Westray survivor shares safety advice for today’s workforce 31 years after tragedy
By Paula Campkin
On a quiet spring morning on Saturday, May 9, 1992, 26 miners were working underground in the Westray mine. At 5:20 am, a massive methane explosion deep inside the mine rocked the small community of Plymouth, Nova Scotia.
Rescue teams searched for survivors, braving conditions described as “terrifying”, and recovered 15 bodies. Eleven miners were never found.
Editor’s note: Paula Campkin, vice-president of operations and Safety Centre of Excellence at Energy Safety Canada, sat down with Gordon Walsh, who worked at Westray at the time of this tragedy, for this special in-depth look for OHS Canada.
Paula Campkin: Gord, you worked at Westray at the time of this tragedy. Why is telling this story important to you?
Gordon Walsh: I was a young, inexperienced miner working at the Westray coal mine for less than a year when the explosion happened. That event changed my perspective, priorities and choices. Improving approaches to safety management and worker training became a central theme in my career.
As you may know, there was a federal inquiry into the disaster that exposed a multitude of contributing factors and severely criticized the mine’s management, provincial regulators and politicians. Then, failure to fully prosecute the mine’s owners and managers led to intense lobbying efforts by Westray miners and their families, unions, and members of parliament to amend the Criminal Code of Canada. The resulting Westray Bill became law in 2004, providing new rules for attaching criminal liability to organizations.
But while the law is intended as a deterrent, the circumstances that led to the Westray disaster still exist for many operations.
Looking back on the incident 31 years later through the lens of Human and Organizational Performance (HOP), there are still opportunities for us to learn from Westray and improve safety at our own work sites.
Context drives behaviour
PC: What was the context that led to the disaster?
GW: The development of the Westray coal mine was a perfect storm: political pressure for a local coal mine to supply a government-owned powerplant; federal and provincial government investment in the operation; and badly needed jobs for the local economy. Workers, community, management and politicians desperately wanted to see the mine live up to the promise of 15 years of sustained work.
It’s critical to recognize how that context drove behaviour. The unrelenting focus on production, rather than safe operations, contributed to people adapting and doing whatever was necessary to meet expectations. For government inspectors, some speculate this meant making allowances for safety deficits. For us workers, it meant accepting unsafe conditions and adapting to work with poor equipment and processes each day.
PC: So how does the idea of ‘context drives behaviour’ apply today?
GW: Context is important in all operations. Workers can only perform at the level of safety that the organization and the system support. If we focus efforts on the most visible hazards without considering what could sneak up on us, it could result in being unprepared for unexpected events.
At Westray, roof collapses were the immediate hazard, so there was little focus on high-risk conditions like excessive coal dust, methane gas accumulation and uncertified underground equipment.
What are your organization’s blind spots? We all have them! What processes do you have to ensure you are anticipating what could go wrong? The things that cause fatalities are often not the same things that cause injuries. We need to make sure we’re asking workers to focus on the right things.
We need to verify that the safety goals we set are having the desired effect. We need assurance that our people will not downplay or overlook safety issues and continue operating at high risk because of pressure to reach a target—whether it’s production, incident numbers, or something else.
Learning and improving is vital
PC: Several experts warned of potentially dangerous issues with the Westray mine. In fact, the Cape Breton Development Corporation, the federal agency that ran underground operations in Cape Breton, Nova Scotia coal industry at the time, explicitly warned the federal and provincial governments: “…due to a complicated geological structure with numerous faults… [the Foord] seams have given off large volumes of gas proven extremely liable to spontaneous combustion.” What was the response?
GW: None of the warnings, or the local history of mining fatalities in more stable conditions, were ever leveraged to make better decisions. Instead, Westray management ambitiously chose to mine the Foord seam, unprepared to deal with explosive methane gas and geologically unstable rock layers.
Learning and improving is vital, but that wasn’t happening. For example, as the inquiry documents reveal, the group planning the mine at Westray was intent on applying room and pillar strategies, which were commonly and successfully used in western Canada.
This mining method only extracts part of the ore, leaving the rest in the form of pillars to support the roof. Unfortunately, the room and pillar method was not appropriate for the Foord seam’s unique geological formations, and its use led to roof collapses. Despite the frequent collapses, management never changed their mining method. As long as they were getting some production results, they were content to continue.
In addition, ignoring the observations of external experts and the people doing the work day in and day out was a recipe for disaster. Many frontline workers and supervisors at Westray offered advice and warnings, none of which were heeded.
Rather than listening and responding to the workers’ concerns and observations, the inactions of management and regulators further cultivated the conditions leading to the explosion. Organizations must enlist the collective experience of experts and frontline workers to solve safety issues. This includes learning from and challenging historic practices and being open to new ways of thinking.
From bad to worse: No capacity to fail safely
PC: Were there other contributing factors to the Westray explosion?
GW: Absolutely. As time went on, the working conditions at Westray degraded further. For example, the mine lacked effective safety plans to address the build-up of methane. Poorly designed ventilation and gas monitoring systems did little to clear or measure methane. And because production came first, it was common for ventilation to be re-routed and for methane monitors to be ineffectively used — or even turned off! — so production could continue. At any time, we could be working in areas with unsafe methane levels affecting workers’ health and creating an explosion hazard.
Coal dust was also poorly managed. In fact, Westray was written up by the mine inspectors many times for failure to implement a stone dusting plan.
As a method of control, limestone powder is typically applied to surfaces in the mine to limit the spread of fire.
As reported during the inquiry, fine coal dust in elevated concentrations can create enough friction in the air to ignite itself. Research by the Canada Centre for Mining and Energy Technology (CANMET) indicates that coal dust the thickness of two sheets of paper is enough to spread an explosion, and we often found ourselves walking through ankle-deep coal dust.
In addition to methane and coal dust build-up and no means of stopping the spread of a fire, Westray did little to reduce the number of ignition sources in the mine. Placement of the return air ventilation in the same tunnel as the conveyor belts created a significant hazard. Air containing methane and coal dust was pushed through directly above the conveyor’s moving parts and hot points. Given the amount of fuel present, almost anything could have ignited the methane and coal dust, and the risk was further heightened using incompatible equipment, exposed electrical wiring, and sparks created by drilling during the roof bolting process.
PC: What lesson should we apply from those examples?
GW: Coal mining is inherently dangerous. Any dangerous work requires expert level planning and careful examination of “what if” scenarios. Where humans are performing work, identifying potential single point failures is a must.
There was no capacity to fail safely at Westray; no room for mistakes or surprises in our operations.
The most basic hazard management practices were disregarded. Considering the inherent risk associated with underground coal mine operations, it is shocking that there were no systems or controls to mitigate the most serious hazards: coal dust and methane. There were no strong safety systems present; nothing in place to help frontline workers mitigate hazards or human error.
Companies have an obligation to fully understand the limitations of their operations and ensure hazards are not left unaddressed. Westray did not do those things, which left no margin for error, no chance to fail safely.
Leadership response matters
PC: Would you say that a lack of safety leadership was the root of this terrible event?
GW: Like any incident, there is no single cause, but the response of leadership was a major factor. The ability to assess and manage risk is key to successful and safe outcomes. Unfortunately, the company leaders and government officials ignored known hazards at Westray and grossly underestimated the risk of operating an underground coal mine.
Additionally, inquiry findings showed workers were inclined to blindly follow directions to perform unsafe tasks or take dangerous shortcuts, demonstrating a lack of appreciation for the unique dangers of underground coal mining. Workers never received training to properly identify or mitigate hazards because those in leadership positions failed to step up and provide them the opportunity.
PC: What were the top three takeaways from the Westray mine disaster that you hope to pass on?
GW: There are many lessons to be learned but, in my mind, the top three are:
• No job should be so poorly designed or managed that you lose your life.
• The importance of production cannot outweigh worker safety.
• Anyone in a leadership role — from managers to regulators — has an ethical responsibility to ensure safe operations.
Now, just as then, we must ask ourselves: do our systems identify and remove hazards, or just teach people to avoid them? Despite the advances in our understanding and technology, are there companies today feeling the pressure of economic challenges with a less experienced workforce that could be on the same path as Westray? Are we challenging our organizations to improve, or assuming that our systems will be able to address any issues that arise? Answering these questions is an opportunity for us to improve safety at our own work sites.
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