OHS Canada 25th Anniversary Best Editorial

The Westray Conundrum

April/May 1998

Westray won an award as Canada's safest mine barely a month before it sent 26 men to their deaths. Six years later, with the release of the report of the Westray Inquiry, a baffling and disturbing picture emerges that should make every health and safety professional think long and hard about how safety systems fail.

By: Dean Jobb

One Saturday morning in mid-April of 1992, Carl Guptill got together with four miners from his old shift at the Westray coal mine in Pictou County, Nova Scotia. Guptill himself had been fired from the mine, branded a troublemaker for blowing the whistle on unsafe practices. He had told government mine inspectors about a long list of illegal practices and mind-boggling safety hazards, but his warnings had been ignored, leaving him at the mercy of bosses who didn't want to hear about safety problems. The mood around Roy Feltmate's kitchen table that morning was tense as they talked about the worsening conditions in the mine. Four crews worked the mine, and the men had even calculated that there was a 25 per cent chance they would be underground when the disaster they considered inevitable struck.

"Carl," his former co-worker Mike MacKay told Guptill solemnly, "if we die in that mine, you go public as soon as she blows, and you tell the world what you know. Do it for our widows."

A few weeks later, on the morning of May 9, 1992, Guptill's telephone rang. It was Roy Feltmate's wife. For her husband, MacKay and 24 others, luck had run out. A powerful explosion of methane gas and coal dust had roared through the tunnels of the Westray mine at 5:18 that morning. Within seconds, all 26 men working below were dead, caught in the path of the fiery blast or overcome by the deadly gases left in its wake.

It was a suprisingly uncomplicated accident. Methane gas, a constant problem in the Westray coal region, had accumulated in the tunnels and working areas of the mine. Coal dust had long been allowed to build up. A spark, probably from the cutting head on a mining machine scraping against hard rock, ignited the mixture of air, methane and coal dust.

The hazards had been present in the mine almost from the start of its short, eight-month life. Allowing any of the three factors to exist while workers were underground was specifically prohibited by the law. But methane detectors on the mining equipment had been tampered with to prevent them from shutting down equipment when the gas levels became dangerous. And coal dust, at levels that would instantly shut down any other coal mine on the continent, was largely ignored. Sources of ignition, including diesel engines near the working areas in the mine and oxyacetylene welding, had routinely — and illegally — been allowed in the mine.

Workers had reported the problems. Inspectors had been called. The explosion had been predicted and was even considered inevitable. But no one did anything.

The basic facts, the causes and the chain of events leading to the deadly explosion came out quickly as the newspapers and national television networks devoted days of live coverage to the aftermath of the dreadful accident. And yet, six years, hundreds of news stories, a flurry of failed court cases and a full-blown inquiry later, the basic cause, the true reason why 26 men died in the darkness underground remains an unfathomable mystery.

The question is not, "How did it happen?". It is and always was mind-numbingly obvious how it happened. Nor is the question, "How could anyone have let it happen?". There is no convenient "anyone" whose lapse or incapacity or criminal neglect can be singled out as the cause. No. The question is, "How could everyone have allowed it to happen?".

FUDGING STATISTICS

On paper, Westray looked like a paragon of safety. The safe work procedures for ventilation and other practices were strictly by the book. Every employee signed a long document outlining his rights and duties under the Occupational Health and Safety Act. Mine manager Gerald Phillips developed an elaborate program of classroom and on-the-job training. In April 1992, barely a month before the explosion, the Canadian Institute of Mining, Metallurgy and Petroleum honoured Westray with the John T. Ryan Award as Canada's safest mine.

It was all window dressing.

The Ryan award, it turned out, was achieved by fudging accident statistics and keeping injured men on the payroll. Workers who grumbled about safety were told the company had hundreds of resumes on file from men eager to take their places. Long after the explosion, the Westray inquiry would hear how Phillips browbeat a rookie miner, Aaron Conklin, who was nervous about returning underground after a cave-in. When Stephen Lilley objected to the use of a welding torch underground — an illegal practice that could have touched off a fire or explosion — he was suspended for several days. He returned to work and was among those who died on May 9.

Training fell by the wayside as the company struggled to meet production targets. Trainees, who were supposed to work under the supervision of a certified miner for six months, found themselves alone at the coal face within days.

A core of experienced coal miners had been recruited from western Canada, but they were outnumbered by men who had worked only in hard-rock mines, where the hazards of methane, coal dust and unstable sedimentary rock are rare. Many others were recruited locally — labourers, construction workers or unemployed men grateful for steady work at dream wages. A Westray miner could earn upward of $60,000, with as much overtime as he wanted. Hazardous practices thrived. Most shift bosses were as poorly trained as their crews, and readily adopted management's mantra: Production first.

The pay made it tough to quit, especially for men who had moved across the country or had taken out mortgages based on Westray's promise of 15 years' work. Others stayed on simply because they had no idea they were in danger. "If I would have known then what I know now," a construction worker turned miner, Gerald MacGillivray, said years later, "there's no way I would have been down there."

Day after day, in nationally televised hearings in the spring of 1996, former miners described the appalling conditions they endured underground at Westray. The tunnels were dry and dusty, the ventilation system incapable of clearing out methane, the roof prone to collapse.

Each continuous miner, large machines that claw coal from the working face, was fitted with a methanometer, a device that cuts electric power to the machine before gas concentrations reach explosive — and illegal — levels. Some operators, however, used an override button to keep the machines and the production going. On many occasions, foremen ordered the devices reset to trip at higher concentrations of gas to squeeze out more production.

Dust did not disrupt production, so it was an afterthought. Coal dust is highly explosive if it becomes airborne in the presence of a source of ignition. The Coal Mines Regulation Act stipulates it be wetted down with water or treated with powdered limestone, known as stone dust, to make it less dangerous.

Despite repeated requests from the Department of Labour, Westray never instituted a system for spreading stone dust. Few workers were interested in the company's solution — staying overtime, after a 12-hour shift, to tackle the task. To most miners, an order to halt production and apply stone dust meant only one thing: An inspector was about to arrive.

Any spark or heat source could ignite the tinderbox, and there were plenty of possibilities — frayed electrical cables, welding torches and the hot engines of diesel-powered vehicles, which one mining expert dubbed "mobile ignition points". But most consultants who studied the explosion believe a metal pick on the cutting head of a continuous miner sparked after striking hard stone, touching off the blast.

An occupational health and safety committee had three miners as members, but it met sporadically and management simply ignored its concerns.

The men also lacked a collective voice. The United Mine Workers of America lost a certification attempt by 20 votes in January 1992, mainly because miners were wary of the union that represented employees at rival Devco, the federal Crown corporation running the collieries on Cape Breton Island. The United Steelworkers of America was in the midst of another certification drive when the explosion occurred.

BOUND TO BE CASUALTIES

Carl Guptill is a large man whose long brown hair, secured in a ponytail, spills out from under a faded blue ball cap emblazoned with the words "Mine Rescue". His rescue training, coupled with years of experience in hard-rock mines, convinced him that Westray was a disaster waiting to happen.

"I'm not one bit scared to do what I have to do to make things right," he says. But he was no match for Westray management. "I think I was half scared of them ... they caused me to back down," he says, the sadness palpable in his voice. "I failed. I'm not used to failing."

Guptill went to work at Westray in the fall of 1991. He was appalled by the lax approach to safety and the crumbling roof. Refusing to work in areas he considered unsafe, he was relegated to the work of hauling timbers and steel beams. His 13th shift, on Dec. 8, 1991, was his last. Foreman Angus MacNeil ordered him to move some beams, ignoring a plea that his helmet lamp was too dim to work. It was a common problem, since the batteries were not designed to hold their charge for Westray's 12-hour shifts. Guptill tripped in the dark and the beam he was carrying landed on his back. He was taken to the surface on a stretcher. MacNeil's response, according to Guptill, was callous and flippant: "This is World War Three down here, there's bound to be casualties." In retrospect, the comment may be the best insight we have into the true culture that permeated the mine.

After his release from hospital two days later, Guptill phoned the Nova Scotia Department of Labour. The call triggered a series of events that were pieced together in testimony before the Westray inquiry. Guptill says he outlined a litany of safety violations at a meeting with Albert McLean, an inspector who conducted most of the Westray inspections. The list included working in high levels of methane and thick layers of coal dust. Crews worked 12-hour shifts, often without a lunch break, even though the law limited shifts to eight hours. Trainees worked without supervision. Vehicles were driven to the coal face in contravention of departmental guidelines, their diesel engines creating a fire hazard.

McLean, however, claimed Guptill made no mention of such practices. His perfunctory investigation focused on the injury and concluded there had been "no flagrant violations of the regulations". Westray promptly fired Guptill, branding him "unsuitable for underground mining" on his separation papers.

In his report on the disaster, Justice Peter Richard rejected McLean's testimony and cited the incident as "a microcosm of employee-employer relations at Westray." Guptill's treatment underscored "the absence of a safety mentality" at the mine and the extent to which inspectors were "either apathetic to the conditions at Westray or so much in thrall to management." McLean's failure to act was "a disservice to a miner with a legitimate complaint," the inquiry concluded, and sent "a clear message" to other miners that the Department of Labour would not support them in a confrontation with management over safety.

Carl Guptill's treatment showed the futility of a direct appeal to the Department of Labour. Buddy Robinson, a veteran coal miner from Alberta, also tried that route, phoning inspector Albert McLean one night to vent his concerns. The inspector's response, Robinson told the inquiry, was that "his hands were tied".

INCOMPETENCE, STUPIDITY, NEGLECT

In the 800-page report of the provincial inquiry into the disaster released last December, Justice Peter Richard acknowledged the events and conditions responsible for the explosion were so extreme that they may never be repeated. "The Westray story is a complex mosaic of actions, omissions, mistakes, incompetence, apathy, cynicism, stupidity and neglect," the Nova Scotia Supreme Court judge wrote, concluding the disaster had been predictable and preventable.

But, he added, the formula for Canada's worst mining accident since the Springhill mine disaster of 1958 was tragically simple: "Management failed, the inspectorate failed, and the mine blew up."

Westray officials were all too willing to push the weak regulatory regime to the limit. Mine management, led by general manager Gerald Phillips and the underground manager Roger Parry, ignored or bullied every government inspector and engineer who dared question their methods.

The political and bureaucratic backdrop to the development of Westray set the tone for how the mine was operated and monitored. In the late 1980s, Nova Scotia politicians were eager to develop the last sizable block of coal in Pictou County, an area of high unemployment where underground mining had petered out by the 1970s. Mine promoter Clifford Frame, chairman and chief executive officer of Toronto-based Curragh Inc., was happy to oblige — if the price was right.

Negotiations dragged on for years. There were fears of competition with Devco. A public rift developed between Ottawa and the Nova Scotia government, which was committed to using Westray coal in a power plant to be commissioned in 1991. Curragh eventually won a generous financing package. Ottawa guaranteed an $85 million bank loan at a subsidized rate of interest while the Nova Scotia government chipped in a $12-million loan — for a project with a $127 million price tag.

Little was said about safety, in public or private, during the funding controversy. But the hazards of the Pictou coal field were no secret — 246 men and boys had perished in explosions and fires since coal mining began in the early 1800s, more than half of them in the coal seam targeted by Westray.

Modern equipment and mining methods were supposed to make such disasters a thing of the past. An engineer with CANMET, the technical arm of the federal natural resources department, did a cursory review of Curragh's plans in 1988. His lukewarm report concluded the project faced "numerous technical uncertainties" and stressed the need to hire experienced miners.

Within the provincial bureaucracy, lines of responsibility were murky. An OHS Act introduced in 1986 conferred responsibility for mine safety on the Department of Labour. The move uprooted mine inspectors who had worked in concert with mining engineers left behind in what eventually became the Department of Natural Resources. Communication was never fully restored, leaving serious gaps in the regulatory structure. While the new act set general safety standards, the technical aspects of coal mining fell within the Coal Mines Regulation Act. An antiquated document, it still contained references to the use of horses and railway locomotives underground. "There was equipment that just wasn't covered by the regulations," mine inspector John Smith protested at the inquiry. If Westray "had come in with, say, picks and shovels and wood and just a couple of horses, I think we'd have been on track," he said.

Within the Department of Labour's mine safety branch, there was a recognition that there was not enough trained staff to oversee a modern colliery using room-and-pillar mining methods new to the region. The director of mine safety, Claude White, appealed for money to train inspectors and hire an engineer to monitor Westray, but his superiors refused.

The Department of Natural Resources, which oversaw and approved mine plans and methods, was also short on expertise. None of its front-line mining engineers had coal mining experience.

When Frame clipped a ceremonial ribbon on Sept. 11, 1991 to officially open the mine, he was flanked by two of the project's biggest proponents — local MP Elmer MacKay, a federal minister, and Nova Scotia Premier Donald Cameron. While the inquiry found no direct evidence of political pressure or interference in the enforcement of safety laws, Westray was clearly the government's pet project.

Ralph Surette, a Halifax newspaper columnist, has argued that in the politically sensitive world of the Nova Scotia bureaucracy, overt influence was unnecessary. "Inspectors," he wrote in The Chronicle-Herald last December, "didn't have to be told to not mess with the Westray mine."

CHARGES DROPPED

Five months after the explosion, the Department of Labour filed 52 charges under the OHS Act against Curragh and four Westray officials, including Phillips and Parry. All were dropped to enable the RCMP to pursue criminal charges.

Phillips and Parry were charged in April 1993 with manslaughter and criminal negligence causing death, based on their alleged failure to control methane, coal dust and other hazards. The case collapsed at trial in 1995 due to problems with disclosure of Crown evidence, but a new trial is pending.

The prosecutions prevented the inquiry from opening until November 1995, and delayed Justice Richard's report until last December. The judge found mine operators and provincial regulators had been "derelict" in their safety duties. Even though Nova Scotia's mine safety laws were outdated, he concluded they would have prevented the explosion had they been observed and enforced.

He laid most of the blame on management. The report slammed mine officials, from chief executive officer Clifford Frame on down, for failing to instil a safety ethic at the Westray mine.

Both Frame and Phillips refused to testify and went to court to prevent the inquiry from forcing them to travel from Ontario to do so. But in newspaper interviews, both pointed the finger at miners who broke the law. Their main target was Arnold Smith, a foreman from Alberta who tampered with the methane detector on a continuous miner — the one believed to have been the source of ignition — only hours before the explosion. Donald Cameron, the former premier, beat the same drum when he testified at the inquiry.

Justice Richard, however, rejected their explanations as "simplistic" and said they were designed to deflect attention from the mismanagement and cavalier attitudes that sealed Westray's fate. "Had it not been for these unsafe practices attributed to the miners, would the explosion of May 9th have occurred?" he asked. "The answer must be yes, it would have...Westray was an accident waiting to happen."

The Nova Scotia government has promised action on all 74 recommendations made by the inquiry. Claude White and Albert McLean have been fired and three Natural Resources engineers have been suspended pending reviews of their conduct. The Department of Labour's safety inspectorate cleaned house and underwent a restructuring soon after the disaster. Nevertheless, at Justice Richard's urging, an independent review has been ordered into its operations.

A revised OHS Act was introduced in 1997, incorporating stiffer penalties, better protection for whistle blowers and improved support for in-house safety committees. The government has agreed to review the act and new mining regulations, which are still in draft form, in light of the report's recommendations.

Could the mistakes of Westray be repeated? Within the industry, Westray is viewed as "a throwback," says Jim Woods, spokesman for the Calgary-based Coal Association of Canada. "Any occupation or industry has some risks and dangers. If appropriate steps are taken, both by the operator and the people involved, those can be minimized."

But labour groups accuse governments of catering to business demands for less regulation at a time when mechanization is creating new hazards in the mining industry. "Deregulation kills people. It's as simple as that," charges Andy King, health and safety coordinator for the United Steelworkers of America, the country's largest mining union. At least two dozen Canadian miners have died, one or two at a time, in underground accidents since the Westray disaster. King calls that bleak statistic "Westray on the installment plan."

These days Carl Guptill runs an aquaculture operation on Nova Scotia's Eastern Shore, raising sea urchins for their roe, which is a delicacy in Japan and France. He kept his word to the men who died, going to the media soon after the explosion and testifying at the inquiry.

It has taken years, but he feels personally vindicated. "When this first happened I was sure that it would just be covered up, the mine would re-open, they'd bury the dead and go ahead and do it again," he says. "I never thought the truth would ever come out." But has the truth come out?

Do we now know why over a hundred miners felt that they had to work in a death trap when some of them had even calculated the odds of being among the dead at one in four? Do we know why mine supervisors and managers could be so derelict in their duties? Do we understand why the inspectors and regulators didn't do their jobs? Can we now see into the minds of the politicians who drove the process?

Eleven of the dead, still underground in the flooded and abandoned mine, have not been laid to rest. Nor has the great mystery of Westray, the first question to be asked and the last question to remain unanswered: How could everyone let it happen?

Dean Jobb is a reporter with The Chronicle-Herald and The Mail-Star in Halifax. He is author of Calculated Risk: Greed, Politics and the Westray Tragedy (Nimbus Publishing).

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Westray: Chronology of a Disaster

• Nov. 1988: Curragh Inc. of Toronto buys rights to Pictou County coal, establishes subsidiary Westray Coal Inc.
• May 3, 1990: Ottawa approves $85 million guarantee after lengthy negotiations; project months behind schedule.
• Sept. 11, 1991: Curragh chairman Clifford Frame officially opens mine.
• Sept. 28-Oct. 12: Three major cave-ins; Opposition MLA Bernie Boudreau sounds alarm about safety.
• Oct. 18: Department of Labour asks Westray to draft plan for spreading explosion-retarding limestone dust; it is never filed.
• Nov. 22: Department of Natural Resources engineers reject changes to mine plans, threaten to rescind mining permit.
• Dec. 8: Miner Carl Guptill injured, takes safety complaints to Department of Labour officials.
• Dec. 20: Natural Resources does an about-face, approves the altered mine plan after all.
• Jan. 6: United Mine Workers of America fails in certification drive.
• Mid-Jan.: Inspectors refuse to act. Carl Guptill is fired.
• Mar. 28: Cave-ins force the sealing off of a major coal-producing area; the makeshift seal fails to contain the methane gas, which leaks out.
• Apr. 6: Westray wins John T. Ryan safety award.
• Apr. 29: Labour department inspector Albert McLean orders the company to spread limestone and clean up coal dust "to prevent an explosion." It is not done.
• May 1, 6: McLean and a Provincial Engineer visit the site, but no effort is made to ensure compliance with orders.
• May 9: Methane and coal-dust blast rips through mine at 5:18 a.m., killing all 26 men working underground.
• May 10-13: Rescue crews recover 15 bodies from southwest section, suspected site of explosion.
• May 14: Search called off as too hazardous. Eleven bodies are left underground.
• May 15: Justice Peter Richard of Nova Scotia Supreme Court named to head the inquiry into the disaster.
• May 21: The Nova Scotia government asks the RCMP to seize Westray records based on allegations that documents are being shredded at the mine site.
• Sept. 11: RCMP seizes documents from inquiry, seeks evidence mine operators were criminally negligent.
• Oct. 5: Labour department files total of 52 charges under the Occupational Health and Safety Act (OHS Act).
• Dec. 10: Public Prosecution Service drops 34 charges under the OHS Act to prevent conflict with expected criminal charges.
• Mar. 4: Prosecutors drop remaining 18 OHS Act charges.
• Apr. 5: Low metal prices and Westray losses force Curragh to seek court protection from creditors.
• Apr. 20: RCMP charges Curragh, Phillips and Roger Parry with manslaughter and criminal negligence causing death.
• July 20: Judge throws out criminal charges, rules they are too vague.
• July 23: RCMP refiles charges with detailed allegations of unsafe practices, including failure to keep methane and coal dust in check.
• Sept. 20: Curragh slips into receivership. Creditors lose more than $200 million.
• June 1994: Consultant advises against re-opening the mine. Ottawa and Nova Scotia write off $83 million in loans and guarantees to Curragh.
• Feb. 6, 1995: Supreme Court trial opens before Justice Robert Anderson in Pictou.
• June 9: Anderson stays charges on 44th day of trial, rules prosecutors failed in duty to disclose evidence to defendants.
• Nov. 6: Inquiry opens hearings in Stellarton, Nova Scotia.
• Dec. 1: Court of Appeal says bias tainted Anderson's ruling, orders new criminal trial.
• July 22, 1996: Inquiry hears closing arguments after 71 witnesses testify at 77 days of hearings.
• Feb. 3, 1997: Judge orders former Curragh executives Frame, and Marvin Pelley to testify at inquiry.
• Mar. 20: Supreme Court of Canada upholds order for a new trial but two dissenting judges condemn Crown's conduct of the case.
• Dec. 1: Inquiry releases its four-volume report, finds Westray management and provincial regulators "derelict" in their duty to ensure mine safety. Justice Richard abandons effort to force Frame and Pelley to testify.
• Dec. 19: Nova Scotia government apologizes to victims' families and promises action on all 74 inquiry recommendations.