Managing Major Hazards: The Lessons of the Moura Mine Disaster
Many organisations live with hazards that have the potential to cause disaster. This was the case at Moura underground coal mine in Central Queensland, where 11 men died in an explosion in 1994... Andrew Hopkins shows that the explosion was the result of organisational failure, and uses it to draw lessons about managing major hazards. He argues that there are always tell-tale signs of impending disaster, and that organisations need to find ways of gathering this information and reacting to it appropriately. The Moura story also demonstrates the need to move responsibility for risk management up the corporate hierarchy to ensure that it is not overshadowed by production pressures. Otherwise disasters will repeat themselves in horrifyingly similar ways... Managing Major Hazards is a gripping story and essential reading for occupational health and safety professionals, executives working in hazardous industries, policy makers, and readers interested in risk management and disaster studies.
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The communication system
The failure of management responsibility
Was Moura safetyconscious?
Production before safety?
The role of BHP
The safety pays argument
The regulatory system
Company and management hierarchies
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accidents action alarm analysis argument Australia Bass Strait behaviour belief benzene Bhopal BHPAC catastrophic risk chapter coal mines concern context control of catastrophic corporate cost crew culture of denial danger deputies develop disaster prevention duty of care effective EFTPOS employers ensure evidence explosive range failed gas monitoring go underground happened head office health and safety heating hierarchy identify ignition indicator industry inspec inspectorates involved Kianga lessons litres per minute lost time injury LTIFR matter mine's Moura disaster normal accidents North Sea noted occurring oil platform oral communication organisation panel particular Perrow perspectives Piper Alpha possible potential practice prescriptive priority problem procedures production Queensland question rational reports of smells responsibility for safety safe safety management plans safety pays sealed self-regulation senior management shift undermanager specified spontaneous combustion system accidents tion trigger underground that night undermanager-in-charge Union Carbide warning signs Windridge workers
Page 46 - Once formed, initial impressions tend to structure the way that subsequent evidence is interpreted. New evidence appears reliable and informative if it is consistent with one's initial belief; contrary evidence is dismissed as unreliable, erroneous, or unrepresentative.
Page 18 - Their defining feature is that they were present within the system well before the onset of a recognisable accident sequence. They are most likely to be spawned by those whose activities are removed in both time and space from the direct humanmachine interface: designers, high-level decision makers, regulators, managers and maintenance staff. Reasons argues that an accident or near miss of the type discussed above is usually an 'organisational
Page 115 - In neo-classical theories of the firm, organisations identify, choose, and implement optimal alternatives. In behavioural theories, organisations simplify the decision problem in a number of ways. They set targets and look for alternatives to satisfy those targets, rather than try to find the best imaginable solution. They allocate attention by monitoring performance with respect to targets. They attend to goals sequentially, rather than simultaneously. They follow rules-of-thumb and standard operating...
Page 113 - Do they need an indicator to tell them whether the deck storekeeper is awake and sober? My goodness!
Page 116 - Clearly, by any objective measure, UCC [Union Carbide Corporation] and its managers benefited from the Bhopal incident, as did UCIL [Union Carbide India, Ltd.]. They were politically able to close a burdensome plant, take aggressive actions to restructure both companies, and enhance management benefits. ... It is ironic that a disaster such as Bhopal would leave its victims devastated and other corporate stakeholders better off" (quoted in Lepkowski 1994, 30).
Page 18 - Latent failures: these arc decisions or actions, the damaging consequences of which may lie dormant for a long time, only becoming evident when they combine with local triggering factors (that is, active failures, technical faults, atypical system conditions, etc) to breach the system's defences. Their defining feature is that they were present within the system well before the onset of a recognisable accident sequence.
Page 49 - ... the onus is on the prosecution to prove beyond reasonable doubt that the...
Page 89 - ... severity risks are being carefully controlled. On the contrary, the danger is that a single-minded focus on reducing the LTIFR leads systematically to the neglect of catastrophic risk. Where there is potential for catastrophe, safety management must not be driven exclusively by a concern to reduce the lost time injury frequency rate. That way lies disaster, quite literally.
Page 71 - Clearly there was no shortage of auditing of the Piper platform and the way it was being operated. What was deficient was the quality of that auditing. Not only were departures from laid-down procedures not picked up, but the absence of critical comment in audit reports lulled senior management into believing that all was well. BHP AUDITING The story at Moura was depressingly similar. Numerous audits had been carried out, the most thorough being the so-called 'corporate' audit conducted by BHP at...