that workplace reforms may undermine OHS performance rather than enhancing it".

6.2.4 Employee Employer Relationships In any workplace for safety improvement it is absolutely vital that individual workers are encouraged to raise occupational health and safety concerns and if necessary refer them to an effective regulator in order to assist in resolution. It was the opinion of the inquiry that the existence of award employees at Mt Whaleback will continue to create problems because of the ongoing employee employer relationship. This is because the employees know that BHPBIO have a preference for individual contracts rather than award employees. There is also a risk that middle management will be anti award employees because senior management prefer if award employees were no longer engaged by the employer. This state of affairs will have an impact on communication relationships, which will create a climate of mistrust, which will have effects on the implementation of safety systems and practices.

The evidence given in the 2004 decision of the WA Industrial Relations Commission to vary the award supports this view. It was claimed by some interviewees that AW A employees receive bonus payments, which are discretionary. It was further suggested that there was a perception that people who get the job done, without fuss, are rewarded and paid their bonus. However people who raise OHS matters may not be seen to be team players and therefore not paid their bonus. It was also suggested that some members of management believe that award people who raise OHS issues see them as industrial relations issues and therefore do not treat them seriously. 6.25 Issues Raised at the Ritter Inquiry At Mt Whaleback Mine the following issues were brought to the attention of the inquiry. These issues were raised generally by award employees and are detailed below; • Speed Limits: Speed limits being changed without consultation with the health and safety committee and speed limits were not policed and practically ignored, unless an accident occurred; • Spotters: These are used to assist dump truck drivers to dump their load when safety is an issue. BHPBIO have wanted to move spotters at Mt Whaleback and give the responsibility to the driver- this has been resisted by several employees on the grounds of safety; • Safety and Health Representatives and Committees: There was concern regarding BHPBIO wanting to reduce the number of safety and health representative on each shift and that attendance by management at safety and health committees was also an issue. The frequency of meetings in some areas was in question. • Working at Heights: A number of people raised the issue of working at heights in the mobile workshop since there are specific hazards, which have been noted given the size of mobile plant, which the workers are required to work on. This has been acknowledged by BHPBIO to be an issue. • Apprentices and Training: The lack of training given to apprentices was said to be an issue and that training had been reduced compared with what used to be the case some years ago. • Contract Drivers: It was suggested that these contract drivers were not adequately trained before coming on site because there were several near miss accidents, which indicated that the drivers were not familiar with established safety procedures. It was also said the there was no signage at Mt Whaleback mine and the traffic rules were different to other mines. • Follow up Action: One middle manager interviewed, said "we don't follow up as well as we could with action items from the safety investigation. Generally we are a bit slow". • Suspicion and Intimidation: Concern was expressed to the inquiry by a number of people about BHPBIO monitoring who is speaking to the inquiry and fears of retribution if it was known that they were making complaints about health and safety matters to the inquiry. Fatigue Management: Concern was expressed about 12 hour shifts and interviewees said that management had said that they wanted to know when an employee was feeling tired, but there was a concern that if they confess tiredness they would end up doing dirty mundane tasks. One person admitted to falling asleep at the wheel of a truck, which is a potentially fatal situation. Job Safety Analysis: There is a perception that management are not happy with the amount of time taken to prepare JSA because they lose too much production time. Another issue is the minimal involvement of employees in the preparation of JSA. Its been stated that JSAs are prepared and employees asked to sign same without involvement in their preparation. Safe Act Observation System: there was a perception by some people that the SAO system is being used to discipline employees rather than to improve safety. Pre-Start Procedure: Although pre start checks are required by the safety policy, if an employee finds fault and raises an issue, they are called a 'whinger' it was stated that not enough time was allowed to do the checks which sends an the wrong message regarding safety improvement. Contractor Hour Issues: It was suggested that a 17-hour day had been worked by a contract work group despite continuous shifts being structured around a 12.5-hour shift. BHPBIO agreed that this was excessive and agreed to address the situation.

6.25.1 Issues Raised at Other BHPBIO Operations Other issues reported to the inquiry at the remaining operations that BHPBIO manage are as follows:

• A number of employees wrote a letter to the CEO of BHPBIO regarding safety concerns about incidents that had occurred at Yandi Mine. The evidence from one of the incidents produced to the inquiry was regarding the operation of a loader. Due to the fact that the automatic fire extinguishers were not working, the person rostered on to drive the loader did not want to drive it. The loaders are also fitted with fire extinguishes and if there is a fire in the engine compartment an operator would have to climb down from the loader to get to the fire extinguishers or jump from the loader. It was reported that one worker had once undertook a similar exercise and broken bones in both legs.

A further incident reported that two employees were working in excess of 15 hours per day to consistently keep production "on the go". One employee's time record book showed approximately 12 to 13.5 hours per day for the last 30 days and the second employee stated that his normal working hours was over 16 hours per day.

It was reported to the inquiry that there was some fear in raising health and safety, particularly by people employed under AWA's. The attitude of management to people who raise health and safety issues is not conducive to the raising of such issues.

It was suggested that LTI figures could be managed to the extent that that people-receiving injuries would not show up in LTI statistics. It was reported that one dozer driver worked close to 24 hours with only a 7-hour break and no sleep.

Hazard reports not being followed up. Safety committee meetings show that problems were not progressed and remain in the minutes for long periods of time, ''you only have to look at the minutes of the Safety Committee to see the same things are repeated for years We have no way of enforcing anything without the drastic step of informing the Department and nobody wants to be responsible for that, the fall out would not be worth it. The behaviour of our senior staff has left few people in doubt that production at all costs is the real agenda". It was stated that ^'Safety is only an option if its convenient

More JSA training is required so employees understand their role regarding the way in which they carry out their work in a safe manner. • Inspector visited a site for the non-reporting of a serious injury, which was a

serious breach of the legislation.

• An audit at Yarrie mine noted that not all managers at the mine are held

accountable for Health Safety Environment and Community (HSEC) and there

is a variation in the degree of HSEC commitment from line manager to line

manager.

• It was reported that there was some evidence of a management style, which is

bullying in nature and that contractors are singled out for minor breaches of

safety procedures, which are applied more stringendy to them than BHPBIO

employees. The inquiry stated that,

• 'T/i/^ attitude discourages near miss reporting and more importantly sends

the wrong message. The people who brought this conduct to the attention of

the inquiry were extremely concerned that if their names or the contractors for

whom they work were brought to the attention of BHPBIO, they would as

individuals and/or companies be severely discriminated against by

managers ".

• The inquiry was informed that there can be a big stick approach to safety

compliance by contractors rather than involving contractors and their

employees in a co-operative attempt to resolve safety and heath issues.

• Patrick Burke manager engineering services Department of Industrial

Resources (DoIR) in WA said, "Certain companies actually penalise the

contractor - significantly and financially -if their LTIFR rises above a certain

threshold. In my opinion it is a despicable thing to do. This is seen [by certain

companies] as enforcing safe behaviour and good management practices. In

fact what happens when an accident occurs, its hidden- the person is sent on

leave or something other than to perhaps to declare an LTI."

• A contract employee said to the inquiry that to foster a positive culture

towards health and safety, BHPBIO needs to convince contractors that genuine, comprehensive incident reporting is to be encouraged, not penalised. It was indicated that BHPBIO do not devote sufficient time in order to discuss health and safety issues

Contractor pay rates effect their capacity to employ people with sufficient skill and level of training to perform work safely which means they have to engage a transient workforce.

At the Boodarie plant, the inquiry made the point that in some areas there may have been a gap between the ideals of the documented safety systems and policies and their implementation on site.

An audit by Dupont pointed to the concern about the degree of compliance with documented safety systems at the workshop and that the culture at Boodarie was found to be; o That accountability is not driven and short cuts are taken, not being able to raise issues or be listened to. o A high tolerance for the loss of respect for risks and cultural issues such as number of contractors, turnover of contractors and treating contractors like second-class citizens.

6252 Issues Raised at Nelson Point Port Facility The following issues were reported to the inquiry at the Nelson point port facility: • Reluctance to raise issues because not considered a team player; • Production pushed ahead of safety in OHS and on the job; • Lack of staffing levels and safety training compromising safety; • Follow up on safety and health issues • Lack of fatigue management policy • Safety used as a disciplinarily measure; Award employees treated more harshly than AWA employees for similar types of health and safety breaches • Reluctance to holding safety and health meetings 63 Management Response BHPBIO responded by indicating that since the introduction of individual contracts there has been an improvement in near miss reporting. This was because there is a union driven perception that workers on AW As and contractors were less safe. Management have indicated the introduction of individual contracts has proved positive because they "facilitate a direct relationship between management and individual employees in relation to their work performance, including safety".

However this individualisation of the relationship has the potential to discourage the workforce from raising occupational and safety matters, this is even more so especially if they are rewarded for their individual safety performance. However BHPBIO indicated that payments made under the incentive programme were dependant on the overall business performance, which includes meeting health and safety targets and that individual performance is assessed through the performance review process.

Another issue with this approach is that as bonus payments for employees are subject to individual assessments by their supervisor then the system is open to the type of exploitation that the award employees fear. The Inquiry formed the view that BHPBIO should take steps to ensure that "the raising of OHS issues by individual employees is counted in a positive rather than a negative sense by middle managers conducting performance appraisals relevant to the payment of bonuses to individual employees ".

6.4 The Issues of "Disconnect" and Mistrust in NSW In September 2004 the Minister for Mineral Resources in New South Wales announced a new mine safety review chaired by Neville Wran which was required in order for NSW to achieve zero mine fatalities and serious injuries. Over the past few years the mining industry in NSW has been moving from a prescriptive regulatory environment to a risk based management system approach. In order to achieve the objective of zero mine fatalities and serious injuries it requires cooperation and collaboration from all stakeholders in the industry. The regulations under the 2002 & 2004 Mine Safety Acts were not in force because of the failure of the major parties to reach agreement on fundamental issues such as hours of work and contractor management and consequently are impeding further progress in advancing safety in NSW. According to Wran (2005), Firstly there is a debilitating mistrust between the members of the tripartite process at all levels; Secondly, there is a disconnect between the intentions of both the DPI and the companies, on the one hand, to reduce risk through systems and management plans and, on the other, the reality of risk encounted at the "coalface" and This mistrust and disconnect must be acknowledged and addressed by all parties. The need to address these critical issues underpins the major recommendations of this review.

63 The Corporate Mining Industry View When one considers these issues it is necessary to investigate the different views, which have been expressed by the corporate mining industry on the one side and the unions on the other, hi 1999 the NSW Department of Mineral Resources (now DPI) introduced its enforcement policy, which has caused the corporate mining industry (CMI) to be critical of a number of enforcements actions that have been taken since its introduction such as prosecutions policies. Other differences by the CMI are as follows; • Policies and processes that achieve voluntary compliance and a sense of trust in the regulator are needed if DPI enforcement actions are to have a long term beneficial effect; • They have called for changes in the union attitude - they feel trade unions have been negative towards the issue of "behavioural safety' because trade unions had instructed their members not to take part in some of the training; • A more systematic approach to safety with a more risk based, safety management process is required for safety improvement. They believe that the risk management approach is not strong enough in the new legislation and that proposed regulations in many respects are too prescriptive; New legislation is confusing because it allows conflict between risk management and prescriptive controls.

6.6 The Unions View The principal union in NSW is the CFMEU and it maintains that the industry is in the same "precarious" state as it was in 1997 when the Mine Safety Review and Gretley reports were made. ''they claim the industry is failing to manage crucial factors such as contractors, hours of work, risk assessment, consultative processes and that the DPI is failing to effectively enforce the existing regulations "

Other concerns the CFMEU have are as follows: • A strengthening of the consultative processes is required throughout the industry; • Contractors and hours of work are the most critical factors which need to be addressed; • The DPIs enforcement record has not improved since the Gredey Report and when you compare their prosecution record against accident statistics it remains "appalling"; • They claim the safety culture of the industry is failing to address the needs of workers and point to worrying trends. They fear that a culture is developing among one third of the industry (contractors), who are fearful of raising safety concerns. • A culture of working longer hours, top down safety management, failure to consult and a culture of using risk assessments to justify unsafe practices. • They claim that the DPIs has its own agenda of seeking to divest itself of many of its regulatory responsibilities • They see production and mining costs verses safety and they claim there is pressure on managers to minimise costs and maximise production at the expense of safety There is distrust by the unions of systematic approaches to safety management, and the serious concerns of unions are symptomatic of their underlying lack of trust in the corporate mining industry and the regulator.

6.7 Discussion This chapter has dealt with the issues of "disconnect" between what management aspire to achieve at corporate level with their safety management systems and what is actually achieved at the coalface. One of the most surprising issues that this chapter has demonstrated is the lack of trust between the mining companies, the unions and the inspectorate particularly in NSW and WA. Without trust between the parties, safety improvement will remain an issue for all the industry stakeholders and it is therefore imperative that these issues are addressed as soon as possible, by all concerned. In NSW in order to address the mistrust issue; the Wran (2005) review recommended

"a strengthened, committed more focused Mine Safety Advisory Council, as well as well as a Board of Inquiry to review enforcement policies."

There seems to be a general recognition amongst stakeholders in the mining industry that the growing use of contractors in the industry has implications for OHS, which require attention. Contractors used to be used in highly specialised activities where their skills and knowledge are required to carry out certain activities in the operations where mine staff do not have the required skills. However it is now becoming increasingly common for mines to obtain part of their normal workforce from contract mining companies, or use the entire workforce supplied by contracting companies like at BHPBIO in WA. The WA Prevention of Mining Fatalities Task Force (1997) said that, " there was a close association between a rising level of fatalities and the growing use of contract labour in the mining industry".

Corporate management has the issue of "disconnect" to deal with in normal circumstances where they are using solely their own employees. However, contractors are using their own safety management systems, or trying to mix their safety management systems with the companies they work for. This just complicates the problems of "disconnect". This was the case when the CEO of BHPBIO, Chip Goodyear, when questioned about the 17 fatalities worldwide in 2003-2004 and whether production was pushed too much, he said that there was no common theme in the fatalities. He then went on to say that

" the one area we do see a commonality in, is contractors. About 65% or 70% of the fatalities involve contractors and the issue is making sure that the contractors have the same type of systems that mesh with our systems" (Kohler 2004).

The increasing use of contractors creates more complex chains of command (multiple employers) on worksites and consequently a risk that OHS responsibilities are diffused.

Other issues with Contractors, discussed in this chapter, were that they were not properly trained to carry out work tasks, not familiar with site safety procedures and contract hours of work were excessive. These issues can have a profound effect on safety as demonstrated by Bluff, Cunningham and Johnstone (2004):

''Increasing prevalence of outsourcing, self-employment and the use of contingent workers can have a significant effect on OHS. This is because of the pressures on sub contractors (resulting in corner cutting, work intensification and excessive hours); disorganised or attenuated control systems in the workplace, under resourced operators, having strangers on site and so on); and undermining of regulatory controls."

There is evidence of bullying of contractors and that they are singled out for minor breaches of safety procedures which are applied more stringently to them than to BHPBIO employees. Contract pay rates are lower than BHPBIO employees and contract employees are tended to be treated like second-class citizens. The Wran (2005) review regarding contractors said: "that by the very nature of their employment they can be under more pressure to perform more work or carry out more production over longer work periods than their regular workforce counterparts ".

There can be a big stick approach to safety compliance by contractors instead of involving contractors and their employees in cooperative approach to safety and health issues. From personal discussions with personnel in the industry this situation applies throughout the mining industry and is one of the reasons for the union distrust in NSW, which has been discussed in some detail in this chapter.

Hours of work is a major issue facing the industry because many of the rosters used in the industry provide blocks of days off together with increased financial benefits from various penalty rates. Although these arrangements have a negative impact on OHS issues employees are reluctant to adopt shorter working hours in the interests of improving safety at work.

hi WA one of the major issues at BHPBIO sites that contributed to concern regarding the operation of OHS systems was the difference between the treatment of union award employees compared to employees on AW As. These differences have been discussed in some detail and range from concern about workplace suspicion, intimidation and distrust issues which is effecting ongoing employee relationships and the lack of proper communication which leads to distrust; a whole range of negative issues such as effective consultation with the workforce and worker safety representatives and The gap between the ideals of documented safety systems and policies and their implementation on site.

In NSW the unions are concerned the industry is failing to manage contractors, hours of work, risk assessment, consultative processes and that the Inspectorate is failing to enforce the existing regulations. According to the NSW Mining Council trust remains the biggest impediment to safety culture improvement and have indicated, ''the trust between key groups (mining and unions) has all but disintegrated" The culture of using top down management for risk assessments to justify unsafe practices is not setting a good example which is necessary for establishing the trust required for the improvement in safety management systems implementation. A culture is developing amongst contract workers, who are fearful of raising safety concerns, which is to the detriment of safety improvement.

The Wran Review found that there is such a wide variation between mine sites in the hours of work, shift patterns and approach to fatigue management as to suggest that the current legislation in relation to the hours of work is largely irrelevant.

The large proportion of contractors in the workforce of the Australian coal mining industry and the impact this is having on the implementation of safety management systems has been reviewed in some detail. One could suggest that all these issues including the problem of disconnect, would indicate that safety in this industry may be declining to the detriment of safety improvement in the industry.

At the time of writing two contractors have been killed at BHPBIO operations one in August and one in September 2008 .The accident in August involved a fly in fly out worker who was involved in an incident in a workshop at Yandi mine. The second fatality occurred when a light vehicle collided with a truck. WA unions believe that these deaths will allow them to use safety as a major issue in their push to re-establish a presence in the Pilbara region. These latest fatalities and the findings of this thesis may help substantiate a view that a different approach to safety in the mining industry is necessary in order for it to improve.

This chapter has demonstrated that there are considerable issues that the mining industry must address in order to improve safety. These issues will be dealt with in the next and concluding chapter.

CHAPTER 7

7 CONCLUSIONS AND RECOMMENDATIONS

7.1 Conclusions The research undertaken for this thesis has challenged the safety paradigm in the mining industry and has been able to add to the knowledge regarding the safety performance of mineworkers. This research was mainly undertaken because the mining industry has an unacceptable level of fatalities and the fact that there is evidence that safety performance is deteriorating.

Such research is important in order to understand what the current safety parameters are indicating and the effects of contractor's impact on safety performance. The research has shown that although safety indicators have been improving over the last decade they have plateaued and over the last few years now show signs of worsening.

A literature review on the history of mining and a legislation review set the scene for this research. The catastrophic failures of mining disasters that were investigated, demonstrated how new legislation evolved. This dramatically reduced the number of fatalities recorded in the mining industry, which had a major impact on safety improvement.

This research also considers how the implications of legislation, safety culture, fatigue, prosecution policies and the issues of disconnect are affecting safety performance.

The research demonstrates that human factors, lack of awareness of rules, procedures, driving fatigue and contractor management have had a dramatic effect on safety performance.

Legislation in Australia varies between the three major mining states and there is no agreement as what constitutes the most appropriate legislation. There seems to be a shift from the more prescriptive type legislation to the more self-regulatory type. There is no proof that either system is more appropriate. However this thesis has indicated that corporate management on one side wants more self-regulation and the union on the other side wants more prescription.

The research has provided evidence that the reported information on safety statistics may not give a true account of injuries and accidents since hundreds of serious injuries are not being reported. There are issues with contractors not reporting injuries due to safety targets being a condition of their employment.

This research has shown that all the safety parameters in Queensland coal mines are increasing at a rapid rate and in NSW notifiable injuries have also increased at a rapid rate, which is a cause for concern with all stakeholders in the industry because miners are still being seriously injured. This safety performance is being exacerbated by the increase in employment numbers where experience and training are major issues that the industry must address in order to meet industry and community expectations.

Important differences between Queensland and NSW legislation have been highlighted including the fact that a large open cut mine in Queensland can be managed by a person with no mining experience or qualifications. This means that the Queensland legislation has departed from common mining practice in terms of essential qualifications and experience. This may ultimately prejudice the safety and health of the mining workforce.

It must be very difficult and unprofessional for a site senior executive at an underground or open cut mine to achieve the management of standards, control of operations, supervision, oversee technical work, monitor and carry out assessments in the working environment without the appropriate qualifications and experience to undertake these responsibilities. In order for an SSE to control events at a mine, he first of all must understand the consequences involved in the often-complex decision- making that takes place at a mine especially since he is the most senior person in the eyes of the law. This statement was some what supported by the coroner in Queensland when investigating a truck driver fatality as mentioned earlier in Chapter 2. The fact that NSW has not followed this direction would tend to indicate disagreement with the Queensland approach.

In Queensland, the only person requiring a statutory qualification at an open cut mine is an open cut examiner. Due to the shortage of open cut examiners the inspections at mines are stretched to the limit. This means that the safety standards in mines are being equally stretched and may be deteriorating.

Since the Queensland legislation has eliminated the position of undermanager it is now possible, in underground mines, for miners to be supervised by persons who do not have any mining qualifications. Admittedly the area has to be inspected by a deputy. However, the industry cannot justify unqualified persons supervising the workforce simply because it is short of experienced qualified people. This may possibly lead to increasing the potential for an accident or incident.

The position of undermanager has traditionally been the link between the mine deputy and the mine manager. Many mining personnel have found that they were able to achieve the level of the undermanager's qualifications, but were not academically able to obtain mine managers qualification. The position of undermanager was an excellent training ground for potential managers. Over the years this position has been the lifeblood of the underground coal mining community. The mining industry in Queensland has lost this vital link between the Deputy and Manager and as a consequence, lost a vital safety management role in underground coal mines.

There are instances whereby the undermanager in the absence of the SSE has acted as the SSE at a large underground mine in Queensland. This illustrates how companies are able to manipulate the law in Queensland since there is no requirement for an SSE to have any qualifications.

Over the last two years the turnover in staff within the Queensland inspectorate has been considerable. It has proved very difficult to recruit inspectors. One would have to assume that the inspectorate has been downgraded because recent changes in legislation would confirm this An inspector in Queensland no longer requires a first class certificate of competency or any mining engineering qualifications to meet the new criteria for an inspector. • There is now essentially no distinction between an inspector and an inspection officer; they are all now acting as inspectors. • This thesis has demonstrated (Ombudsman 2008) that miners lives are at risk in Queensland because of the shortage of inspectors and that the Department was understaffed and in a state of flux and that the inspectorate may not be fulfilling its compliance role (Chapter 2).

It may be concluded that the inspectorate in Queensland will be continued to be downgraded until it operates in a similar fashion to the US model, whereby several inspectors go to a mine site and tick boxes, such that eventually the inspectors who tick the boxes have little or no knowledge of what constitutes an operating mine. The days of the mine manager being able to work in close harmony with the inspectorate will have disappeared to the detriment of safety in the coal mining industry.

In New South Wales, the legislation regarding the qualifications and experience of management positions and appointment of inspectors has remained essentially unchanged. However the adoption of risk management principles and hazard and effects management is closely aligned with that in Queensland. One would have to conclude that NSW has a much more robust stable inspectorate in which to confront the future challenges in the coal mining industry.

The arguments in favour of having one set of national OHS laws for Australia are very clear. At present there are at least 11 separate statutory regimes applying throughout the country, each with its attendant regulations and codes of practice. The conventional arguments in favour of conformity are that it will lead to more equitable outcomes in that employees will be protected to the same standards where ever they work and that economic efficiency will be promoted because employers and employees, and other duty-holders will have only one set of laws with which to comply. This lack of uniformity in the Australian OHS legislation needs urgent attention. For example, duty holders in the coal mining industry in Queensland operate with different Acts and Regulations than those in NSW and yet are operating with the same hazards in both underground and open cut operations. There is a lack of uniformity when developing inspection, enforcement policies, strategies, level of fmes, infringement notices, and the considerable variation in health and safety representative provisions.

The formation of the National Mine Safety Framework is a very necessary and worthwhile initiative, with three of the seven strategies being acted on currently namely the legislative framework, data analysis and consultation. The issue of federal and state mutual recognition acts of 1992 overruling any requirement for a statutory official appointed from NSW to demonstrate knowledge of Queensland mining law, and vice versa will take some considerable time to fix. However at least this issue will be one of the first on the agenda.

The Australian labour market is changing rapidly with unemployment at historic lows at the "time of writing". The regulators need to develop standards, guidance material, enforcement, and inspection that address the need for labour hire, sub contracting and franchise arrangements.

More flexibility is required regarding safety and health representatives, which are usually limited to employees and generally exclude contractors.

The research has shown that if the workforce observe good attitudes and behaviour of management an effective safety culture can be developed which will have a huge impact on safety performance by promoting teamwork, building good will in the workplace and creating a positive environment.

Communication and consultation are issues that can have the most positive impact on safety improvement. New legislation is based on risk management and for this to succeed miners must be continually made aware of what hazards and their controls are. Provided that proper communication and training is given to employees and supervisors the new legislation can have a positive impact towards the prevention of accidents.

The thesis has demonstrated that SHMS are an important part of the way forward, however in order to be successful they need to be less complex and the elements need to be standardised across the industry. One of the most important issues to be addressed is that of training the workforce so it understands its obligations under the SHMS particularly when considering the level of literacy in the industry. This is further exacerbated when one considers the large number of contractors in the industry. It is also necessary to conduct more system audits rather than compliance audits.

The main issue that has surfaced with risk management is that it takes away the ability of miners to think for themselves. It can also have a tendency for supervisors to abdicate responsibility and there is evidence that assessments can be manipulated towards the outcome that suits management. Staff are not properly trained to conduct risk assessments or take into account the full nature of the risks. This is one of the main reasons the union would prefer a more prescriptive framework in order to improve safety performance in the industry.

The research has shown that one of the effects of awareness and fatigue issues suffered by mine workers today is the move away from the traditional eight-hour to a twelve-hour shift and four and seven day rosters. The Howard Governments industrial relations laws encouraged companies to move to these longer working hours for productivity reasons. Mineworkers initially rejected these new arrangements but have now overwhelmingly accepted them because of life style considerations to the detriment of fatigue considerations throughout the mining industry. Given that the effects of fatigue are similar to the effects of moderate alcohol consumption it is difficult to understand why fatigue performance impairment has not been subjected to similar levels of intervention.

It has been demonstrated that vehicle crashes are occurring, where miners are driving home after working a 12-hour shift, through the effects of fatigue. It has been established that miners in NSW are working long hours when compared to international mining operations. From current information it is known that Queensland miners would be working similar hours if not longer. These hours are most probably understated due to the fact that overtime is not tracked and therefore not reported.

It has been shown that 60% of the high potential incidents in underground operations and 41% in open cut operations in Queensland are attributable to awareness from fatigue issues and since the rate of HPIs is increasing at a rapid rate it is a real concern for safety in the coal mining industry.

Industry now accepts that fatigue is a problem and is in the process of implementing fatigue management plans, which vary considerably across the industry with the larger companies leading the way. One way to address fatigue is to concentrate on risk assessments and concentrate on work hours and sleep opportunity. The move back to eight-hour shifts should be contemplated particularly in underground operations, which would improve safety in the industry. In the interests of improving safety the industry should not expect a miner to work a 12-hour shift underground.

If companies are advised by the legal profession to be careful about generating reports and employees are encouraged not to write written documents without approval from the manager it is not possible to establish the true facts regarding an accident or incident. The lessons that would be learned from open and honest communications are lost to the detriment of preventing a recurrence. It is therefore logical to assume that based on past history the important gains which have been made in occupational health and safety in the coal mining industry over recent years will be lost with the real potential of serious injuries increasing.

The current approach to prosecution is counterproductive, inhibits thorough safety investigation and creates a defensive rather than a proactive safety culture. In any incident or accident the first objective is to find out what happened, why did it happen and what can be done to prevent a recurrence. The trust between the parties is non- existent due to legal privilege where potential information that would be useful in finding out the facts is lost in the legal minefield. It has generated a defensiveness on the part of the companies that has resulted in an unwillingness to examine the root causes of accidents and incidents for the fear of being prosecuted.

The policy encourages employees not to report near misses because the findings could be used against them in future prosecutions. Recent prosecutions targeting individual duty owners have created a disincentive for young people to consider a statutory role in the mining industry.

In NSW this policy has broken the trust between management and the mines inspectorate such that the regulators and the regulated do not listen to each other. This is a sad reflection on the industry, because if OHS is to improve then both parties need to trust each other and work together in a constructive manner. It is very easy to forget that one of the main reasons that OHS has improved in the coal mining industry is largely due to the excellent working relationships between management and the inspectorate over many years.

The industry needs to develop a just culture which in turn generates an atmosphere of trust between the parties where persons are encouraged to provide the essential information required to investigate accidents and incidents. At the same time the industry must clarify the line between acceptable and unacceptable behaviour.

It is time for industry, unions and the inspectorate to work together in harmony to establish a culture between all parties whereby trust is the link pin towards improving occupational health and safety in the mining industry.

The lessons that would normally be used to prevent a recurrence of an accident or incident are not being applied until many years later due to legal privilege. These policies are impacting negatively on the objective of reaching zero harm. This policy is creating a climate of distrust between all the parties whereby the vital information is being withheld that may well prevent a recurrence of the incident or accident.

The research has indicated that if the current prosecution policies continue then more information to prevent accidents and incidents will be lost to the detriment of attracting mining engineers into mine management positions but also the safety improvement which is necessary in the industry. The industry should consider a no blame culture and move to a system like the Wardens Court where there is a free flow of information without the fear of prosecution. The findings are completed in a shorter time frame which means the lessons learned are available in a quicker time frame than the current outcomes in Queensland and NSW, with a consequent positive outcome for safety improvement.

Currently, in the event of a serious injury the first person on site can be the company legal people who are there to protect the company's interest at the expense of finding out the true facts appertaining to the incident such as to what happened and why and what can be done to prevent a recurrence. This statement is substantiated by BHPB, one of the largest mining companies in the world, when in January 2008 they refused to allow the inspectorate to investigate a fatality for 24 hours, which caused the

Minister for Mines to intervene. This behaviour is not in the best interest of safety improvement.

The industry must move away from the prosecution policy and if companies or individuals act recklessly or have a wilful and fragrant disregard for safety they should be disciplined in an appropriate manner. Prosecution should only ever be used as a last resort.

This research has indicated that there is a lack of trust between mining companies, the unions and the inspectorate and there is a disconnect between what mining companies aspire to achieve at the corporate level with their safety management systems and what is actually achieved at the coal face.

One of the main issues affecting trust between the parties is the growing use of contractors in the industry, which is having serious implications for OHS, and is in urgent need of attention. This research has shown that there is a close association between the level of fatalities recorded and the growing use of contract labour in the industry (Chapter 6).

Large companies are experiencing issues with disconnect in their own managed operations and that this problem is further exacerbated when companies try to mesh their safety management systems with those of contractors. The increasing use of contractors creates a more complex chain of command especially when multiple employers are used with a consequent risk that OHS responsibilities are diffused. It was found that contractors were not properly trained to carry out work tasks, were not familiar with site safety procedures and their hours of work were excessive. There is evidence of bullying of contractors for minor breaches of safety procedures and a big stick approach to safety compliance would suggest that they are treated like second-class citizens. It is evident from the research that a culture is developing amongst contract workers who are fearful of raising safety concerns, which will be to the detriment of safety improvement.

The research demonstrates that excessive hours are being worked in the mining industry. The rosters used provide blocks of days off together with financial benefits, which suit the life style of miners who are living in some cases in coastal and other communities away from the mining areas. These arrangements have a negative impact on OHS issues because employees are reluctant to adopt shorter working hours, which would mean a change in life style considerations.

The research confirms that unions are concerned that the industry is failing to manage contractors, hours of work, risk assessments, consultative processes and that the inspectorate is failing to enforce existing regulations.

Significant advances have been made in safety improvement throughout the mining industry. However that improvement has definitely plateaued and is now deteriorating. Safety improvement is at the cross roads and in order for the industry to address this problem the following issues must be addressed with some urgency: • Prosecution policies; • The growing use of contractors; • Lack of trust; • Hours of work and fatigue issues; • Lack of consultation; • Lack of experienced qualified people; • Safety culture; • Lack of training and; • Underreporting of Incidents.

One way to address the growing use of contractors is for all companies to operate with their own employees and to use contractors for specialist work tasks or for peaks and troughs, as was the case in the past. This would automatically remove the problems associated with pay differentials between contractors and company employees and would also go a long way to addressing the problems of disconnect. It would also enable the safety culture of the industry to improve and would be more cost efficient over time with a consequent safety improvement in the industry.

7.2 Recommendations It is recommended that instead of the industry going down the path of a prosecution policy, which is a detriment to the interests of safety improvement, the industry consider a system similar to the Wardens Court of Inquiry where there is no fear of prosecution. As a consequence discussion is open and free which results in a better outcome in less time than the current process. This would also encourage young mining engineers into mine management and enable the stakeholders to trust each other, which is so necessary for safety improvement.

It is recommended that companies only use contractors for specialist work tasks or for peaks and troughs at their work sites. This would dramatically improve the implementation of safety management systems.

It is recommended that the effects of fatigue performance impairment should be subjected to similar levels of intervention when compared to the effects of moderate alcohol consumption. Also, more research into fatigue measurement should be carried out so that fatigue issues can be better managed.

It is recommend that more training be given to mine staff in order that they are able to conduct appropriate risk assessments with the workforce. Also, further training should be given to the workforce so that they understand their obligations under the SHMS.

It is recommended that 12-hour shifts for underground miners should be addressed with some urgency.

It is recommended that the industry conduct more system audits rather than compliance audits.

It is recommended that the remuneration for inspectors should be addressed so that it becomes more attractive for engineers to consider spending time in the inspectorate, particularly in Queensland. REFERENCES

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