THE WESTRAY MINE EXPLOSION

Organizational Behavior: The Westray Mine Explosion

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THE WESTRAY MINE EXPLOSION The Westray Mine Explosion Problem statement

On the 9th of May 1992 at 5:18 am a blue-grey flash lit up the predawn sky of the small town of Plymouth, Nova Scotia. Homes more than a mile away shuddered as shock waves rumbled through the ground. The Westray coal mine had exploded, with several men in their final hours of a four-day shift trapped underground. A sudden gush of methane gas from the foord coal seam erupted into flames, exploding with a thundering blast. Within minutes of the explosion, family members and neighbours began to gather at the ill-fated mine site. Within a few hours, local, national and international media had their equipment and reporters on site. Family members stared with baited breath for news of their loved ones, resenting the prying cameras and intrusive reporters. After eight days of crying and comforting their children and each other with hopes of a triumphant rescue, the last of the men trapped in the hell hole were taken out alive. Twenty six miners were confirmed dead after weeks of rescue efforts. Over twenty women left widows and over forty children fatherless. On the 15th of May, a day after Colin Benner, President of operations, had called off the search for miners, the Premier, Donald Cameron appointed Justice Peter Richard to lead the inquiry into the explosion. He was to determine whether any negligence had contributed to the Westray disaster. After 71 witnesses, 76 days of testimony, 16,815 pages of transcripts, 800 boxes of documents and a cost of nearly five million dollars, Justice Richards findings were documented in a 750-page report entitled, The Westray Story: A predictable Path To Disaster (Richard, 1997). His conclusion was that the Westray explosion was both predictable and preventable. In his report, Justice Richard noted, the Westray Story is a complex mosaic of actions, omissions, mistakes, incompetence, apathy, cynicism, stupidity, and neglect. Fredric Le Play, the French sociologist and inspector of mines, said, the most priced thing to emanate from a mine is the miner. However, at Westray this was never the case. The most important thing that was supposed to come out of Westray was the coal, with total disregard of the welfare, safety and health of the miners. The levels of methane in the mine were consistently high than was permitted. This was caused by inadequate ventilation of the mine caused by rerouting without provision for personnel. Contaminated air was also used to ventilate the working areas. Intake air was also

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allowed to pass by unventilated abandoned workings. Inadequate airflow to clear the methane from working areas during mining, inadequate airflow to prevent methane from layering at the roof, and inadequately constructed airflow devices for controlling underground ventilation made Westray a disaster waiting to happen. Mining was continued despite inoperable methane detection devices. Flammable coal dust concentrations were also above permissible levels due to inadequate cleanup, and the fact that no crew was in charge of inerting the coal dust with dolomite or limestone. Fuel storage and refueling of vehicles was done in non-flame-proof areas underground. These and many other factors contributed to continually poor working conditions at Westray coal mine making it an accident waiting to happen. These substandard and practices could be accredited to the lack of concern the management had towards health and safety issues at the mine. This was one of the primary root causes of the problem at Westray. Personal factors also contributed to this disaster. Lack of mining experience by the personnel working at the mine is one of them. Miners also lacked safe underground work practices. Methane overexposure and fatigue due to 12-hour shifts also caused physiological stress. Miners also suffered psychological stress caused by the constant fear of reprisal for reporting safety concerns. Job factors that contributed to the Westray explosion include, among others, a lack of proper training and orientation for new employees at the mine. Mine inspectorate personnel also did not do adequate follow-through on recommendations. There was also poor communication of mining standards. For example, the roles and responsibilities of occupational health and safety committees were not specified. Inadequate leadership in terms of the assignment of responsibilities also existed. For example, the responsibilities of the production supervisor and mine examiner were undertaken by the same person (Wilde, 1997). Adequate engineering during mine design and planning with respect to potential loss exposures was also lacking. For example, the mine was designed with intersecting geological fault lines resulting in frequent roof-falls. Was the Westray mine explosion preventable? Evidence shows that the disaster would have been prevented if the mine operator had acted prudently and followed the appropriate, safe mining practices. The explosion would also have been prevented if public officials responsible for mining regulation had carried out their duties diligently and enforced the statutes within their

THE WESTRAY MINE EXPLOSION authority. The Westray mine was permitted to operate in a regulatory void with government

officials deferring to mine managers instead of carrying out their statutory duties. There is no evidence to show that miners who were underground on the morning of the May 9th were engaging in unsafe acts that would have contributed to the explosion. These men were mining coal and supporting the roof, following the mine operators directions, and using equipment provided by the mine operator and ratified by the government inspectorate. Nevertheless, it is likely that one of the miners created a spark in the mine.in a properly regulated mine this would, however, have been an insignificant event. The spark would have probably gone unnoticed. But this was Westray and all elements of disaster had been put in place by the time the B Crew went into the mine that Friday evening. There is no doubt from the evidence that the Westray mine project enjoyed preferential treatment from political leaders of Nova Scotia. For Donald Cameron, the creation of the Westray mine was a principal cause. Through his efforts and those of likeminded politicians, Westray came to life, surrounded by government concessions and support (Jobb, 1994). Indeed, there would have been no mine without this political support. Cursory review of this support package shows what a good deal Frame, Messrs, Pelly, and Phillips, got from Mr. Cameron in exchange for their investment in this project. First, there is the twelve million dollars, on which by the time of the explosion only interest had been paid (Jobb, 1994). There was also the eight million dollars loan given against the advice of senior public servants. Then there was the loan guarantee of eighty five million dollars by the federal government (Jobb, 1994). In addition, Westray was provided with an unusually generous take-or-pay agreement by the Province, a deal that senior public servants did not approve. Donald Cameron convinced his cabinet colleagues to agree to pay extra 275,000 tons of Westray coal annually, whether or not it was taken from the mine (Jobb, 1994). This was to cost the Province 15 million dollars a year for the lifetime of the deal. A final item on the list of favors was the permission given to Westray to mine 200,000 tons of bulk sample coal from the surface mine at Stellarton. By calling this coal bulk test sample, Westray was able to avoid environmental and mining regulations. The government and the company knew this was coal production, not coal testing, although no one admitted publicly. When you compare the princely treatment the company got to the deteriorating resources provided to the mine safety division in the Department of Labour, a clear picture the priorities of

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the Provincial government transpire. The inspectors at the mine safety division knew they were not ready for the Westray and the continually asked for help. They asked for a new engineering position. They asked for an improvement in training on mining methods at Westray. They continually asked for approval to hire independent consultants to provide expert intelligence on roof support and control. Each of their requests was turned down. There was no financing to assist the inspectors to meet the challenges at Westray. In fact, the work force of the mine safety division was cut at the very same time Westray was belligerent to get into coal production. As John Smith testified, perhaps they should have asked Clifford Frame for cash (Wilde, 1997). In addition to the death of twenty six men, several other losses resulted from the Westray explosion. There was extensive damage to the mining equipment and the mine itself, not to mention bankruptcy of the parent mining company, Curragh Resources. The mine was closed since it was rendered inoperable. A default of millions of dollars in federal and provincial government loans also resulted. Millions of dollars of severance, unemployment insurance payments, workers compensation and pension plans were also lost. The Nova Scotia Power (the electricity utility company), also lost approximately 700,000 tons of Westray coal. Families and of the twenty six miners also suffered enormous personal losses, on which it is impossible to put a price tag. Potential solutions and alternatives Several important lessons can be learnt from this costly tragedy. It is obvious, viewed from a proactive manner, that the Westray mine had multiple opportunities for loss control. These opportunities presented themselves at the precontact stage, contact (incident) stage, and post contact (loss) stage. In precontact control, the main objectives are to reduce risks and prevent accidents from occurring in the first place. In the case, of an accident occurring, precontact control also involves ways of reducing the severity of the loss. Contact control (the second level of control) involves measures taken to reduce the degree of damage to property and loss of human life at the time of the accident. Post-contact control aims at containing the extent of loss after the accident has occurred. Several lessons can be heeded from Westray for the mining industry- reminders of the importance of, for example, underground ventilation and rock dusting. Most of the reminders are, however, technical in nature, and would find little, if any, application in business, other than perhaps by extension into the realm of mitigation techniques and explosion suppression such as

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relief venting. The most decisive lessons from Westray, nonetheless, are the ones that transcend industrial boundaries and are related to the fundamental principles of loss management. Recommendations In loss management, it is ultimately desired to eliminate risks and accidents altogether (Munro, 2000). Therefore, pre-contact control should be emphasized. This calls for both system and attitude perspectives. A loss management system, supported, implemented and enforced by the management is absolutely critical. Process Safety Management, PSM, is an approach widely used by the Canadian chemical industries. This management system incorporates key features such as training, incident investigation and hazard identification. I would recommend the PSM suite for any modern industry (Munro, 2000). Nonetheless, the only adequate attitude towards industrial safety, both morally and legally, is expressed by the Internal Responsibility System, or IRS. The concept, a foundation of the Canadian health and safety legislation, states that each and every individual in an organization is responsible for safety and health (Munro, 2000). Primary responsibility thus lies with each individual; manager, employee, supervisor, contractor, et cetera, to the extent of their ability to ensure a healthy and safe work environment. This concept, hopefully, avoids the unfortunate occurrence where people of lower management levels are asked to do tasks for which they are not adequately equipped. While the IRS is in one sense a management system for preventing accidents, attitude towards industrial health and safety in an organizations hierarchy is as important as the actual safety management system itself. Immediate technical recommendations would have been to remove the coal dust accumulations or inert them with limestone and relocate the fuel and vehicles to the surface (Jobb, 1994). In addition, recommendations to avoid the hazard would have been to minimize methane accumulation through adequate ventilation systems and design and, minimize the length of miners shifts. An auxiliary ventilation system also needed to be installed. This should have had the ability to ensure adequate airflow to clear methane from the working face of the mine. An alternate design and location of the main ventilation fan so that it does not pick dust and other debris from the coal return conveyor belt would also have ensured adequate air flow. Westray should also have purchased an adequate rock dusting inventory and implemented a rock dusting program in addition to a reliable, robust mine air monitoring and alert system.

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Recommendations to improve the management system would have included program elements such as hiring procedures, safe work procedures, training, and risk identification. Program standards such as suitable follow-through on inspection results and compliance to internal and external standards should have been put in place. The existing Occupational Health and Safety Act ought to be amended to add an objective or purpose clause that evidently states the objective of the legislation is to prevent injury and illness resulting from work (Occupational Health and Safety Act, 1996). One of the most profound lesson form Westray is that tragic consequences are bound to follow if the government and its administrative arm place the economic success of a specific organization r industry above the safety and health of the employees (Jobb, 1994). We recommend section 2 of the Manitoba Health and Safety at Work legislation as an example of a clause setting. We also recommend that the House of assembly creates a Standing committee to address occupational health and safety matters in recognition of the safety and health at work to the people of Nova Scotia. Via this committee, the Occupational Health and Safety Advisory Council and others can publicly report on their activities and answer questions raised by members (Occupational Health and Safety Act, 1996). We, in addition, recommend that mine inspectors should receive adequate training to enable them to effectively enforce legislation. The curriculum should have a tripartite design to include management, labour and representation from government ministries (Jobb, 1994).

Implementation From our perspective, the implementation of these recommendations should reflect four broad principles: First, the health and safety of workers should be given the highest priority by all those that exercise public responsibilities. Second, people who represent the public interest must be adequately trained and professional. They must be the equal of those they regulate. Third, the regulator ought to be accountable to the workers and the community at large. Fourth, the regulation process by which public interest is protected must be open and transparent to public scrutiny at all levels.

THE WESTRAY MINE EXPLOSION References:

Jobb, D. (1994). Calculated Risk: Greed, Politics and the Westray Tragedy. Halifax, Nimbus. Munro, B. (2000). Westray Mine: Managing Risk in The Public Sector. 4th Biennial Process Safety and Loss Management Conference. Calgary, AB, Canada. Occupational Health and Safety Act, (1996). Chapter 7. Province of Nova Scotia, Queens Printer, Halifax, NS, Canada. Richard, J. K. P. (1997). The Westray StoryA Predictable Path To Disaster, Report of The Westray Mine Public Inquiry (Province of Nova Scotia, Canada). Wilde, G. (1997). Risk Awareness And Risk Acceptance At The Westray Coal Mine. Report To The Westray Mine Public Inquiry.