A small lump of coal
I make this pledge to the families. Westray will not be some vague memory of a tragic accident. It will be a living, active presence in workplaces across Nova Scotia. Your husbands, your fathers, your sons, your brothers, your friends, will never be forgotten. Every time someone wants to cut a corner or bend a rule, we will remind them there can never be another Westray and this government will not allow it.
Minister of Transportation and Public Works
speaking on the floor of the Nova Scotia Legislature, 1 December 1997
Coal – the rock that burns – is a fuel, a source of energy. Coal is composed mainly of carbon (50-98 percent), hydrogen (3-13 percent) and oxygen, with lesser amounts of nitrogen, sulphur and other elements. Some water is always present, as are grains of inorganic matter that form an incombustible residue known as ash.
Coal provides a large part of the world's energy supply (a largely unknown fact). In the 1990s and continuing into the new millennium, coal was/is the primary energy source for about 55% of all electric power generation in the United States and Canada. In Nova Scotia, coal accounts for about 80% of all electric power generation.
| Electric Power from Coal Nova Scotia |
|
|---|---|
| Year | Generated from coal |
| 1993 | 71.4% |
| 1994 | 79.9% |
| 1995 | 78.1% |
| 1996 | 85.8% |
One kilogram of coal contains enough energy to generate about two kilowatt-hours of electrical energy – this figure varies considerably depending on the quality of the coal but 2 kWh per kilogram is a reasonably representative average for coal burned in a modern high-pressure boiler (producing steam at a pressure of about 1800 pounds per square inch) to drive a steam turbine to generate electricity.
Westray was an underground coal mine located in the tiny village of Plymouth, near Stellarton in Pictou County, Nova Scotia. Westray was developed to mine coal from the Foord seam, long known for its high-quality coal and for being exceptionally gassy.
It has been known for centuries that methane-rich gases are trapped in most coal seams. The quantity of gas trapped in any particular coal seam varies widely. The Foord seam has been known since the mid-1800s as being exceptionally gassy. Any digging or drilling activity that disturbs the Foord seam releases quantities of methane (firedamp), which doesn't matter much in an open-pit mine with lots of fresh air, but in an underground mine like Westray, methane mixed with air can be an extremely dangerous explosive. The Foord seam contains roughly 100 to 500 cubic feet [3 to 15 cubic metres] of methane per ton of coal.
The Pictou coalfield, with its thick and gassy seams, has been mined for some 200 years.
...Foord coal has among the lowest sulphur content of any North American coal... The Oil Coal Seam (or Stellar Seam) – seven layers below Foord – was mined in the early 1850s and oil extracted from it was used to light Boston streets; that ended when oil was discovered in Pennsylvania in 1859...
— Halifax Chronicle-Herald, 11 May 1992
The Foord seam, which Westray was mining, has hosted at least eight mines. The Allan mine, the most productive and the one that lay just northwest of Westray's workings, finally closed in the 1950s, but during its 40-year lifetime, it experienced at least eight methane explosions. This history was well-known in Pictou County when the proposal to open a new mine, called Westray, was promoted in the late 1980s.
Local historian James Cameron has estimated that 576 deaths occurred between 1866 and 1972 in mining in Pictou County and that 625-650 died "from colliery misadventures in Pictou County" since coal mining began in the early 1800s. In the Foord pit there is special danger "on account of the liability of cutting heavy feeders of gas"... – quoted from a report by Henry S. Poole, Inspector of Mines, in the Nova Scotia Department of Mines Annual Report, 1873.
Because of the promise of a substantial number of well-paid jobs in an economically depressed area, the development of the Westray mine received considerable political support from the provincial and federal governments despite the opposition of technical experts and despite the history of mining fatalities in the area.
Charlie Angus described it vividly: "When Curragh Resources' mining boss Clifford Frame started talking about opening a mine in the economically depressed area of Stellarton, Nova Scotia, in the late 1980s, politicians flocked to him like seagulls at the beach."
Pictou County has been a political powerhouse for decades. The federal electoral district of
Central Nova (which included Pictou County) was represented, from August 1983 to September 1984, by
Brian Mulroney. Mr. Mulroney's next job was Prime Minister of Canada from 17 September 1984 to 24 June 1993, a time which included the promotional phase, the construction and the entire working life of the Westray Coal Mine.
From September 1984 to September 1993 – including the promotional phase of the Westray Coal Mine, its construction and its entire working life – Pictou County was represented in Ottawa by MP
Elmer MacKay, a member of the federal cabinet as Solicitor General of Canada, then Minister of National Revenue, then Minister of Public Works – powerful senior ministerial offices.
The Provincial MLA for
Pictou East, which included the Westray Mine, was
Donald Cameron, who had been elected as MLA in 1974 and appointed Minister of Fisheries in October 1978. By the time Frame began promoting the Westray coal mine, Cameron, then Minister of Industry and a member of cabinet for more than a decade, had a deep understanding of the levers of power in the Nova Scotia government. Mr. Cameron was Premier of Nova Scotia from 26 February 1991 to 11 June 1993.
The Westray mine was promoted by Curragh Resources Incorporated, an Ontario company controlled by
Clifford Frame. In November 1987, Curragh incorporated a subsidiary company, Westray Coal, to construct and operate the new mine.
On 9 September 1988, Westray finalized a deal for the purchase of coal interests in Pictou County then owned by
Suncor Inc. – 75% owned by Sun Oil Company (Sunoco) – and signed an agreement with Nova Scotia Power Corporation — Nova Scotia's largest electric utility, then owned by the Nova Scotia government — which agreed to purchase Westray coal for its new coal-burning electric generating station at nearby Trenton, Nova Scotia. A letter dated that same day was sent to Westray by Donald Cameron, provincial minister of industry, trade, and technology, which committed the province to a mining lease, a loan of $12,000,000 and a take-or-pay agreement for 275,000 tonnes of coal per year for fifteen years.
After two years of protracted and difficult negotiations, on 27 June 1990 a deal was finalized, between the Federal Government and Curragh Resources Inc., to provide funding for the development of the Westray coal mine. Construction of the mine had been going forward for some time before that date. Early in 1989, Curragh's subcontractor, Canadian Mining Development, began driving (constructing) the main access tunnels.
The mine was financed through massive infusions of Federal and Provincial funds in the form of loans and loan guarantees. The Federal contribution consisted of an 85% guarantee of a $100,000,000 bank loan. The Province of Nova Scotia contributed $12,000,000 by way of a fully-subordinated loan – meaning that this loan will be repaid only after all other lenders have been paid in full, and if there isn't enough money to go around (there wasn't), the provincial loan will not be paid back. The Provincial government also entered into a rather controversial "Take or Pay Agreement" whereby the province agreed to purchase any excess coal which was not taken by the Nova Scotia Power Corporation.
The contribution by Curragh Resources Inc. to the project consisted of a $9,000,000 cash investment plus a "deferral" of management fees allegedly owing to Curragh.
The official opening of the mine was on 11 September 1991.
On 5 May 1992 — four days before the Westray mine exploded — the company's name was changed from Curragh Resources Incorporated to Curragh Incorporated.
The Westray mine commenced operations (began producing saleable coal) in June of 1991 amid claims of it being a veritable "State of the Art" operation utilizing the latest in mining technology and equipment with computerized safety monitoring devices which were said to be at the leading edge of current technology. After the explosion, the claim that the mine was designed and built with state-of-the-art techonolgy was called into question. The mine was plagued with serious ground control problems related directly to the geological configuration of the Foord seam. This problem was exacerbated by the lack of competent planning. The ground control problems led the Westray Mine Public Inquiry to conclude that "The cost of operating in such an adverse environment and the inherent uncertainties would suggest that the financial viability of the Westray project should have been in doubt from the very beginning".
Production was erratic during the brief (less than a year) life of Westray and production quotas were never realized.
At 5:18 Saturday morning, 9 May 1992, the mine blew up killing all 26 men working underground. The explosion was so strong it blew the top off the mine entrance, more than a mile above, and blew away steel roof supports throughout the mine. In the nearby towns, windows shattered and houses shook.
The mine ceased operations at the moment of the explosion and never re-opened.
Westray Coal Inc. and Curragh Inc. both went bankrupt. Curragh's residual assets were subsequently acquired by 1235866 Ontario Inc. (which was owned by former Curragh creditors including the Yukon government). The Province of Nova Scotia's $12,000,000 loan would never be repaid. The Federal Government's 85% guarantee of Curragh's $100,000,000 bank loan was called by the bank after the explosion, and the government paid $85,000,000 to the bank — that money is gone forever (but, because these payments are now part of the government debt, the interest on the $12,000,000 is an expense paid every year by Nova Scotia taxpayers, while the interest on the $85,000,000 is an expense paid every year by Canadian taxpayers.)
More about the Westray Coal Mine Wikipedia
Chronology: Westray explosion, 9-10 May 1992
by Halifax Chronicle-Herald
Chronology: Westray Mine Public Inquiry, May 1992 - 1996
by Westray Mine Public Inquiry
Chronology: Westray legal proceedings, May 1992 - May 1995
Source: The Queen versus Curragh Incorporated
Supreme Court of Canada, [1997] 1 S.C.R 20 March 1997
This court decision contains a detailed timeline of the legal proceedings associated with the Westray Criminal Trial. The timeline begins about one-quarter of the way down the page, at
paragraph 22: "To appreciate the complicated background and procedural activity that occurred throughout the course of this case it is helpful to follow a time line..."
Curragh Resources Clifford Frame's website
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Leroy Legere was Minister of Labour from February 1991 to November 1992. In his report on the Westray Mine Disaster, Justice Peter Richard said that Legere "appeared to have a confused and uncertain appreciation of his role as a minister of the crown", that he had "little understanding of the operation of the Occupational Health and Safety Division of the Department of Labour" and that it was incumbent on Legere "to keep informed and to ensure that adequate remedial action was taken" once he was informed of deficiencies in his department — things Legere failed to do.
(All quotations taken from v2, pages 529-530, of the inquiry report.)
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Dr. Susan Dodd, testifying before the Standing Committee on Justice and Human Rights in Ottawa, on 22 May 2002
...When I first started thinking about this, it didn't seem possible that...the burden of holding the culprits responsible would fall to bereaved relatives of the dead. But not only was it possible, it's exactly what happened...ten years ago when the highly subsidized Curragh Resources (Westray coal mine) management intimidated workers, bullied compliant inspectors, and then evaporated into bankruptcy with millions of dollars in taxpayers' money...
We need to recognize organizational culture as something people make and remake on a daily basis, and that deaths like those in the Westray mine are not the inevitable outcomes of things left undone. It's not a matter of neglect, but of the consequences of positive acts, of choices made in pursuit of profit, and these days, of increasingly deregulated workplaces.
Often the authors of those choices are hidden within the black box of the corporate hierarchy, and this black box is a culture within which corporate decision-makers decide on the priorities of the organization. If this government wants people to believe there is justice in this country, it will need to draw on the rich literature on corporate criminology and develop ways to either shed light on the contents of such black boxes or to compensate for this lack of transparency by finding means to discipline the corporation as if it were an agent in its own right...
http://cmte.parl.gc.ca/cmte/CommitteePublication.aspx?SourceId=15933
...although many studies have been conducted on grieving people, the loss experienced by family members of the fallen Westray miners is unique. "This traumatic loss has been complicated by the senselessness of the event, the belief that justice has been denied, and the betrayal felt by many of the family members." The aftermath of the disaster is well documented. The response from the parent company (Curragh Resources) and the Government of Nova Scotia was that the explosion was an accident. This explanation outraged family members of the deceased. Their loved ones had openly criticized the dangerous conditions underground and had even reported the company to the provincial Department of Labour. The families argued that the explosion was entirely foreseeable and preventable – that it was a case of criminal negligence... after a series of mishandled criminal prosecutions and despite the findings of the inquiry, no one was ever held accountable for the 26 deaths... Although the sample size is small, it is believed that the results still shed light on how people cope with losses that are perceived to be unfair...
— Source:
Carleton Now May 2007 (Cover Story)
Carleton Now is the "flagship internal communications vehicle" of Carleton University, Ottawa
This report describes the results of an analysis of the public inquiry hearings held after the Westray Coal accident in May 1992. At the request of Mr. Justice K. Peter Richard, Commissioner, I investigated the content of the hearings in order to develop insight into the degree to which Westray employees perceived the risk of accident as imminent and why the miners either accepted or rejected the risk they perceived. While some miners terminated their employment with the mine because they were unwilling to accept the accident risk, others continued to work until the accident happened. Various factors that contributed to the employee perceptions of accident risk were identified, and it may be inferred that the perceived probability and expected seriousness of an accident was both high and general throughout the underground workforce. Moreover, the willingness to accept high levels of danger amongst those miners who did not quit may be atrributed to the operation of various factors, among which economic pressures and economic incentives played a major role. Mine management, rather than putting in place a safety-incentive programme of a type known to significantly improve cautious and accident-free performance, instituted instead a remuneration schedule with a progressive production bonus component that appears to have exacerbated risk acceptance and the frequency of imprudent practices among the miners. The pursuit of short-term economic gain may well have set the stage for the fatal explosion and the mine's premature demise.
At the top of his paper (next above), Dr. Wilde has the following quotation — from Day 33, February 20, 1996, of the transcript of the Westray Mine Public Inquiry Commission — in bold red type:
The way we blind ourselves to honest assessment of risk goes back a long way. I wrote an essay on risk management philosophy in general, giving Titanic as the specific example, and put it on the Web
(see "The Titanic Disaster: An Enduring Example of Money Management vs. Risk Management" below)
... As individuals, we may learn from close shaves and warnings; as a society, we only learn from blood... The touchiest thing in risk management is the calculation of cost per fatality averted... Vaughn's five steps: New information would come in that signalled danger. Engineers would document the danger and express concern. This evidence would be given close examination, but of course by a process that was aware that terrible schedule or money consequences would result from a negative decision. However, unacceptable risks with life or mission cannot be just accepted; the positive decision would be that the risk itself was in fact tolerable. What was a deviation at step one would, after further launches, become the new normal. So the cycle could repeat — a few more percent of change each time... There were no lies told... It was far deeper than that. They learned how to lie to themselves...
(boldface emphasis added)
...The week in 1995 I wrote the original essay, thousands of semi-trailers in Canada were being pulled off the road to have their outer wheels inspected. Two cars full of people had been killed in two weeks by semi wheels that had come loose and run wild. It turned out that such things had been happening every month or two all along; this was just the first time that several fatalities had happened. As individuals, we may learn from close shaves and warnings; as a society we only learn from blood... The touchiest thing in risk management is the calculation of cost per fatality averted. It makes perfect sense to an engineer, but in public debate, such numbers can always be twisted in any direction... The problem for the engineer is to tackle these fears with his own art, which involves quantifying things. The summary of one paper in those conference proceedings went right to the heart of the issue – he had calculated the cost per fatality averted for various different approaches of ship subdivision, so as to recommend which design to use. This is good engineering and I wish all society thought that way; but I guarantee you that any politician or top bureaucrat will flee the room, eyes averted, if he shows them the paper; they'll want deniability in public debate... I think that all engineers face the same two kinds of problems in the end. The junior ones have to crank out the most effective design they can, given a cost envelope and set of standards. The senior ones have to run the calc in reverse, starting with a design that fits their conscience, to sit on the standards committees, and push for the cost envelope that will make it possible. Sometimes they don't, or can't, push hard enough. But to be fair, they do have a handicap – scientific people often don't communicate well with policy makers, or the general public. They tend to argue with facts, formulas, simulations, and other kinds of sweet reason. These don't work well. What does work well are shameless appeals to emotion... Like baby seals covered in oil. And always, always, casualty lists. Best of all are individual stories of casualties, to make the deaths real. We only learn from blood.
(boldface emphasis added)
As I sit down to write, it is 11:40pm, April 14th, 1995. Ignoring the time zone difference, it was 83 years ago this minute that the RMS Titanic, on her maiden voyage in 1912, struck an iceberg... Most of the problems all came from a larger, systemic problem: the owners and operators of steamships had for five decades taken larger and larger risks to save money – risks to which they had methodically blinded themselves. The Titanic disaster suddenly ripped away the blindfolds and changed dozens of attitudes, practices, and standards almost literally overnight. The perception persists that the Titanic was, if obviously not "unsinkable" (though the White Star line actually never used that word in advertising), then very safe, as safe as the art could build her. That, despite various errors, the accident was mostly enormous bad luck. Nothing could be further from the truth. It was amazing good luck that there had been no similar accidents years earlier. For over 50 years, safety standards had been steadily deteriorating in various ways – almost always because of pressures to be "competitive"... The first great liner, the Great Eastern, built in 1858, was designed by I.K. Brunel, England's most celebrated engineer, who got every feature he wanted. Great Eastern was not the most profitable ship, but she was a triumph of safety. She had an entire inner hull two feet inside the outer. Inside that, the ship was divided by 15 transverse bulkheads, and one lengthwise into 32 compartments. Watertight lower decks further divided those... All risks need rational consideration, and some must be accepted... Even today however, it is still often the case that money management wins out over risk management...
Abstract: Technological crises are predictable and inevitable, particularly in a high-risk industry such as mining. Corporations are advised to have a crisis communication plan to facilitate proactive behaviour. Such a plan presumes a commitment to honesty, openness, and ethical behaviour. Journalists are also encouraged to have a crisis communication plan so that they are prepared for inevitable events, informed about the industries in their area, and able to tell the story substantively, accurately, and in context. The Westray coal mine, owned by Curragh Incorporated of Toronto and located in Pictou County, Nova Scotia, exploded on May 9, 1992, killing the 26 miners who were underground. This paper analyzes the relationship between Curragh and the media, particularly during the week following the explosion. It observes that the relationship was severely tested, as is often the case in time of crisis and human tragedy. The paper also observes that neither Curragh nor the participating media had crisis communication plans, which negatively affected their performance. It concludes that Curragh did not satisfy legitimate media needs and that the company's lack of open, prompt, and accessible communication fed a media suspicion that officials had something to hide. On the other hand, journalists relied on human interest, made mistakes, and decontextualized their coverage of the story.
...the job of gouging and moving coal is much like it was in the early 18th century. Methanometers have replaced canaries as early detection systems, but the linear process of extraction and the risks of methane gas and flammable coal dust haven t changed. Why then is the fatality rate for mine workers still five times the national average for workers?
Evidence from Westray shows a long-standing pattern of safety violations: combustion engines refueled with the motors running, a "volunteer" system for applying limestone to reduce coal dust concentrations, cigarette butts and oily rags littering the mine floor.
"We found at Westray a pattern of behaviour that sociologists call mock bureaucracy – a situation in which workers fail to follow regulations and the managers fail to enforce compliance," says Hynes, whose investigation of Westray is part of his doctoral research. Rules are ignored because they are perceived as "bureaucratic paraphernalia" without legitimacy in themselves. What is remarkable at Westray though, he says, is that rules tied to workers survival, which should be deeply meaningful, were ignored.
...a network of financial and political forces pushing managers to value production results over safety rules. For instance, an agreement with the Bank of Nova Scotia linked financing to production data. Government funding also depended on a commitment to the Nova Scotia Power Corporation to produce a certain number of tons of coal per year.
Miners had their own reasons for participating in unsafe working procedures. One worker left his job to avoid dangerous conditions, and suffered penalties in his UIC claim. In job-strapped Nova Scotia, brutal labour market discipline could have stopped miners from taking action.
But why would miners make matters worse by smoking in areas where explosions were a constant and predictable danger? Hynes and Prashad point to the culture of danger that has always surrounded mining. Memorials found in many mining towns depict the miner as a tragic hero and probably incline the workers to accept higher risks as part of their occupational identity. Hynes and Prasad conclude that while managers and miners broke safety rules for different reasons, they ended up supporting each other in making Westray a dangerous place...
Using Westray as an example, at a surface level, reports of events at the mine seem contrary to common sense and raise many questions. Why did miners (who stood to lose their lives), managers (who stood to lose their business and their reputations), and inspectors (who stood to lose their jobs and their credibility) appear to ignore dangerous levels of coal dust? What were they thinking? Did the situation make sense to them? Clearly, the press, and later the Richard inquiry, were able to make sense of events by imposing a common sense framework on events, thus rendering the accounts plausible. A Weickian account, on the other hand, suggests that we need to understand events not simply through what makes sense to us but through the processes by which a dominant sense of the organization came to be enacted by those involved.
The importance of Weick's (1995) approach is that it directs us away from rational accounts of organizations that focus on coping with or reproducing hierarchical notions of organization. Instead it directs our attention to the process of organizing and the social psychological linkages that encourage a sense of organization (Weick, 1969). Thus, as important as the Richard inquiry is in establishing responsibility and discouraging a repeat of the events that led to the disaster, another disaster will occur unless we understand the social psychological processes whereby people put themselves in harm's way...
The explosion that took the life of 26 men in the Westray Coal Mine in May 1992 has come to represent much more than a loss experience felt by a handful of families. Several commentators have noted the profound effects this event and its aftermath have had on the values and attitudes of Nova Scotians, but little is known about the longterm effect these events have had on family members of the men who died. Drawing from personal interviews with more than fifty of these family members, I describe the personal legacies of Westray. An emergent theme is that this event has shattered deeply held assumptions about the public accountability, trust, and belief in a just world... (emphasis added)
Recent studies on the antecedents of industrial crises have tended to focus on disasters in high-risk systems involving complex technologies and tightly-knit processes. This paper examines events leading up to mining disasters which past research has characterized as being typically more foreseeable and avoidable. We discuss how many mining disasters are likely to be the result of 'mock bureaucracies' or situations characterized by overt violation of safety rules at the workplace. Using the Westray mine explosion as an illustrative case, the paper traces the development and institutionalization of a mock bureaucracy in an organization. Implications for further research and understanding of industrial crises are drawn.
Communication issues in high-risk industries can be summarized as due to:
• internal resistance to safety and reputation feedback
• failing to properly participate in public debate
The case of the 1992 Westray mines accident, one of the worst industrial disasters in Canadian history, illustrates these failures. The result of the Westray disaster was that the company and its owners became bankrupt. Much of this can be attributed to the poor internal and external communication strategies the company employed...
The Westray Mine Disaster Case
...Coal mining is dangerous and underground mining in Pictou County has always been very dangerous. From 1838 to 1950, when it ceased due to the advent of fuel oil, aging facilities and deep seams too expensive to mine at the time, 246 miners had been killed in a series of explosions. From 1866 to 1972, another 330 were killed in other kinds of accidents (i.e. stone falls, crushing by coal cars, mangled in machinery). The Foord coal seam, of which the Westray mine was a part, while particularly dangerous, was singularly attractive. Unusually thick, with low sulfur content and high BTU rating, its reserves were estimated at 45 million tons. The location is known to exude large quantities of methane, is geologically faulted so that mine roofs will collapse, and has a problem of spontaneous combustion (even in the absence of sparking machinery.) Indeed, almost a year before the disaster, one provincial opposition politician argued, "[b]ecause of the fault structure and gas contained in the formation of coal seams in Pictou County, Westray mine is potentially one of the most dangerous mines in the world"...
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The Westray Mine Disaster Case Archived: 2000 March 6 http://web.archive.org/web/20000306194642/http://www.commerce.usask.ca/faculty/haiven/comm206/westraycase.htm Archived: 2000 October 14 http://web.archive.org/web/20001014102426/http://www.commerce.usask.ca/faculty/haiven/comm206/westraycase.htm Archived: 2001 June 22 http://web.archive.org/web/20010622175348/http://www.commerce.usask.ca/faculty/haiven/comm206/westraycase.htm Archived: 2001 November 23 http://web.archive.org/web/20011123215743/http://www.commerce.usask.ca/faculty/haiven/comm206/westraycase.htm Archived: 2002 February 2 http://web.archive.org/web/20020202234612/http://www.commerce.usask.ca/faculty/haiven/comm206/westraycase.htm Archived: 2002 June 14 http://web.archive.org/web/20020614095401/http://www.commerce.usask.ca/faculty/haiven/comm206/westraycase.htm |
Westray was an underground coal mine in Stellarton, near New Glasgow, Pictou County, Nova Scotia that blew up on May 9, 1992 killing all 26 people working in the mine instantaneously. Westray was a corporation wholly owned by Curragh Resources, a company controlled by Clifford Frame and based in Ontario. The development of the mine in Stellarton received considerable political support from the provincial and federal government despite the opposition of technical experts and despite the history of mining fatalities in the area. Local historian James Cameron estimates that 576 deaths occurred between 1866 and 1972 in mining in Pictou County and that 625-650 died "from colliery misadventures in Pictou County" since the industry's debut in the early 1800s. The Federal MP for Pictou County was Brian Mulroney, later Prime Minister of Canada and the Provincial MLA was Donald Cameron, then Minister of Industry and subsequently Premier of the province...
What has been done about the recommendations of the Westray Inquiry? The Nova Scotia government hired a consultant, Ian Plummer, a former Inspector of Mines of Ontario, to review the activities of the Ministry of Labour. Plummer's report was released with no substantive recommendations to improve health and safety of workers in the province. Instead, he hides behind bureaucratic reorganization of the department without any consideration of the lack of effectiveness in protecting workers' lives.
Ian Plummer, as a mines inspector, sat on the panel of industry experts which awarded Westray the mining industry's J.T. Ryan Award for Safety as the safest coal mine in Canada in 1991, eleven days prior to the explosion that killed 26 men...
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Corporate Criminal Responsibility and the Westray Mine Disaster Archived: 2001 April 30 http://web.archive.org/web/20010430084716/http://www.uswa.ca/eng/hs&e/bkg468_2.htm Archived: 2001 June 17 http://web.archive.org/web/20010617203048/http://www.uswa.ca/eng/hs&e/bkg468_2.htm Archived: 2001 August 3 http://web.archive.org/web/20010803214445/http://www.uswa.ca/eng/hs&e/bkg468_2.htm Archived: 2002 February 2 http://web.archive.org/web/20020202225720/http://www.uswa.ca/eng/hs&e/bkg468_2.htm Archived: 2002 June 06 http://web.archive.org/web/20020606151436/http://www.uswa.ca/eng/hs&e/bkg468_2.htm |
...A result of the Westray inquiry, the study was commissioned in January (1998) by Justice Peter Richard of the Nova Scotia Supreme Court. It was conducted by Ian Plummer, retired provincial co-ordinator of mining for the province of Ontario. Mr. Plummer reviewed the division's internal responsibility system, staff competency, training programs, internal and external communications, performance management systems and organizational structure. Over the course of his study, Mr. Plummer interviewed division managers, staff members and officials of similar organizations in other jurisdictions...
Source: [
Government press release 16 April 1998
http://www.gov.ns.ca/news/details.asp?id=19980416002
Westray Coal Inc. has been stripped of a prestigious mine-safety award bestowed [eleven days] before its Nova Scotia mine exploded, killing 26 men.
The Canadian Institute of Mining, Metallurgy and Petroleum rescinded the John T. Ryan Trophy last month, based on an inquiry's finding that company officials fudged accident statistics.
It is the first time the 57-year-old award, given annually to the Canadian coal mine with the fewest accidents, has been rescinded. The Westray inquiry reported in December that mine management was derelict in its duty to train miners and run a safe mine.
The Ryan award, administered by the Montreal-based institute, is based on the ratio of hours worked to the number of reportable injuries.
Westray reported 15 injuries in 1991, but inquiry evidence showed at least three other injuries were not disclosed.
The company won the award on April 9, 1992, one month before the massive explosion of gas and dust.
Westray manager Gerald Phillips and underground manager Roger Parry are to stand trial next year on charges of manslaughter and criminal negligence causing the miners' deaths.
Mine Safety Appliances Company of Canada Limited was founded in Montreal in 1937. In 1942 the head office was relocated to Toronto. The name was officially shortened to MSA Canada Inc. in the 1980s. In 1941, MSA Canada began sponsoring the John T. Ryan safety trophies to promote safety in coal and metal mines. Named the John T. Ryan Trophy in honor of the co-founder of Mine Safety Appliances Company (in the United States), the trophies have since become the most prestigious safety awards in the Canadian mining industry. They are still sponsored by MSA Canada and are now presented nationally and regionally in three mining categories: metal, coal, and select other mines such as potash, salt, gypsum, etc...
— Source:
Canadian Enterprises Gallery
Westray — 1992 John T. Ryan Trophy winner
• Based on "injury" statistics only (frequency or recordable injuries)
• Frequency not a good indicator of "risk"
• Tells you nothing about risk management
• Too easy to "cook the books"
• Only about "records"...
Hazmat Clinic: Do Incentive Programs Work? Perhaps, But Only if Used Carefully
by Wayne Pardy and Ralph Stuart, 27 July 1998
...The John T. Ryan Trophy was first introduced in 1941 by the Mine Safety Appliances Company of Canada (now MSA
Canada Inc.) to promote mine safety achievements. Eligibility for the award
is based on calculating the frequency of reportable injuries.
While Westray management was notorious for its ignorance of safety, it
apparently was interested in the outward trappings of safety. Westray
applied for the John T. Ryan Trophy, and won. In an April 9, 1992 memo to
employees, the Vice President and General Manager of the Westray mine
congratulated the workers on their achievement.
The problem with the award, as evidenced by so many "safety" awards of this
type is that it tells you nothing about safety or risk management. It
simply tells you that for a given period, usually the artificial period of1
year, lost time and injury frequency or severity was low, but it doesn't
tell you why.
On the other hand, a key finding of the Westray report examined the issue
of the production bonus system. Depending on the work being done, workers
could earn a bonus for average monthly production in excess of 500 tons per
machine shift. Workers had a percentage of their bonus deducted if they
missed work: a one day absence meant a 25% reduction; a two day absence
meant a 50% reduction. These competing incentive schemes gave a clear
indication of management's priorities.
The report concluded that based on the evidence of the miners and an
outside expert's analysis of that evidence, the bonus scheme based solely
on productivity was clearly not conducive to safety at Westray...
— Source:
http://list.uvm.edu/cgi-bin/wa?A2=ind9807D&L=SAFETY&D=0&T=0&P=10639
(Note: You can access this online article by using your browser's Copy and Paste feature to paste this URL into your browser's URL window.)
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United Steelworkers Union's Westray Campaign Archived: 2001 April 20 http://web.archive.org/web/20010420001649/http://www.uswa.ca/eng/westray/westray.htm Archived: 2001 August 03 http://web.archive.org/web/20010803214155/http://www.uswa.ca/eng/westray/westray.htm Archived: 2002 February 02 http://web.archive.org/web/20020202231301/http://www.uswa.ca/eng/westray/westray.htm Archived: 2002 October 19 http://web.archive.org/web/20021019174839/http://www.uswa.ca/eng/westray/westray.htm Archived: 2003 June 18 http://web.archive.org/web/20030618144523/http://www.uswa.ca/eng/westray/westray.htm Archived: 2004 February 19 http://web.archive.org/web/20040219130942/http://www.uswa.ca/eng/westray/westray.htm Archived: 2004 October 10 http://web.archive.org/web/20041010030622/http://www.uswa.ca/eng/westray/westray.htm |
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National Director's Update: Westray Edition, Sep. 2003 Archived: 2003 September 25 http://web.archive.org/web/20030925235751/http://www.uswa.ca/eng/news_letter5/letter5.htm Archived: 2004 January 07 http://web.archive.org/web/20040107234228/http://www.uswa.ca/eng/news_letter5/letter5.htm Archived: 2004 March 14 http://web.archive.org/web/20040314055518/http://www.uswa.ca/eng/news_letter5/letter5.htm |
2003 November 7 — Legislation that the United Steelworkers has promoted for nearly 12 years became law today when Bill C-45, the 'Westray' Bill, was given Royal Assent in the Senate. The legislation amends the Criminal Code of Canada to hold corporations, their directors and executives accountable for criminally negligent acts in the workplace...
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Corporate Accountability for Criminally Negligent Acts Westray Bill Gets Royal Assent Archived: 2004 January 08 http://web.archive.org/web/20040108084410/http://www.uswa.ca/eng/news_releases/westray_royal_assent.htm |
Queensland Mining Industry Health & Safety Conference 2005 Australia
This report contains many informative nuggets about mining hazards and effective means to improve working conditions for miners.
[page 22]
Westray was a room and pillar mine in Nova Scotia in Canada, which exploded in 1992 killing 26 miners. The district had a long history of gassy mines and explosions which had resulted in the closure of all mines by the 1950s. Westray was opened in 1989 by a small entrepreneurial company convinced they would bring new thinking to reinvigorate coal mining in an economically depressed area. They received considerable government support. Unfortunately gas did accumulate and exploded. The source of ignition was never determined...
[page 22]
The Williams Station Mine belonging to Pyro Mining Company is a long wall coal mine in Kentucky. An explosion in September 1989 resulted in the deaths of ten miners. The explosion took place during a long wall move... The ignition source for the explosion could not be determined but there were plenty of candidates, including a cutting torch, explosive caps, and a defective scooptram. Subsequent charges resulted in prison terms for three of the mine executives including 18 months for the General Superintendent. The charges were lying to MSHA inspectors and failing to follow safety procedures...
(boldface emphasis added)
[page 22]
Southmountain Number 3 was a privately owned coal mine in Virginia. An explosion in December 1992 killed eight miners. The cause of the explosion was ascribed to an accumulation of methane due to poor ventilation practices, ignited by a cigarette lighter. MSHA prosecuted the mine and five individuals, exacting $2,100,000 in fines. The mine owner pleaded guilty to concealing his identity and received a six month jail sentence. The Superintendent pleaded guilty to allowing smoking in the mine and other safety violations and received a twelve month jail sentence...
(boldface emphasis added)
[page 31]
Digging into the earth to provide raw materials for the community's fundamental needs is an honourable and rewarding occupation. It is also one which exposes participants to considerable risks. Managing those risks is the business of mining professionals. There is no reason that mining cannot be safely conducted with a goal of zero fatalities. Achieving that goal requires an understanding of the mistakes made by others in the past and taking actions to prevent those mistakes occurring again...
[page 89]
"Everyone, and that includes you and me, is sometimes careless, complacent, overconfident and stubborn. At times each of us becomes distracted, inattentive, bored and fatigued. We occasionally take chances, we misinterpret and we misread. These are completely human characteristics." ...I think we can at this stage of our evolution be reasonably confident in saying that people will continue to make mistakes and human error is here for the foreseeable future...
[page 14]
The Bottom End: Regulating Incompetents and Recalcitrants
The mining industry itself has recognised that while "some will be content to comply with whatever is seen to be the minimum requirements, others will have little motivation even to achieve that". While not confined to small and medium sized operators, this group is likely to include a disproportionate number of small, unsophisticated operators. How should this group best be regulated? Unsurprisingly, the recalcitrant and the incompetent are likely to respond to different regulatory strategies...
...A safe workplace demands a responsible and conscientious commitment from management — from the Chief Executive Officer down. Such a commitment was sadly lacking at the Westray mine. Since there was no discernible safety ethic, including a training program and a management safety mentality there could be no continuum of responsible safety practice within that workplace. Complacency seemed to be the prevailing attitude at Westray — which at times regressed to a heedless disregard for the most fundamental safety imperatives. As I stated in the report, compliance with safety regulations was the clear duty of Westray management. To Insure that this duty was undertaken and fulfilled by management was the legislated duty of the inspectorate. Management failed, the inspectorate failed, and the mine blew up.
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The Westray Mine Explosion: Aftermath Did we learn anything from it? Mr. Justice K. Peter Richard Archived: 2001 August 3 http://web.archive.org/web/20010803215529/http://www.iwh.on.ca/Pages/99/Papers/P_1B6_1.html Archived: 2001 November 21 http://web.archive.org/web/20011121115806/http://www.iwh.on.ca/Pages/99/Papers/P_1B6_1.html Archived: 2002 January 10 http://web.archive.org/web/20020110124535/http://www.iwh.on.ca/Pages/99/Papers/P_1B6_1.html Archived: 2002 November 2 http://web.archive.org/web/20021102064821/http://www.iwh.on.ca/Pages/99/Papers/P_1B6_1.html Archived: 2003 February 1 http://web.archive.org/web/20030201222004/http://www.iwh.on.ca/Pages/99/Papers/P_1B6_1.html Archived: 2003 June 18 http://web.archive.org/web/20030618095817/http://www.iwh.on.ca/Pages/99/Papers/P_1B6_1.html |
...Nothing better illustrates the incompetence with which the inspectors dealt with the dust problems at Westray than their actions after the coal dust orders were issued on April 29th, 1992 (ten days before the mine exploded). The order had four parts: The coal dust was to be removed immediately and stone dusting was to be done immediately. Within fifteen days, a stone dusting plan was to be developed and filed and within fifteen days a dust sampling program was to be developed and filed. The company was to notify the Department, in writing, when it had complied with each part of the order. As we know from the evidence, nothing was done ... What is worse, nothing was done by the Department to monitor compliance ... One reason for the paralysis of the inspectors may lie with the dominant philosophy in the health and safety division of the Department. It was, and apparently still is, a philosophy of non-engagement that in this case encouraged blind deference to the decisions of the mine operator ... There was a sinister side to the management of the mine beyond the incompetence and the neglect ... However, it would be wrong to suggest that Westray or Curragh were rogue companies that can be set aside as anomalies. They were part of the Canadian mining industry. Their executives were leading lights in that industry. In a sense, the industry as a whole must bear some responsibility for what happened here. We regret the fact that both the Coal Association of Canada and the Canadian Institute of Mining, Metallurgy and Petroleum refused your invitation to participate in these hearings. The Institute was the body which awarded Westray the John T. Ryan Trophy for mine safety a few weeks before the mine blew up ...
...The lack of training and education of miners and company officials in safety matters played a prominent role in the failure to develop a culture that rejects acceptance, condonation, and participation in activities which present unmanageable safety risks. We agree that we could have done more to detect that deficiency, we agree we could have done more by way of education. Policies, procedures, and safety practices should have been scrutinized more systematically for their adequacy, and more effort should have been made to determine their impact on day to day activities. We now know that the reality at Westray often did not match company records, or what the inspectors were led to believe by management, or the things they saw at the mine ...
...On the eve of our national holiday, Canada Day, July 1, 1998, government prosecutors have announced that the Westray managers, Phillips and Parry, will no longer have to face criminal prosecution for their role in the death of 26 men on May 9, 1992. Despite the public testimony, and the two volumes of documentation of mismanagement, violations of safety regulations and practices, and failure to protect the safety of the workers from the Public Inquiry into the Westray Explosion, this is not enough to prove a crime by a corporate manager, according to the Crown Attorney in charge. Mr. Justice Richards was very careful in his report to describe the behaviour of the Westray managers as "willful blindness" towards what was happening and the tragic consequences that could and did result. "Willful blindness" is a standard of proof sufficient to convict you or I of any crime, but not, so it seems, managers and CEO's. The behaviour of the office of the Crown Attorney from the beginning has been nothing more than a cover-up and a screw up. The Supreme Court of Canada had to order them back to trial! Judges at all levels have commented on the bad behaviour of the prosecution. Now we are expected to accept their judgement to give up. ...
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The Wayback Machine has archived copies of this document:
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Effective Safety Management Without Regulation Archived: 2001 December 17 http://web.archive.org/web/20011217233639/http://www.ams.mod.uk/ams/content/docs/stgweb/pages/ssmo/lecture/Without_regulation.htm Archived: 2002 June 12 http://web.archive.org/web/20020612065639/http://www.ams.mod.uk/ams/content/docs/stgweb/pages/ssmo/lecture/Without_regulation.htm Archived: 2002 October 26 http://web.archive.org/web/20021026163411/http://www.ams.mod.uk/ams/content/docs/stgweb/pages/ssmo/lecture/Without_regulation.htm Archived: 2003 February 01 http://web.archive.org/web/20030201211128/http://www.ams.mod.uk/ams/content/docs/stgweb/pages/ssmo/lecture/Without_regulation.htm |
The ebullition of fire damp (methane) at the East River was similar to that of a steam boiler, with the same kind of rapidity, so that putting flame to it on a calm day it would spread over the river, like what is commonly termed 'setting the Thames on fire'; it often reminded me of that saying. It is very common for the women to go to the river with the washing they have to perform for their families and dig a hole about ten inches deep by the river side. This they then fill with pebbles, and put a candle to it; by this means they have plenty of boiling water. I mention this to show how highly charged the coal was with gas. When we first reached the seam at a depth of 180 feet [60m], the gas roared as the miner struck the coal with his pick; it would often go off like the report of a pistol. The noise which the gas and water made in issuing from the coal was like a hundred thousand snakes hissing at each other.
—
page 44 The Coal-Fields and Coal Industry of Eastern Canada, A General Survey and Description
by Francis W. Gray, Canada Department of Mines, 1917
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Westray Coal Mine Public Inquiry Report issued 1 December 1997 Westray Coal Mine Public Inquiry Report, Contents Westray Coal Mine Public Inquiry Report, Executive Summary Prelude to the Tragedy: History, Development, and Operation The Explosion: An Analysis of Underground Conditions The Regulators: Departmental and Ministerial Responsibility The Aftermath: Rescue Efforts and the Inquiry Westray Coal Mine Public Inquiry Report, In Conclusion Westray Coal Mine Public Inquiry Report, Consolidated Findings Westray Coal Mine Public Inquiry Report, Consolidated Recommendations | |
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A Westray Coal Mine Public Inquiry Chronology
was available in 1998 at http://www.gov.ns.ca/legi/inquiry/westray/about.htm but for some reason was removed in 1999 from the Government website.
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Westray Mine Public Inquiry Archived: 1998 January 28 http://web.archive.org/web/19980128013202/www.gov.ns.ca/legi/inquiry/westray/ Archived: 1998 June 26 http://web.archive.org/web/19980626045353/http://www.gov.ns.ca/legi/inquiry/westray/ Archived: 1998 December 3 http://web.archive.org/web/19981203101446/http://www.gov.ns.ca/legi/inquiry/westray/
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Westray Coal Mine Public Inquiry Report Chronology Archived: 1998 January 28 http://web.archive.org/web/19980128021808/www.gov.ns.ca/legi/inquiry/westray/about.htm Archived: 1998 June 26 http://web.archive.org/web/19980626055633/http://www.gov.ns.ca/legi/inquiry/westray/about.htm Archived: 1998 December 5 http://web.archive.org/web/19981205195603/http://www.gov.ns.ca/legi/inquiry/westray/about.htm Archived: 1999 April 22 http://web.archive.org/web/19990422172431/http://www.gov.ns.ca/legi/inquiry/westray/about.htm Archived: 1999 April 27 http://web.archive.org/web/19990427065611/http://www.gov.ns.ca/legi/inquiry/westray/about.htm
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Westray Coal Mine Public Inquiry Report Contents Archived: 1998 January 28 http://web.archive.org/web/19980128035223/http://www.gov.ns.ca/legi/inquiry/westray/contents.htm Archived: 1998 June 26 http://web.archive.org/web/19980626071634/http://www.gov.ns.ca/legi/inquiry/westray/contents.htm Archived: 1999 January 17 http://web.archive.org/web/19990117001233/http://www.gov.ns.ca/legi/inquiry/westray/contents.htm Archived: 1999 April 22 http://web.archive.org/web/19990422175534/http://www.gov.ns.ca/legi/inquiry/westray/contents.htm Archived: 1999 April 27 http://web.archive.org/web/19990427071458/http://www.gov.ns.ca/legi/inquiry/westray/contents.htm Archived: 2000 January 21 http://web.archive.org/web/20000121234504/http://www.gov.ns.ca/labr/westray/contents.htm Archived: 2000 June 21 http://web.archive.org/web/20000621181659/http://www.gov.ns.ca/labr/westray/contents.htm Archived: 2000 October 13 http://web.archive.org/web/20001013031403/http://www.gov.ns.ca/labr/westray/contents.htm Archived: 2001 February 10 http://web.archive.org/web/20010210005529/http://www.gov.ns.ca/labr/westray/contents.htm Archived: 2001 August 3 http://web.archive.org/web/20010803212742/http://www.gov.ns.ca/labr/westray/contents.htm Archived: 2001 November 21 http://web.archive.org/web/20011121155520/http://www.gov.ns.ca/labr/westray/contents.htm Archived: 2002 February 2 http://web.archive.org/web/20020202085209/http://www.gov.ns.ca/labr/westray/contents.htm Archived: 2002 June 12 http://web.archive.org/web/20020612082414/http://www.gov.ns.ca/labr/westray/contents.htm |
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Westray Coal Mine Public Inquiry Report Executive Summary Archived: 1998 January 28 http://web.archive.org/web/19980128014425/http://www.gov.ns.ca/legi/inquiry/westray/execsumm.htm Archived: 1998 June 26 http://web.archive.org/web/19980626050413/http://www.gov.ns.ca/legi/inquiry/westray/execsumm.htm Archived: 1998 December 3 http://web.archive.org/web/19981203043732/http://www.gov.ns.ca/legi/inquiry/westray/execsumm.htm Archived: 1999 April 27 http://web.archive.org/web/19990427075202/http://www.gov.ns.ca/legi/inquiry/westray/execsumm.htm Archived: 2000 January 15 http://web.archive.org/web/20000115220702/http://www.gov.ns.ca/labr/westray/execsumm.htm Archived: 2000 June 21 http://web.archive.org/web/20000621204448/http://www.gov.ns.ca/labr/westray/execsumm.htm Archived: 2000 October 13 http://web.archive.org/web/20001013101459/http://www.gov.ns.ca/labr/westray/execsumm.htm Archived: 2001 February 4 http://web.archive.org/web/20010204011400/http://www.gov.ns.ca/labr/westray/execsumm.htm Archived: 2001 April 13 http://web.archive.org/web/20010413154054/http://www.gov.ns.ca/labr/westray/execsumm.htm Archived: 2001 August 3 http://web.archive.org/web/20010803213203/http://www.gov.ns.ca/labr/westray/execsumm.htm Archived: 2002 February 8 http://web.archive.org/web/20020208231143/http://www.gov.ns.ca/labr/westray/execsumm.htm Archived: 2002 June 11 http://web.archive.org/web/20020611093744/http://www.gov.ns.ca/labr/westray/execsumm.htm |
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Westray Coal Mine Public Inquiry Report Parties With Status Archived: 1998 January 28 http://web.archive.org/web/19980128021816/http://www.gov.ns.ca/legi/inquiry/westray/parties.htm Archived: 1998 June 26 http://web.archive.org/web/19980626055639/www.gov.ns.ca/legi/inquiry/westray/parties.htm |
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Westray Coal Mine Public Inquiry Report Order in Council Archived: 1998 January 28 http://web.archive.org/web/19980128021755/http://www.gov.ns.ca/legi/inquiry/westray/terms.htm Archived: 1998 June 26 http://web.archive.org/web/19980626055627/http://www.gov.ns.ca/legi/inquiry/westray/terms.htm Archived: 1998 December 3 http://web.archive.org/web/19981203131204/www.gov.ns.ca/legi/inquiry/westray/terms.htm |
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Westray Coal Mine Public Inquiry Report Witnesses at Public Hearings Archived: 1998 January 28 http://web.archive.org/web/19980128021823/http://www.gov.ns.ca/legi/inquiry/westray/hearings.htm Archived: 1998 June 26 http://web.archive.org/web/19980626055646/www.gov.ns.ca/legi/inquiry/westray/hearings.htm |
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Westray Coal Mine Public Inquiry Report Inquiry Staff and Support Services Archived: 1998 January 28 http://web.archive.org/web/19980128021830/http://www.gov.ns.ca/legi/inquiry/westray/staff.htm Archived: 1998 June 26 http://web.archive.org/web/19980626055653/www.gov.ns.ca/legi/inquiry/westray/staff.htm |
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