The Weekly Reflektion Week 41 / 2020

Major Accidents often lead to a revision of relevant standards to help prevent a recurrence. There have often been signals that improvements have been needed, but perhaps these have not been heeded.

This month is the 99-year anniversary of the Mount Mulligan mine disaster in Australia, and we will revisit the accident in this Reflektion.

Do we need a Major Accident to revisit the regulations, or are there better ways?

The Mount Mulligan mine in North Queensland in Australia had been open for six years when, on September 19th, 1921, an explosion killed 75 workers, including 4 standing at the mouth of the pit. There were no survivors, and only 11 bodies were recovered. The explosion could be heard 30 km away from the mine, giving a measure of the size of the explosion. Every household in the small town suffered a loss in this disaster.

The coal mine was considered a safe mine since there was no methane associated with the coal deposits. Open flame was used as lighting in the tunnels, although electric safety lamps were available at the time. The Royal Commission set up to investigate the explosion found that the cause of the ignition was “the firing of an explosive, either accidentally or otherwise, on top of a large block of fallen machine-cut coal, such explosive not being placed in a shot hole”. This was followed by a massive coal dust explosion throughout the mine. They found that a culture had developed where explosives were distributed, used and stored underground in “a careless manner’’, and that mine inspections were made by men without mining experience, without the necessary equipment, and these inspections were not made as frequently as necessary. The mine was extremely dry and dusty and no adequate means to combat the build-up of coal dust were adopted as prescribed by the regulations of the day.

Following the disaster, a Coal Mining Act was introduced, with provisions to ensure mining inspectors had practical experience, rules to ensure safe use of explosives in coal mines, banning of naked flames in mines, and requirements for air flow and the use of ventilation fans. It may seem obvious with hindsight that these risks should have been mitigated, but coal mining fatalities in Australia were common at that time, and it appears that coal mine management accepted this as inevitable. This disaster came as a ‘wake-up’ call.

At the Reflekt breakfast seminar in April 2018 we talked about the Kings Cross Underground station fire in London in November 1987. The management of London Underground considered fires inevitable and hence made little attempt to prevent them and limit their escalation.

Are there accidents and incidents that you consider inevitable and do not try to prevent? Does your audit and inspection plan achieve its goals? We have learned a lot in the past century, but do we still need Major Accidents to make a step change in safety?

Reflekt AS