Wilkinson Fatality Review

Following an apparent increase of significant incidents at the same time as significant adjustment and change in the industry in 2013/2014, the Minister for Resources and Energy, The Hon. Anthony Roberts MP, instructed the Mine Safety Advisory Council to conduct a review to identify and respond to any systematic and underlying issues contributing to serious incidents.

In August 2014, NSW Department of Trade and Investment contracted Noetic Solutions Pty Ltd (Noetic) to examine four fatal incidents which occurred in 2013/2014 in the New South Wales mining industry (including companies, workforce and regulator).

The review was undertaken by Peter Wilkinson and a report presented to the Mine Safety Advisory Council.

• Download the full report of the MSAC Fatality Review 2013-14 (PDF, 447.84 KB) or read the Executive Summary below.

Executive summary

(extract from MSAC Fatality Review 2013-14)

Noetic Solutions Pty Ltd (Noetic) was contracted by the NSW Department of Trade and Investment (the Department) to examine four fatal incidents which occurred in 2013/2014 in the New South Wales mining industry (including companies, workforce and regulator). Noetic were asked to:

• consider the current industry circumstances
• identify contributing factors to the incidents using information available to the Department
• explore systemic and underlying issues that may influence serious incidents.

Interim observations were presented to the Mine Safety Advisory Council (MSAC) on 4 September 2014, with the current report finalising Noetic's findings.

The four incidents were:

• a single fatality which occurred on 30 November 2013 at Ravensworth Open Cut Mine when a haul truck collided with a light vehicle
• a double fatality on 15 April 2014 at the Austar Coal Mine in the Hunter Valley when a rib burst occurred
• a single fatality on 21 May 2014 involving a mobile elevated work platform, where the deceased was trapped by the head between the platform's safety rail and part of the structure being built
• a single fatality on 11 June 2014 when a worker entered water in a sump to clear a borehole and disappeared beneath the surface and was found trapped by his leg in the borehole under the water.

Noetic did not find any obvious immediate similarities between the incidents. However, there were a number of possible common factors which it is recommended that the MSAC should consider. From the information provided Noetic concluded that three of the four incidents represented the tragic outcome of well-known risks in the mining industry. Given this finding, Noetic then looked for evidence of the extent to which the controls for these risks are normally implemented in the mining industry (i.e. when no incident has occurred). This is important to help determine if these incidents are exceptional and how well risk controls are routinely implemented. Unfortunately, apart from some limited information mainly in relation to specific incidents, this type of information was not readily available. Noetic believes information on the implementation of controls for significant risks should be available to industry in a form which supports their ability to formulate appropriate incident prevention strategies.

Noetic makes three recommendations in the Report:

Recommendation 1: MSAC should consider how information on the implementation of risk controls for significant risks could be routinely collected, analysed and used to support a data led accident prevention strategy.

Recommendation 2: Drawing on the discipline of Human Factors, including human and organisational factors expertise, identify the reasons which make it more likely risk controls will be successfully and reliably implemented.

Recommendation 3: Consider if the regulator should explicitly focus on critical controls for significant risks as part of an incident prevention strategy.