Westray: Read my lips

1. Westray: Read my lips Simple, repeated lessons to avoid tragedy

2. “The most important thing to come out of a mine is a miner” Frédréric Le Play (1806 – 1882) French sociologist and inspector general of mines in France

3. “The Westray Story is a complex mosaic of actions, omissions, mistakes, incompetence, apathy, cynicism, stupidity, and neglect. ” “It was clear from the outset that the loss of 26 lives at Plymouth, Pictou County, in the early morning hours of 9 May 1992 was not the result of a single definable event or misstep. Only the serenely uninformed (the wilfully blind) or the cynically self-serving could be satisfied with such an explanation.” Report of the Westray Mine Public Inquiry Justice K Peter Richard, Commissioner

4. The Foord seam is said to be the thickest in the world with estimates of coal seams being as thick as 48 feet has hosted at least 8 mines including Westray. However, it is also known for being very gassy. The Allan Mine was one of the most productive coal mines in the area closed in 1950 but had eight methane explosions in its life time. In Nova Scotia many deaths in the industry have occurred, the nine major catastrophe’s are: 1873 Drummond Colliery Disaster, Westville, (60-70 deaths) 1880 Foord Pit Explosion, Stellarton, (50 deaths) 1891 Springhill Mine Disaster, (125 deaths) 1917 Dominion No. 12 Colliery Explosion, (65 deaths) 1918 Albion Mine Explosion, Stellarton, (88 deaths) 1938 Sydney Mines, cable break in mine shaft, (20 deaths) 1956 Springhill Explosion, (39 deaths) 1958 Springhill Bump, (74 or 75 deaths) 1992 Westray Coal Mine Explosion, Plymouth, (26 deaths) 532 + 26 = 558 Deaths in the area, not counting fatalities under 5

5. The Westray Mine was a coal mine in Plymouth, Nova Scotia, Canada. In 1991 Westray was owned and operated by Curragh Resources Incorporated (Curragh Inc.), which obtained both provincial and federal government money to open the mine, and supply the local electric power utility with coal. It opened in September 1991, but closed eight months later when it was the site of an underground methane explosion on May 9, 1992, killing all 26 miners working underground at the time.

6. About a week later, the Nova Scotia government ordered a public inquiry to look into what caused one of Canada's deadliest mining disasters, and published its findings in late 1997. A criminal case against two mine managers which delayed the report, went to trial in the mid-1990s, but ultimately was dropped by the crown in 1998, as it seemed unlikely that a conviction could be attained. Curragh Resources went bankrupt in 1993, partially due to the disaster. The report stated that the mine was mismanaged, miners' safety was ignored, and poor oversight by government regulators led to the disaster. The report had 74 recommendations.

7. Bernie Boudreau of the Nova Scotia House of Assembly, wrote to Nova Scotia Labour Minister Leroy Legere, asking why the mine was using potentially dangerous mining methods not approved for coal mining. The Labour Ministry gave Curragh Inc. a special permit to use these methods to tunnel until they reached the coal seam, but not actually mine coal. Legere, the regulator, was not aware that the company continued to use these methods, three months after the mine opened. Accusations were made by mine workers of company cutbacks in safety training and equipment and of negligent and outright criminal behaviour toward safety inspections. Miners complained about working in deep coal dust.

8. In November 1991, coal miner Carl Guptill made safety complaints to Labour Ministry inspectors, but they were not investigated, and he was fired in January 1992 for making his claims. - MacDonald, Michael (May 7, 2012). "Westray mine disaster remembered 20 years later". Justice Richard relays “The inspectorate's actions in the Carl Guptill incident were a disservice to a miner with a legitimate complaint, and a clear message to other members of the Westray workforce that the inspectorate was not going to support them in any safety-related confrontation with the management.” Justice Richard continues in his executive summary that it was clear : • that the Department of Labour did not investigate all the complaints raised by Guptill; • that department officials, in the cursory investigation conducted, relied on statements prepared by the company without sufficient verification; • that department officials revealed the name of the complainant to the company; and • that references to the complaint were removed from meeting minutes in an apparent effort to avoid confrontation with the company.

9. Department / Inspectorate Modus Operandi • The inspectorate relied on Westray management for guidance and choice of inspection routes. Such reliance led to careless inspection and ignorance of the true state of operations underground at Westray. • The department's own records of dealings with Westray were sometimes altered. The editing removed some references to potentially embarrassing matters. • The inspectors' handling of the equipment permits was inadequate. • The inspectorate in particular, was markedly derelict in meeting its statutory responsibilities at the Westray mine. • The inspectorate was untrained, poorly supervised, and improperly motivated. • By and large, through incompetence and apathy, the inspectorate of the Department of Labour did a disservice to the Westray miners and the people of Nova Scotia. Recommendation 55 - Mine inspectors “The unacceptable performance of Claude White and Albert McLean in the conduct of their duties as mine-safety inspectors and regulators, coupled with their demeanour at the inquiry hearings, must surely have destroyed any confidence the people of Nova Scotia might have had in the department's safety inspectorate. Accordingly, both White and McLean should be removed from any function relating to safety inspection or regulation.”

10. Other recommendations from Justice Richard • Rec 9 - Incentive bonuses based solely on productivity have no place in a hazardous working environment such as an underground coal mine. • Rec 15 - The regulator, in consultation with a qualified ventilation engineer, should draft regulations dealing with main fans and auxiliary fans • Rec 16 - No booster fan should be installed underground without the approval of the regulator. • Rec 17 - Every main ventilating fan should be mounted above ground… (In 2009 Pike River had installed their main fan underground) • Rec 34- Every coal mine operator should prepare a program for the regular clean-up and removal of coal dust and other combustibles from the floor, roof, and ribs of roadways and work areas in the mine. A copy of the program should be filed with the regulator .. (Before contractors arrived at Pike, there was dust on the roadways up to 200mm thick.) • Rec 34- Wetting Coal-It is prudent that all areas close to the working face and areas in which coal is transferred from one device to another be wetted • Rec 35(a)- All coal-cutting picks should be equipped with water-spray jets of sufficient number and size to ensure that the areas of the coal face being worked are maintained in a damp condition… (it has been noted that turning water off at the tailgate end of a longwall was the practice of some operators in QLD.) • Rec 52 - The Department of Natural Resources should no longer act as both promoter and regulator of the development of mineral and energy resources in the province, since this dual mandate constitutes a conflict-of-interest situation.

11. Sharp lessons from Westray The examples set by events at Westray and later demonstrated at Pike River set a clear picture The hardest question for all is “Why are these disasters repeated?” We have not yet found an investigation or commissioners report for a mine disaster that states : “This disaster and the events leading up to it are totally unique and have never happened before” Common contributors to the disaster: Assumptions Arrogance Not understanding the environment Not understanding the risk Market / Financial demands Complacency

12. For regulators the lessons are also clear Resources Safety and Health have already recognised the expensive lessons from the past and make a valuable contribution to the industry. To maintain awareness it is advantageous to review these lessons from the past to eliminate complacency and possibilities of any future tragedy. Know the mandate and purpose Audit, report, review, apply, repeat Learn from other disasters and apply knowledge Invite criticism then study it Openly share learnings to provide a better Queensland

13. Along with Australian miners, the Westray miners have made a contribution to the lessons we now study. Trevor Martin Jahn, 36 Laurence Elwyn James, 34 Eugene W. Johnson, 33 Stephen Paul Lilley, 40 Michael Frederick MacKay, 38 Angus Joseph MacNeil, 39 Glenn David Martin, 35 Harry A. McCallum, 41 Eric Earl McIsaac, 38 George S. James Munroe, 38 Danny James Poplar, 39 Romeo Andrew Short, 35 Peter Francis Vickers, 38 John Thomas Bates, 56 Larry Arthur Bell, 25 Bennie Joseph Benoit, 42 Wayne Michael Conway, 38 Ferris Todd Dewan, 35 Adonis J. Dollimont, 36 Robert Steven Doyle, 22 Remi Joseph Drolet, 38 Roy Edward Feltmate, 33 Charles Robert Fraser, 29 Myles Daniel Gillis, 32 John Philip Halloran, 33 Randolph Brian House, 27 the Westray miners

14. Further reading • Westray Bill (Bill C-45) – Overview – • This information has been obtained from the Canadian Centre for Occupational Health and Safety • The ideological construction of risk in mining – Alan Hall • The-westray-story-4-executive-summary – Justice Richard • The Road From Westray: A Predictable Path to Disaster? – Eric Tucker • Ontario_Mining_review_2015_final_report-1 – Department of Labour, Ontario • These can be found on the RSH SharePoint