1. Please read this before using presentation
This presentation is based on content presented at the Mines Safety Roadshow held in October 2013
It is made available for non-commercial use (e.g. toolbox meetings, OHS discussions) subject to the condition that the PowerPoint file is not altered without permission from Resources Safety
Supporting resources, such as brochures and posters, are available from Resources Safety
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2. Review of fatal accidents on WA mines 2000-12
What do the findings tell us?
This review undertaken by the Department of Mines and Petroleum looked at mining fatality reports for Western Australia over a 13 year period from 2000 to The aim was to identify some key activities and areas where improvements can be made.
Let’s consider the historical context.
In the 1940s and 50s there was an average of 2 fatalities per 1,000 employees each year. With today’s mining workforce approaching 100,000 this would equate to 200 fatalities each year.
There was a step change in 1960s to 70s with a decrease to 1 fatality per 1,000 employees, which would be 100 deaths per year in today’s terms.
By the 1980s to 90s, there were about 8 to10 fatalities each year for a workforce of around 30,000.
In the 13 years covered by this review, there was an average of 4 deaths per annum.
There appears to be another step change at the end of the review period with no fatal accidents in 2012, and to the present time, one in 2013.

3. What are the employer’s duties?
Provide a safe working environment so far as is practicable
A safe workplace, plant and systems of work
Information, instructions and training
Consult and co-operate with safety representatives and employees
Personal protective equipment (PPE)
Arrangements for safe use, cleaning, maintenance, transportation and disposal of plant
Arrangements for safe use, handling, processing, storage, transportation and disposal of substances
First, let’s look at the legislative framework for mines safety in Western Australia the Mines Safety and Inspection Act
The slide summarises section 9.
The legislation outlines the duty of the employer to provide and maintain a safe working environment, so far as is practicable, so as to prevent employees being exposed to hazards which could cause injury.
A safe work environment involves work places, equipment, and systems of work where the hazards are known and controlled.
People are provided with information, instruction (including supervision) and training so they are prepared for the tasks they will undertake. Training involves knowledge not just how to do the job, but knowledge of the hazards they might have to face during their daily working activities.

4. What are the employee’s duties?
Take care of own safety
Do nothing to adversely affect others
Report incidents and hazards
Assist with development of safe systems
Safety representatives and committees
The employee has duties to not to do anything that would interfere with their own safety and do nothing to adversely to affect other people’s safety. They need to report incidents and hazards, which the employer should respond to and come up with solutions. Employees should directly assist with the development of safety systems themselves, or through safety committees and safety and health representatives.
This slide summarises sections 10, 11 and Part 5 of the Mines Safety and Inspection Act, 1994.

5. What are the objectives of this review?
Identify common causation factors
Look for any trends and clusters
Analyse data for hazards and critical activities
Provide information to industry stakeholders
Recommend improvement areas for safety performance
Reduce risk of injury to employees at mines
What were the aims of the review?
Identify common causation factors, which can be any immediate or underlying issue that can effect an outcome.
Millions of tasks were completed over the 13 years covered by this study. These led to 52 fatal accidents. This sample size is too small for statistical comparison and therefore the reviewers looked for any trends and clusters that contributed to these accidents.
Analysis of the data identified common hazards and critical activities. A person might conduct 50 to 100 tasks during a shift, of which 1 or 2 could lead to a situation with the potential for serious injury or death. So knowledge of these critical tasks is important when addressing risks.
Provide information to industry stakeholders through events such as the Mines Safety Roadshow, and releasing this toolbox presentation for industry use.
Recommend areas for industry to tackle that may result in improved safety performance to reduce the risk of injury to employees.

6. Methodology
Archives of 52 fatal accidents from WA mining industry for 2000 to 2012
Records of investigations from DMP archives
Current investigations
Selected causation factors
Analysis of data
Presentation of results to industry
Methodology looked at archives and reports held by the Department of Mines and Petroleum.
Every time there is a fatality, there is a detailed investigation conducted by the Department. The inspector who leads that investigation completes a report which goes to the State Mining Engineer. The report is used for a number of purposes. As well as supporting any legal proceedings that may ultimately arise, it also provides information to the Coroner for the inquest process and is used to raise awareness of any safety improvements required.
The review includes investigations that are still in progress and proceeding through the system. Note that individuals, individual cases and companies are not identified in the data presented here.
Findings indicate that many of these fatalities are caused by situational factors – the task or activity the person was doing at the time probably had the greatest influence on the outcome. Understanding the total safety environment around the task is important in coming up with a full analysis of the situation.
Note also that not all investigations contained information that was consistent with another. Not everything was investigated in precisely the same way, although the structure of the investigations was the same. When the fatality reports were being prepared, some situations require more information on particular aspects than others – therefore the numbers in some graphs don’t always add up to 52 (the total number of fatal accidents during the review period). Again, from the perspective of statistical analysis, we need to remember that the sample number is small (fortunately).

7. Employee statistics for WA mining
3,517
35,465
769
38,982
Employee statistics over the review period
Shows the industry went through a period of tremendous growth.
Increase from about 40,000 to almost 100,000.
Increase in all environments – exploration, underground mining and surface mining.
13 year period, about 4 mining-related fatalities per annum.
Although 52 is statistically a small number over such a long period, every one was tragic and traumatic for all involved.
Click through to highlight numbers:
Click 1 - Exploration fatalities
Click 2 - Mining fatalities
Click 3 - Mining labour force
Click 4 - Surface labour force
Click 5 - Underground labour force
Click 6 - Exploration labour force
4,059
3,211
10,500
85,190
96,690 2 50

8. 2000-2012 Total employees and fatalities
Here is graph showing in red the workforce numbers for the WA minerals sector and in blue the number of fatalities over the period of the review.
The red line shows how the number of people have grown in industry – fairly steady and consistent rise except for slight dip about 2009 due to layoffs during the global financial crisis.
Many people came into the minerals sector who had never worked in mining workplaces before – they may have had no association with the mining industry or Western Australian conditions.
The blue line shows number of fatal accidents each year. The graph starts from a peak continuing on from the 1980s to 90s. Much work was done in the late 1990s to reduce the number of fatalities in underground mines. We then see a rise that somewhat parallels the pattern of employment, peaking in 2009.
In 2009, under direction of the then-Minister, Commissioner Kenner released his report on a detailed review of the safety regulation of the mining industry in Western Australia. The report made a number of recommendations for Resources Safety and most were enacted. Some of them are still being implemented today as part of the Reform and Development at Resources Safety (RADARS) strategy. RADARS has resulted in changes to the delivery of safety regulator services by the Department, while also reinforcing the need for industry as a whole to ensure adequate risk management processes are in place.
Since 2009, there has been a decrease in the number of work-related fatalities, with the first fatality-free year being recorded for 2012.

9. Factors considered Principal employer Mine site
Date and day of fatality
Age – deceased and supervisor
Occupation
Category – surface or underground
Activity – maintenance or production
Commodity group
Procedure and compliance
Modifications to original equipment manufacturer’s (OEM’s) procedure
Trigger – unsafe act or workplace
1st of 2 slides. Factors considered (all categories looked at)
Developed progressively through the study of archive reports.
Not all factors considered in all the investigation reports.

10. Factors considered Roster cycle – deceased Days into roster
Shift – day or night
Time of accident
Hours into shift
Duration of employment at mine site
Duration in the role – deceased and supervisor
Contractor
Visa status – 457 Visa
Language – English speaking
Events resulting in fatality and additional information
2nd of 2 slides. Factors considered (all categories looked at)

11. Occupation of deceased
Tradesmen 9
Fitters 3
Electricians 4
Technicians
Maintenance
Operators 5
Haul truck drivers 4
Service vehicles 3
LHD (bogger)
Jumbo 1
Bulldozer
So who was actually killed over the review period?
The occupations have been broadly categorised. Tradesmen and operators represent about 70% of the total.
Fitters were the category most at risk – working on large plant (mobile and fixed) and heavy mobile equipment
Over the review period, there was a transition of who was at risk. There has been a major shift over the years from more “traditional” mining occupations [involving underground jumbos, air-leg miners and load-haul-dump (LHD) machines] to general mining environments including construction and maintenance activities.
Let us look at what the data may be telling us. During the review it became apparent the first year was vitally important.
The next three slides consider duration, how long people have been:
in the roles and jobs
at the mining operation
in supervisory positions
comprise 70% of total

12. Duration in role – deceased
0-12
25-36
37-48
49-60
61-120
>120
13-24
Months in job
The bar graph on the right shows the employee’s time in the role. Duration is number of years that person has been in the role (e.g. a fitter, truck driver, dozer) even it was at a different mine.
Number of fatalities in first year is higher than other years. Note that number of fatalities has been combined for 10 years or more (>120 months).
The pie graph on the left shows the data another way (as proportion of total fatalities rather than actual number) and highlights the importance of the first year in a job when considering risk factors.
31% of fatalities were in the first year, and almost half that again in the first two years.
Possible reasons:
May reflect turnover rates to some degree.
Still developing skills and competency.
Hazard ID and knowledge of critical tasks.
Importance of training and supervision.
48% of fatalities were employees within first 24 months in the job or role
Risk of fatality is nearly three times higher within first year in job or role, compared with third year
Relevance to total numbers employed in each category is not shown as statistics for totals are not available

13. Duration at mine site – deceased
49% of fatal accidents occur within first year at mine site
This graph shows the importance of the first year at the mine. Nearly half of all the fatal accidents were associated with people who had been at a particular mine for less than one year.
Even in the first week and first month, people were getting killed.
Possible reasons:
Still developing familiarity with –
Workplace
Tasks
People

14. Duration in role – supervisor
1-6 days
3-4+ years
5-6+ years
1-2+ years
1-11+ months
11 years and more
6% of fatalities occurred under supervision of supervisors who had been in role for less than one week 44% of fatalities occurred under supervision of supervisors who had been in role for less than one year 68% of all fatalities occurred under supervision of supervisors who had been in role for less than three years
This pie graph shows how long the supervisor had been in that role when the fatal accident occurred.
Again, look at the importance of the first year in a supervisory role. 44% is a huge indicator of the influence of supervisor training and development on the fatality data.
Possible reasons:
Technical and experienced operating staff given supervisory position without any supervisory training.
Supervisors need to understand potential hazards within their workplace and ensure employees are completing tasks in line with procedures and processes.
May also reflect turnover of staff and staff tenure.
No fatalities for 1-4 weeks, 7-8+ years, years
Relevance to total numbers employed in each category is not shown as statistics for totals are not available. Small sample size as incomplete records due to information not being requested at that time

15. Compliance with procedures
Were procedures in place at the time of accident, for the work being conducted? This impact that procedures have on fatality data is shown as a percentage of total.
The chart shows that in nearly three quarters of the fatal accidents, a procedure was available for the task being undertaken. Non-compliance with the procedure accounted for 62% of all fatalities compared to the 11% that were compliant. In the remaining 27% of fatalities procedures for the task were absent.
Possible solutions:
Hazard- and precaution-based safety focuses on importance of following procedures, if there is a known hazard with a known precaution.
Have systems in place that ensure people do the job properly the first time (don’t reinvent the wheel).
Conduct a risk assessment for any new tasks, machinery or change management where there may be unidentified hazards.
Once written procedures are in place, implement training processes to make sure all employees and supervisors are well trained in the jobs they have to do, and employees have knowledge of hazards they might face.
Take-away messages:
Start thinking about the effectiveness of current procedures in the workplace and the effectiveness of administrative controls.
If people are well trained and involved in the developing the systems of work (as legislation requires), you can make a huge impact on performance in the workplace.
73% of fatalities occurred when there was a procedure in place

16. Time of day No trends in roster type No trends for days of week
Some clusters identified:
last 2-3 hours day shift
5 hours into the shift
11 pm and 3 am on night shift
Biorhythms
Fitness for work
Human error
Fatigue and concentration
What about the time of the fatality, based on whether it was a day or night shift, given a shift is usually 12 hours?
The axis for time of day covers 24 hours and starts at 6am, when most day shifts get underway.
A wide range of rosters were represented, with the majority being 2 weeks on and 1 week off arrangements. People sometimes suggest that the roster type or day of the week is significant. This notion however, was not supported by the sample under the review period.
The graph shows there are peaks at the following times:
3-6pm, the last 3 hours of the day shift. Clock at 4 pm. Note that this is not reflected in the night shift data – the last 2 hours of the night shift (4-5am) appear to be two of the safest hours in the working shift.
11 am (day shift) and 11 pm (night shifts), which is roughly 5 hours into the working shift.
Another peak at 3 am during night shift.
Possible reasons:
Human factors, such as a person’s biorhythms, may influence the likelihood of an error.
For a standard day shift for worker: May include waking early and then working for an extended period of time until lunch (may become fatigued, lose concentration, and more prone to accidents – 11am). After lunch break and another long work period the worker is focused on finishing-up for the day and shift change (lose concentration – 3-6pm).
For a standard night shift for worker: May include an extended work period with fatigue setting in (11pm) before the break at midnight (normally a time everyone is in bed). After working through dead of night (a time favoured for military action, a time when people are least alert; 3am), the last two hours of the shift sees the worker feeling refreshed, getting ready to finish, in sync with their biorhythm cycle.
Fitness for work issues.
- e.g. Road safety campaigns promote driver breaks every two hours or so to maintain concentration.

17. Days into roster
More fatalities at beginning of roster cycles than at end
Peak is on day Wide range of roster types
Longest roster cycle was 28 days
This graph charts the number of days into the roster the fatality occurred. These results indicate there was nothing really to show any particular roster type is worse than another type. The longest roster cycle was 28 days. If anything there were more accidents towards the beginning of the swing than at the end.
Possible reasons:
Difficult to say as insufficient data to normalise. It is not known how many people in the workforce were on what roster.
There is a peak on day 5 with 9 fatalities, but then only 1 fatality on day 6. If these two days were averaged, there would be 5 fatalities for each of those days, which would match the trend of about 4 fatalities each day of the roster, for the first 10 days or so.

18. Age group of deceased 29% of fatalities aged 18-27 (10 year increment)
17% of fatalities aged after completion of apprenticeships (5 year increment)
29% of fatalities aged (10 year increment)
44% of fatalities aged 18-32
There was no clear pattern from the evidence to suggest that the age group of the deceased was a significant factor. The youngest person who died was 18, and the oldest was 62.
It has been said that the younger more inexperienced age group may be more at risk, but there is not a pronounced difference when compared with other age groups. It should however, be noted that there is no information to show total number of workers in each age group, and therefore whether any group is over-represented.
These statistics are not shown relevant to total numbers of employees in each age group

19. Commodity group Gold and nickel account for 56% of mining fatalities
Iron ore
Nickel
Other
This pie graph shows the commodity being mined where the fatality occurred.
The gold sector was the main problem area during the review period. When gold and nickel results are combined, they account for well over half of the fatalities (particularly in the earlier years of the review period). This probably reflects their similarities in terms of the geological environments and geographic locations, and significant proportion of underground operations. Most of the gold and nickel fatalities took place in the Eastern Goldfields within the Yilgarn Craton, where rocks are under significant stress.
Iron ore accounts for a third of the mining fatalities (with numbers increasing in the later years of the review period, when significant projects commenced in the Pilbara).
Considerations:
Each commodity has a distinct natural risk profile.
Most underground mines are in the gold and nickel sectors.
The Pilbara has large open pits and big machines moving large quantities of material.
The South West has mineral sands, stone quarries, aluminium operations and open pit coal mines.
Gold and nickel account for 56% of mining fatalities
33% iron ore
11% others (limestone, hot briquetted iron, diamonds, alumina)
Major mining provinces in Goldfields and Pilbara still areas of concern

20. Surface and underground fatality comparison
Total underground fatalities are about half that of surface
As a proportion of the total workforce, underground workers were over-represented in the fatality numbers by a factor of almost five
Marked improvement in underground safety since 1990s
Historically, in the 1980s to 90s, underground fatalities exceeded those on the surface. A 1997 review of fatalities found that of the 25 fatalities over a three year period, 11 of these fatalities related to fall-of-ground incidents.
Although underground workers were over represented by a factor of five when normalised to workforce numbers, this trend started reversing over the review period. The most recent fatal accidents have been in the iron ore sector (i.e. surface), rather than underground.
Possible reasons:
Changes in ground support standards and geotechnical knowledge have led to improved safety performance for underground mining.
Improved mine planning and stope scheduling in underground mines.
Use of remote loading techniques and raise-boring instead of rise-mining.
About 10 times more employees in surface operations than underground.

21. Ten critical factors – multiple fatalities
1. Fall arrest equipment
2. Departure from OEM procedures
3. Run-away vehicles
4. Vehicles over edges
5. Vehicle collisions
6. Electrical contacts
7. Rock falls
8. Pit wall failures
9. Inrush situations
10. Tyre handling
These top ten critical factors have been highlighted as they have led to multiple fatalities. These ten factors comprise over three quarters of the total fatalities and involve a number of single-incident repeat situations – apart from the inrush situation – which involved three fatalities in a single event. Only one quarter are one-off situations during the review period.
The selection of critical factors was based on the evidence and findings presented in the fatality reports.
Each factor is detailed to help outline the factors at work in these major areas of concern:
Fall arrest – If there is an edge, hole, gap then people can and will fall through it. Falls studied were not just from significant heights (i.e m) but also from just over 1m, which can also result in a fatal injury (i.e. head injuries). If people are working in an elevated work area and they are not protected correctly, there is the potential to fall. In some cases, people were wearing the correct fall arrest harness but these were not attached to a secure anchor point.
Departure from OEM procedures – Incidents occurred mainly where fitters were working on large pieces of gear, the procedure was there but not followed. If you work in workshop maintenance, make an attempt to check procedures are available and followed. If not, the applicable work should be subjected to a thorough risk assessment.
The next 3 factors relate to mobile equipment:
Run-away vehicles were mainly related to park-up procedures or a loss of control on an incline.
Vehicle over edge – Large equipment (mainly haul trucks) going over the back of a waste dump or stockpile area, or small vehicles tipping over.
Vehicle collisions – This contact is associated with layout of roadways, operating pit rules, and operating procedures.
These are covered in more detail in a separate toolbox presentation. See Mobile equipment issues (2013) presentation.
Electrical contacts – These were carbon copy situations – someone was working in an open electrical panel and has come into contact with a live circuit, either through their body or a tool. This is a critical accident situation that electrical people need to be aware of.
Rock falls – Used to be ranked number 1 in 1980s and 90s – a lot of work has been done in this area (i.e. improved geotechnical monitoring systems; elimination, substitution and engineering out of hazards – e.g. remote bogging underground).
Pit wall failures – Pit walls have failed behind people. This can be addressed by improved pit design and monitoring.
Inrush situations – 3 people were killed in one accident when a tailings fill wall collapsed because the hydraulic head behind it exceeded the wall’s design capabilities. Resulted in the tailings rushing into the mine.
Tyre handling – Issues included gravity and weight (tyres falling onto people) and compressed air during tyre inflation.
Note: Safety bulletins and significant incident reports are available on the DMP website in relation to fatalities on WA mine sites.

22. Less critical factors The mine The employer The type of roster
Day of the week
457 visa
Maintenance, production, operations
The most significant critical factors relate to safe systems for common tasks and mining methods. The focus should be on the task, job or activity.

23. Proposed areas for improvement
Identification of hazards and critical tasks
Principal hazard management plans
Written work procedures
Involvement of employees
Training processes – employees and supervisors
Supervision to standards
Site familiarisation and induction
Adequate breaks during the shift
What can industry do with this information to improve safety performance?
Identification of hazards and critical tasks (most important) – Everyone needs to understand what hazards they are going to be faced with during the day and what critical tasks everyone does on a day-to-day basis. We need to know what can go wrong and what can kill when doing a particular job.
Principal hazard management plans (PHMPs) – The repetitive failures that we see in the review match the principal hazards identified by the National Mines Safety Framework. All operators need to have knowledge of the hazards on their site that can cause multiple fatalities and repeat fatalities.
Written work procedures – Need to be developed for hazards that have been identified, and modified if the situation changes.
Involvement of employees – Employees need to know the written work procedures and need to be involved with developing those procedures.
Training processes (employees and supervisors) and supervision to standards – Once the procedures are in place, there needs to be training processes to ensure all employees and supervisors are well trained in the jobs they have to do and have knowledge of the hazards they might face.
Site familiarisation – People need to be conscious of employees entering the industry, they need time to familiarise themselves with what’s going on, the roster cycles and different working environments (this may include a site tour at night, when things look different). They need time to get to know work mates, supervisors and work processes.
Adequate breaks during the shift – The need for breaks during shift is a long standing issue. We need to be conscious that people cannot sustain focused activities for long periods of time and breaks are needed. The likelihood of someone making an error increases with fatigue and lack of concentration. As a minimum, the site’s fatigue management plan should be reviewed in regard to the problem times identified around 3am, 11am, 4pm and 11pm. What sort of breaks might be required?