MINE SAFETY MANAGEMENT:Making Advances in Managing Known

knowns, known unknowns and unknown unknowns

Raja V. Ramani The Pennsylvania State University

Sukumar Bandopadhyay University of Alaska Fairbanks

OUTLINE

SAFETY PERFORMANCE SAFETY MANAGEMENT SAFE MINE? HAZARDS – KNOWNS & UNKNOWNS STATISTICS ON U.S. MINING INDUSTRY IMPLICATIONS FOR MANAGEMENT CONCLUSIONS

“There are known knowns. These are things we know that we know. There are known unknowns. That is to say,

there are things that we know we don't know. But there are also unknown

unknowns. There are things we don't know we don't know.”

Donald Rumsfeld

KNOWN KNOWNS – THINGS WE KNOW

KNOWN UNKNOWN – THINGS WE KNOW WE DO NOT KNOW

KNOWN UNKNOWN – THINGS WE DO NOT KNOW WE DO NOT KNOW

THIS STATEMENT HAS EVOKED CONSIDERABLE DISCUSSION

WHY SAFETY PERFORMANCE ENHANCEMENT?

TREMENDOUS INCENTIVES TO INCREASE SAFETY PERFORMANCE

DO NO HARM – HUMANITARIAN ASPECTS SAFETY IS GOOD BUSINESS – ECONOMICS CORPORATE IMAGE – DIFFICULT TO REPAIR

NATIONAL SAFETY COUNCIL [NSC]BUREAU OF LABOR STATISTICS [BLS]

BUREAU OF LABOR STATISTICS 2009 DATA12 WORKERS KILLED PER DAY ON THE JOB4.1 MILLION WORK RELATED INJURIES 50,000 DEATHS FROM OCCUPATIONAL DISEASES

AFL-CIO 2011 REPORT SUSPECTED UNDER REPORTING OF INJURIESTOTAL COST OF INJURIES - $200 TO 300 BILLION

NATIONAL SAFETY COUNCIL 2009 DATA COST OF A FATALITY - $1.3 BILLIONCOST OF A DISABLING INJURY - $50,000

WHY MANAGEMENT?

MANAGEMENT HAS AUTHORITY TO ESTABLISH POLICIES AND PRIORITIES COMMIT RESOURCES SELECT MINING SYSTEMS AND EQUIPMENT CHOOSE PERSONNEL FOR SPECIFIC JOBS REWARD MANAGERS AND WORKERS

MANAGEMENT DOES THIS BY PLANNING, ORGANIZING, IMPLEMENTING AND CONTROLLING

THE ORGANIZATIONAL RESOURCES.

OBJECTIVES OF THE SAFETY FUNCTION

PROVIDE LEADERSHIP IN SAFETY WITH DEFINITION

OF GOAL AND MEANS DEVELOP OUTSTANDING ORGANIZATIONAL

FRAMEWORK IN SUPPORT OF SAFETY EQUIPMENT, PROCESSES AND PROCEDURES ARE

DESIGNED HAZARD FREE OR REDUCE HAZARD DEVELOP KNOWLEDGE AND SKILLS – QUALITY

TRAINING AN ENVIRONMENT WITH COMMITMENT TO SAFETY

WHEN IS A MINE SAFE?

SAFE MINE IS A PRODUCTIVE MINE WHAT ARE THE CHARACTERISTICS OF A SAFE MINE? HOW ARE INJURIES, ILLNESSES AND DISASTERS RELATED TO SAFETY? HOW IS COMPLIANCE RELATED TO SAFETY?NECESSARY CONDITIONS AND SUFFICIENT

CONDITIONS

ACHIEVING A SAFE MINE

The problem to achieving a completely safe mine is rooted in identifying and meeting all the sufficient conditions. The universe of hazards - defined as unsafe conditions that have potential to cause harm - is not easily identified. The objective of safety management is to identify, eliminate and/or control all the hazards.

KNOWN KNOWN HAZARDS – HAZARDS WE KNOW WE KNOW

KNOWN UNKNOWN HAZARDS – HAZARDS WE KNOW WE DO NOT KNOW

UNKNOWN UNKNOWN HAZARDS – HAZARDS WE DO NOT KNOW WE DO NOT KNOW

HIGHLY RELEVANT FOR MAKING PROGRESS TOWARDS CREATING A SAFE MINE

UNIVERSE OF HAZARDS

KNOWN KNOWNS

• CAUSES, CONSEQUENCES AND MANNER OF CONTROL ARE KNOWN WITH CERTAINTY

• MANAGEMENT THROUGH ELIMINATION IS MOST EFFECTIVE

• HAZARD REDUCTION, HAZARD CONTROL AND DAMAGE CONTROL ARE ALL APPLICABLE DEPENDING ON THE MANNER OF CONTROL

• ARE ALL KNOWN HAZARDS ELIMINATED???

KNOWN UNKNOWNS

• CAUSES, CONSEQUENCES AND MANNER OF CONTROL ARE NOT KNOWN WITH CERTAINTY

• QUESTIONS OR UNCERTAINTIES EXIST WITH DATA, ANALYSES, DESIGN AND CONTROL PROCEDURES

• ASSUMPTIONS HAVE TO BE MADE• OBJECTIVE IS TO REDUCE THE RISK TO

TOLERABLE LEVELS – RISK MANAGEMENT

KNOWN UNKNOWNS – MINE SAFETYConsider the case of trying to open a mine in an

old mining district.• Known knowns - [1] There are old mines, [2] There

are maps available of old mines from agencies. [3] There can be issues with reserves and health and safety during operation

• Known unknowns - [1] The accuracy of the maps - extent of workings. [2] The conditions of the workings - water-filled or gas-filled, etc. [3] Exact nature of the health and safety issues.

QUECREEK MINE INUNDATION INCIDENT, JULY 24, 2002

UNKNOWN UNKNOWNS

• THESE ARE SERIOUS THREATS AS NO ONE PLANS FOR AN “UNKNOWN UNKNOWN”

• IMPORTANT TO RECOGNIZE INADEQUACY OF KNOWLEDGE

• EXPERIENCE AND RESEARCH HAVE UNEARTHED NEW PARAMETERS, NEW RELATIONSHIPS, AND NEW KNOWLEDGE

“THE ORDER OF NATURE: NOTHING HAPPENS BY ACCIDENT, AND THERE IS NO

SUCH THING AS CHANCE”

“CHANCE AND ACCIDENTS ARE ALIASES OF IGNORANCE”

THOMAS HENRY HUXLEYINTRODUCTORY, MACMILLAN AND CO, 1880

ARE THERE TRUE UNKNOWN UNKNOWNS?

IMPORTANT ROLE OF HUMANS

KNOWLEDGE AND EXPERIENCE – TAKE TIME TO BUILD IGNORANCE IS QUITE COMMON CORRECT DECISION MAKING – NOT EASY MANAGEMENT OF CHANGE

RECENT EXAMPLES OF UNKNOWN UNKNOWNS

9/11 TERRORIST ATTACK TRIPLE WHAMMY IN JAPAN – EARTHQUAKE, TSUNAME AND NUCLEAR DISASTER THE CURRENT GLOBAL FINANCIAL CRISIS

UNKNOWN UNKNOWNS – BUILDING MODELS

• PARAMETERS’ VALUES AND RELATIONSHIPS KNOWN – KNOWN KNOWNS

• PARAMETERS KNOWN – UNCERTAIN OF EXACT VALUES AND RELATIONSHIPS – KNOWN UNKNOWNS

• PARAMETERS NOT KNOWN – UNKNOWN UNKNOWNS, NOT INCLUDED IN THE MODEL

MINE SAFETY – UNKNOWN UNKNOWN EXAMPLE

• Unknown unknowns - Existence of old mines for which there are no maps, no indications. How can one be sure that [1] all mines have been mapped? [2] all maps are available? and [3] all relevant information have been considered?

All available data have been considered is no assurance that there are no unmapped mines.

ABSENCE OF PROOF IS NOT

PROOF OF ABSENCE

WILLIAM COWPER

"These occurrences, I confess, are of exceeding gravity, and more over fraught with terror and peril , so that I should consider that the metals should not be dug up at all, if such things were to happen very frequently to the

miners, or if they could not guard against such risks by any means."

GEORGIUS AGRICOLA DE RE METALLICA, 1556

WILLIAM COWPER

PRECAUTIONARY PRINCIPLE

“WHEN AN ACTIVITY RAISES THREATS TO HUMAN HEALTH OR ENVIRONMENT, PRECAUTIONARY MEASURES SHOULD BE TAKEN EVEN IF SOME CAUSE AND EFFECT RELATIONSHIPS ARE NOT FULLY ESTABLISHED.”

“IF AN ACTIVITY MIGHT POSE SEVERE DAMAGE TO HUMAN HEALTH, WE OUGHT TO CONSIDER CONSEQUENCES WITHOUT NECESSARILY WAITING FOR PROOF.”

MINE HEALTH AND SAFETY EXPERIENCE

• FATALITIES AND FATALITIES RATES DECREASING WORLDWIDE

• DISASTERS AND DISASTER RATES DECREASING WORLDWIDE

• INJURIES AND SEVERITY, AND INJURY AND SEVERITY RATES DECREASING

• OCCUPATIONAL DISEASES – PREVALENCES DECREASING

NUMBER OF FATALITIES IN THE U.S. MINING INDUSTRY, 1910-2000

U.S. MINE FATALITY RATE, 1930-2000

STEEP DECREASES IN FATALITY RATES FOLLOWMAJOR CHANGES IN PRACTICES

0

50

100

150

200

250

300

Nu

mb

er o

f F

atal

itie

s

1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

U.S. Mining Fatalities CY 1978 - 2010

Year Fatalities Fatality Rate

1978 242 0.0515

2010 71 0.0234

2006 2007 2008 2009 2010

Number of Mines Coal Metal/Non-Metal Total

2,11312,77214,885

2,03012,84114,871

2,12912,77814,907

2,07612,55514,631

1,94512,31914,264

Employment Coal Metal/Non-Metal Total

122,975240,522363,497

122,936255,187378,123

133,828258,918392,746

134,089221,831355,720

135,415225,148360,563

Fatalities Coal Metal/Non-Metal Total

472673

343367

302353

181634

482371

Fatality Rate1

Coal Metal/Non-Metal TotalAll U.S. Industry2

0.04000.01220.02200.0042

0.02930.01490.01990.0040

0.02370.01070.01560.0037

0.01480.00920.01150.0035

0.03840.01290.0234

All Injury Rate1

Coal Metal/Non-Metal TotalAll mines NFDL Rates3

All U.S. NFDL Private4

4.463.193.642.434.4

4.213.023.432.314.2

3.892.873.252.173.9

3.692.543.012.023.6

3.422.382.811.87

U.S. MINING INDUSTRY ACCIDENT-INJURY EXPERIENCE, 2006-2010

Mine Injury Experience2006-2010

Average for the 5-year period: 2006 – 2010 MINE EMPLOYMENT 370,000NUMBER OF COAL MINES 2,060NUMBER OF M/NM MINES 12,600NUMBER OF FATALITIES 60FATALITY RATE 0.0185ALL INJURY RATE 3.94ALL U.S. INDUSTRY FATALITY RATE 0.0038

MINING DISASTER INCIDENTS AND FATALITIES, 1900-2010

MINE DISASTERS: 2001-2010YEAR MINE NAME LOCATION TYPE OF

DISASTERMINERAL MINED

NUMBER OF VICTIMS

2001 No. 5 BROOKWOOD, ALABAMA

EXPLOSION COAL 13

2006 SAGO BUCKHANNON, WEST VIRGINIA

EXPLOSION COAL 12

2006 DARBY No. 1

MIDDLESBORO,KENTUCKY

EXPLOSION COAL 5

2007 CRANDALL CANYON

HUNTINGTON, UTAH

GROUND FALL [FACE OR RIB]

COAL 6

2010 UPPER BIG BRANCH

MONTCOAL, WEST VIRGINIA

EXPLOSION COAL 29

http://www.cdc.gov/niosh/mining/pubs/pdfs/tsomf.pdf

Reported fires for the U.S. mining industry from 1990 to 2007

TOTAL NUMBER OF REPORTED FIRES [1990-2007] = 1601

Percentage of miners with CWP by tenure in mining, CWXSP, 1970-2006

MANDATORY DUST STANDARDS WERE INTRODUCED IN 1969 AND REVAMPED IN LATER

YEARS. THE INCREASE IN PREVALENCE IN RECENT YEARS IS OF CONCERN.

MINE SAFETY – PRESENT STATUS• LAWS AND REGULATIONS HAVE BEEN TIGHTEND.• INSPECTIONS AND PENALTIES HAVE INCREASED• MINES ARE DESIGNED BETTER• ACCIDENTS CONTINUE TO HAPPEN – DEATH AND SERIOUS

INJURIES, DISASTERS – EXPLOSIONS, FIRES, INUNDATIONS• QUECREEK MINE INUNDATION [2002] – MIRACULOUS ESCAPE

OF 9 MINERS AND RESCUE OF 9 MINERS• ARACOMA MINE FIRE AT ALMA No. 1 MINE [2006] – 2

FATALITIES, 10 ESCAPED.

ALL ACCIDENTS CAN HAPPEN

ALL ACCIDENTS CAN BE PREVENTED

BAD NEWS

GOOD NEWS

QUESTIONS

• ARE WE DOING WHAT WE KNOW?• ARE WE FINDING AND FIXING THE RIGHT

PROBLEMS?• ARE WE USING THE RIGHT METRICS FOR

ASSESSING SAFETY CONDITION?• ARE WE PROVIDING THE RIGHT KIND OF

TRAINING? MANAGEMENT?• ARE THERE BETTER METHODS?

ARE WE DOING WHAT WE KNOW?• ACCIDENT/DISASTER INVESTIGATIONS• COURTS OF ENQUIRIES• FREQUENT CONCLUSIONS:

1. CAUSES – DETECTABLE2. DISASTER – PREVENTABLE3. HUMAN ERRORS – DOMINANT4. NON-TECHNICALFACTORS EVIDENT –

ORGANIZATIONAL FACTORSNOT DOING WHAT WE KNOW. WHY?

ARE WE USING THE RIGHT METRICS?

WHY MEASURE?[1] TO ASSESS AND EVALUATE EFFECTIVENESS OF

CONTROL

[2] WHAT GETS MEASURED, GETS DONE

[3] IF YOU CAN’T MEASURE IT, YOU CANNOT MANAGE IT

41

ARE WE USING THE RIGHT METRICS? “WHAT GETS MEASURED GETS DONE”

• TRUE ONLY WHEN WE MEASURE THE APPROPRIATE THINGS RIGHTLY AND TAKE ACTION

• SAFETY IN INDUSTRIAL SYSTEMS1. TECHNICAL SAFETY2. OCCUPATIONAL SAFETY3. PROCESS SAFETY

UNDERSTANDING THE RELATIONSHIPS BETWEEN THESE THREE AND MANAGING ALL THREE IS ESSENTIAL FOR GOOD

OVERALL SYSTEM SAFETY

Technical Safety - the focus is on engineering and design of systems, generally mine design, equipment design, process design, etc Process Safety - the focus is on process related events that have high consequences, acute consequences. Occupational Safety - the focus here is on worker health and safety and providing a safe working environment.

Causes and consequences of events affecting these three kinds of safety can be vastly different. The metrics to monitor occupational safety may not indicate the true state of affairs with process or technical safety.

Most common available data is on occupational safety – mostly lagging indicators [what happened?]

High performance in the metrics of occupational safety may provide a false sense of security on system’s safety and occurrence of catastrophic failures in the process.

KEY PERFORMANCE INDICATORS [KPIs]• PERFORMANCE INDICATORS – CHARACTERISTICS• TECHNICAL, PROCESS AND OCCUPATIONAL SAFETY

INDICATORS• LAGGING INDICATORS• LEADING INDICATORS• COMPOSITE INDICATORS – VERY USEFUL • INTERVENTIONS BASED ON INDICATIONS

Percentage of Job Safety Analyses completed for critical activities Percentage of safe behaviors observed Percentage of actions implemented from observations Percentage of hazards rectified

EXAMPLES OF LEADING INDICATORSBHP BILLITON

Percentage of Incidents investigated Number of near misses reported Ratio of near misses to accidents reported. Number of repeat incidents Percentage of significant incidents reviewed and closed out

EXAMPLES OF LEADING INDICATORSBHP BILLITON

PRO-ACTIVE AND REACTIVE SYSTEMS SAFETY ANALYSIS RISK ANALYSIS NEAR-MISS INCIDENTS ACCIDENTS AND DISASTERS

INVESTIGATION OF NEAR MISS INCIDENTS IS ONE OF THE KEYS TO UNEARTHING UNKNOWN UNKNOWNS

LEARNING CURVES FOR DISASTER CONTROL

2003 2004 2005 2006 2007 Total

Gas & Dust Ignitions

59 49 36 57 63 264

Fires 07 13 07 08 15 50

Inundations 19 14 13 13 23 82

Total 85 76 56 78 101 396

UNDERGROUND COAL EVENTS 2003-2007

SOURCE: MSHA, 2008, PERSONAL COMMUNICATION

CONCEPT OF PRECURSOR EVENTS – FORETELL POSSIBLE FUTURE EVENTS

PARADOX OF ACCIDENT INVESTIGATIONS

“THE MORE YOU INVESTIGATE, THE LESS YOU HAVE TO INVESTIGATE”

ARE WE PROVIDING THE RIGHT KIND OF TRAINING?

• DEVELOPING KNOWLEDGE AND SKILLS• DEVELOPING THE ENTIRE PERSON• TRAINING VERSUS LEARNING• LIFE LONG LEARNING• INDEPENDENT LEARNING• DEVELOPING INTO A LEARNING ORGANIZATION

“One thing a person cannot do, no matter how rigorous his analysis or heroic his imagination, is to draw up

a list of things that would never occur to him”

Thomas Schelling’s Impossibility Theorem

www.therisktoolboxshop.com/Harm_Process.jpg

THINK 6 – LOOK 6 HAZARD-RISK MANAGEMENT

PROCESS TOOL

IDENTIFY RISK, ASSESS RISK AND MINIMIZE RISK

LOOK 6 – LOOK ALL AROUND YOU

UP, DOWN, LEFT, RIGHT, FRONT AND BACK

THINK 6 – EVALUATE

1. WHAT ARE THE HAZARDS AROUND YOU?2. WHAT TRIGGERS WILL RELEASE THE HAZARD?3. WHAT INCIDENT OR ACCIDENT COULD OCCUR?4. WHAT WILL BE THE CONSEQUENCES OF THE ACCIDENT?5. HOW WILL YOU CONTROL THE HAZARDS AND TRIGGERS?6. HOW WILL YOU MINIMIZE THE CONSEQUENCES AND RECOVER THE SITUATION?

SAFETY MANAGEMENT SYSTEMS

OSHA - Process Safety Management [PSM] EPA - Risk Management Program [RSM] BOEMRE - Safety and Environmental Management Systems [SEMS] OSHA - I2P2 - Injury and Illness Prevention Program MSHA - SHMP - Safety and Health Management Programs for Mines ANSI-AIHA - Z10-2005 - Occupational Health and Safety Management Systems

SAFETY MANAGEMENT SYSTEMS

ISO - ISO 9001:2008(E) - Quality Management Systems Requirements BSI - BS OHSAS 18001:2007 - Occupational Health and Safety Management Systems – Requirements ILO - ILO-OSH 2001 - Guidelines on Occupational Safety and Health Management SystemsAPI RP 75 - Recommended Practice for Development of a Safety and Environmental Management Program for Offshore Operations and Facilities, May 2004

KNOWLEDGE AND SKILLS ARE NECESSARY CONDITIONS BUT ARE NOT SUFFICIENT TO ENSURE HIGHLY EFFECTIVE INDIVIDUALS.

PROCESS IMPROVEMENT REQUIRES/DEMANDS INNOVATION,

CREATIVITY, TEAMWORK, INTERDEPENDENCE AND TRUST

Knowledge, skills and desire shape the habit of an individual

Why and what of things

Want to do thingsHow to do things

Knowledge

Skills Desire

Habit

From Stephen Covey’s ‘The 7 habits of Highly Effective People’

Internalized principles and patterns of behavior

ATTITUDE ATTITUDE IS A WAY OR

METHOD OF DOING THINGS WHICH SHOWS ONE’S NATURE OR TENDENCY

GOOD ATTITUDE RIGHT ATTITUDE POSITIVE ATTITUDE BAD ATTITUDE NEGATIVE ATTITUDE

ATTITUDE IMPACTS OUTCOME

• I CAN’T • I WON’T• I WISH I COULD• I WANT TO• I CAN• I WILL

GREATER THE POSITIVE ATTITUDE,

GREATER THE CHANCES OF SUCCESS

FAILURE

SUCCESS

Knowledge and skills:What?Why?How?Able to

Desire:YearningThirstAspireLoveWant to

Organization:CorporateDivisionPlantsUnits

Policies and proceduresGuidelines and manuals

NormsCulture

Individuals:ExecutivesManagersSupervisorsWorkers

Education and trainingExperience

AttitudeMotivation – intrinsic/extrinsic

ARE THERE BETTER METHODS?

1. KNOWN KNOWNS – WE STILL CAN SEE THEM CAUSING MAJOR HEALTH AND SAFETY PROBLEMS – IMPROVE ENGINEERING, OPERATIONS, AND MANAGEMENT

2. UNKNOWN KNOWNS – DEPENDING ON THE ISSUE, INCREASE ATTENTION TO PROACTIVE RISK ANALYSIS AND RISK REDUCTION THROUGH ELIMINATION AND CONTROL.

3. RECOGNIZE THAT THE SYSTEM HAS RESIDUAL RISKS – RISKS NOT ELIMINATED OR CONTROLLED.

KNOWNS, UNKNOWNS AND UNKNOWN UNKNOWNS

1. RESIDUAL RISKS ARE MADE UP OF IDENTIFIED RISKS THAT ARE REGARDED AS ACCEPTABLE AND RISKS THAT ARE NOT KNOWN OR UNIDENTIFIED.

2. UNKNOWN UNKNOWNS – A. BE WARY – NEVER BE CERTAINB. NEVER ASSIGN A ZERO PROBABILITYC. SEEK CONTINUOUS PROCESS IMPROVEMENT AND

D. SUPPORT RESEARCH AND DEVELOPMENT TO INCREASE RELIABILITY OF DATA, ASSUMPTIONS, MODELS AND ANALYSIS

KNOWNS, UNKNOWNS AND UNKNOWN UNKNOWNS

Six Basic Requirements for Enhancing Safety

Outstanding Engineering Design Knowledgeable Workforce Realizable Laws and Regulations Enlightened Management Research to unearth new hazards, and new

solutions to eliminate, reduce or protect against all hazards

Educated public – realistic expectations and risk aware

CONTINOUS SAFETY IMPROVEMENT

PLAN

CHECK

ACT

DO

Use PDCA processes and procedures as a part of integrated management system for continuous improvement.