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Ten Pathways to Death and Disaster

Ten Pathways to Death and Disaster

Learning from Fatal Incidents in Mines and Other High Hazard Workplaces

By Michael Quinlan


Why do mine disasters continue to occur in wealthy countries when major mine hazards have been known for over 200 years and subject to regulation for well over a century? What lessons can be drawn from these disasters and are mine operators, regulators and others drawing the correct conclusions from such events? Why is mining significantly safer in some countries than in others? Are the underlying causes of disasters substantially different from those that result in one or two fatalities?

This book seeks to answer these questions by systematically analysing mine disasters and fatal incidents in five countries (Australia, Britain, Canada, New Zealand and the USA) since 1992. It finds that there are 10 pattern causes which repeatedly recur in these incidents, namely:

  • engineering, design and maintenance flaws,
  • failure to heed warning signs,
  • flaws in risk assessment,
  • flaws in management systems,
  • flaws in system auditing,
  • economic/reward pressures compromising safety,
  • failures in regulatory oversight,
  • worker/supervisor concerns that were ignored,
  • poor worker/management communication and trust, and
  • flaws in emergency and rescue procedures.

The vast majority of incidents entailed at least three of these pattern causes and many exhibited five or more. The book also demonstrates these pattern deficiencies are not confined to mining but can be identified in other workplace disasters including aircraft crashes, oil-rig explosions, refinery and factory fires, and shipping disasters. At the same time, the examination finds no evidence to support other popular explanations of mine safety which focus on behaviour, culture or complex technologies. It finds that there is little to differentiate the failures that lead to single death or multiple deaths and ‘disaster’ studies would benefit from also examining near misses.

The book examines why pattern causes have proved so resistant to intervention by governments while also identifying instances where lessons have been learned. How, for example, do governments strike a balance between prescriptive regulation and risk management/system-based approaches? Only by understanding and modifying the political economy of safety can these problems be addressed. It concludes by proposing an agenda for change that will address pattern causes and contribute to safe and productive work environments. The book is written for those studying OHS, mine safety and risk management as well as those involved in the management or regulation of high hazard workplaces.

In the news...

  • Ten steps from disaster, The International Trade Union Confederation – Health & Safety News, 20 April 2015 Read full article...
  • Disasters in high hazard workplaces are ‘predictable and preventable’, Hazards Magazine, March 2015 Read full article...
  • Mine Accidents and Disaster Database, Mine Safety Institute Australia, March 2015 Read full article...
  • OHS Reps - Research News, SafetyNetJournal, 12 February 2015 Read full article...
  • The 10 "pattern" causes of workplace disasters, OHSAlert, 11 February 2015 Read full article...
  • New book challenges current OHS trends, SafetyAtWorkBlog, 2 February 2015 Read full article...
  • Tasmania needs more mines inspectors, Australian Mining Magazine, 2 October 2014 Read full article...
  • Australian mine deaths preventable if warnings heeded, WorkSafe seminar hears, ABC News, 2 October 2014 Read full article...
  • Lessons from Tasmania’s mining industry for all workplaces,, 1 October 2014 Read full article...
  • Auditor Says Tasmanian Mine Safety in need of Urgent Review, Australasian Mining Review, 16 July, 2014 Read full article...
  • Damning report on Tasmanian mine safety finds inspectors over-stretched, poorly paid, ABC News, 15 July 2014 Read full article...
  • Call for support for grieving families backed, The Examiner, 22 April 2014 Read full article...


Table of Abbreviations

1.  Death and Disaster at Work
2.  Setting the Context: Regulatory Frameworks in the Mining Industry in Five Countries 1970-2011
3.  Patterns of Disaster and Death: An Examination of Fatal Mine Incidents in Five Countries
4.  Do These Patterns Apply to Fatal Incidents in Other Workplaces?
5.  Learning from Failure: Some Practical Implications
6.  Learning from Failure: Broader Policy Implications



The book has been rigorously researched and the original research concentrates on five countries to analyse and answer the questions posed. By analysing disasters (defined here as three or more fatalities) and other fatal incidents in Australia, New Zealand, the United Kingdom, Canada and the USA the book finds that there are ten pattern causes which repeatedly occur in mining incidents as well as in other industries. … The book is an interesting read and if it achieves nothing else is a good snapshot, especially for the five countries used in the analysis, of what has been achieved since 1970. The book shows that there is no single method of achieving zero fatalities in the mining industry, and that fatalities – whilst important – are not the only metric that needs to be considered. Near miss or near hit events are also important. Read full review...

Michael Tuck, The AusIMM Bulletin, April 2016

Occupational health and safety expert Michael Quinlan’s latest book is a well researched and readable resource in a small package. A book like this is important because: “Work remains a prominent source of death even in the wealthiest and most advanced industrial societies”.
         Ten Pathways to Death and Disaster is a relatively small book, densely packed with valuable insights. … clients in hazardous industries and anyone interested in work safety management or regulation will find it a compelling read. Read full review...

Elissa Steel, Ethos, Law Society of the ACT, December 2015

Michael Quinlan has extensive experience over 30 years in the field of work health and safety and high hazard workplaces, as a researcher and member of inquiries in mines and road transport safety. He was engaged by the New Zealand Department of Labour to prepare background reports on mine safety for its response to the 2010 Pike River mine disaster that killed 29 miners, and in 2006, he reviewed management processes and the role of the mine inspectorate for an investigation into the Tasmanian Beaconsfield gold mine rockfall in 2006 that killed one miner and trapped two more underground for two weeks. Subsequently, he was appointed in 2013 to an Expert Reference Group to recommend enhanced regulation of mine safety in New Zealand, and was engaged in 2010 to audit the Tasmanian mines inspectorate.
         It is worth recounting this depth of experience because, together with Quinlan’s historical skills, it forms the basis for identifying patterns of fatality in hazardous workplaces over 200 years. Read full review...

Raymond Markey, Journal of Industrial Relations, October 2015

Mining disasters have been happening for centuries, as if working in the entrails of the Earth demands human sacrifices. Michael Quinlan’s book questions the fatalism with which this slaughter is sometimes viewed. It analyses mining disasters in five highly developed countries: Australia, the United Kingdom, Canada, New Zealand and the United States.
          Michael Quinlan has become one of the world’s most renowned specialists in this field. He uses working methods that value the collective experience of miners and their trade unions. He has served on various commissions of inquiry in Australia and New Zealand.
          This book has the merit of not isolating disasters from the daily reality of working conditions. As the author states, although disasters attract the attention of the media, public and governments, they are a distraction from the fact that the greatest number of deaths are caused by accidents occurring during the normal course of production. The author stresses the underlying political dimension in any discussion on improving prevention. Clearly written and with an obvious knowledge of the technical questions, this book provides a review of the predominant themes in the field of safety at work. Read full review...

Laurent Vogel, HesaMag, Spring-Summer 2015, 11

[Quinlan] has studied a large number of major incidents, each involving numerous fatalities, primarily in the mining industry, but also in other major hazard industries such as petrochemicals and aviation. This has enabled him to identify what he calls ‘pattern causes’ that repeatedly occur in these accidents.
         Not all of these causes were identified in every accident, but Quinlan found something very interesting – the more thorough the inquiry, the more of these pattern causes it uncovered. In particular, the inquiry into the Pike River mine disaster, one of the most thorough inquiries, found all 10 issues. What this suggests is that most if not all of these causes would have been identified in the other inquires, had they been sufficiently thorough. One can be fairly confident, then, that this list will be relevant for most major accidents, and conversely that getting these things right will make such events far less likely. To be able to draw this conclusion is one of the major benefits of this book. Read full review...

Andrew Hopkins, The Economic and Labour Relations Review, August 2015

This is a surprising book. I was expecting a dry as dust academic treatise full of facts and figures, charts and graphs, and impenetrable jargon. Instead what I got was a revolutionary critical analysis that took me back to the heady days of the 1980s and my political economy studies at Sydney University…
         … there is a lot to be learnt from this book and Professor Quinlan is to be congratulated on raising a number of detailed, practical and useful suggestions for further improvements in work health and safety. Read full review...

Neil Napper, Workplace Review, Winter 2015

… Michael Quinlan… has pulled off quite a trick here. He has written a well researched scholarly book which is nevertheless easily digested and oriented around ten broad causal factors which any health and safety practitioner could usefully reflect upon. … He provides compelling evidence that the ten pathways he identifies also apply to industries outside mining, and that the causes of single-fatality incidents are largely the same. In other words, just because your organisation doesn’t use processes liable to catastrophic energy release doesn’t mean this book isn’t for you. … The author is keen to set out the book’s practical credentials: to provide – if nothing else – a checklist of a number of types of failure of particular use to organisations trying to prevent low frequency but high impact events. He has succeeded. Read full review...

Peter Bateman, Safeguard, May/June 2015

We highly recommend it. In fact it is excellent. It should be mandatory reading for every current and future mine manager and supervisor (and every other management position at a mine, whatever you want to call them). The information analysed from so many incidents and disasters is extraordinary. It is a great piece of work. ... Let us not repeat the mistakes of the past. This book is a great first step to a safer industry.

Mark Parcell, Mine Safety Institute Australia, March 2015


Published 18 December 2014
Publisher The Federation Press
ISBN 9781862879775
Australian RRP $165.00
International Price $150.00
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Law - Mining
Law - Occupational Health and Safety
Law - Industrial & Employment
Occupational Health and Safety
Industrial Relations / EEO

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