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 DATA
 12 WORKERS KILLED PER DAY ON THE JOB
 4.1 MILLION WORK RELATED INJURIES
 50,000 DEATHS FROM OCCUPATIONAL DISEASES

AFL-CIO 2011 REPORT

 SUSPECTED UNDER REPORTING OF INJURIES
 TOTAL COST OF INJURIES - $200 TO 300 BILLION

NATIONAL SAFETY COUNCIL 2009 DATA

 COST OF A FATALITY - $1.3 BILLION
 COST 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.

UNIVERSE OF 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

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 SAFETY

Consider 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 HUXLEY
INTRODUCTORY, 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

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

STEEP DECREASES IN FATALITY RATES FOLLOW

MAJOR CHANGES IN PRACTICES

U.S. MINE FATALITY RATE, 1930-2000

U.S. Mining Fatalities CY 1978 - 2010

300

250

Year

Fatalities

Fatality
Rate

1978

242

0.0515

2010

71

0.0234

Number of Fatalities

200

150

100

50

0
1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

U.S. MINING INDUSTRY ACCIDENT-INJURY

EXPERIENCE, 2006-2010
2006

2007

2008

2009

2010

Number of Mines
Coal
Metal/Non-Metal
Total

2,113
12,772
14,885

2,030
12,841
14,871

2,129
12,778
14,907

2,076
12,555
14,631

1,945
12,319
14,264

Employment
Coal
Metal/Non-Metal
Total

122,975
240,522
363,497

122,936
255,187
378,123

133,828
258,918
392,746

134,089
221,831
355,720

135,415
225,148
360,563

Fatalities
Coal
Metal/Non-Metal
Total

47
26
73

34
33
67

30
23
53

18
16
34

48
23
71

Fatality Rate1
Coal
Metal/Non-Metal
Total
All U.S. Industry2

0.0400
0.0122
0.0220
0.0042

0.0293
0.0149
0.0199
0.0040

0.0237
0.0107
0.0156
0.0037

0.0148
0.0092
0.0115
0.0035

0.0384
0.0129
0.0234

All Injury Rate1

Coal
Metal/Non-Metal
Total
All mines NFDL Rates3
All U.S. NFDL Private4

4.46
3.19
3.64
2.43
4.4

4.21
3.02
3.43
2.31
4.2

3.89
2.87
3.25
2.17
3.9

3.69
2.54
3.01
2.02
3.6

3.42
2.38
2.81
1.87

Mine Injury Experience

2006-2010
Average for the 5-year period: 2006 2010

MINE EMPLOYMENT
370,000

NUMBER OF COAL MINES
2,060

NUMBER OF M/NM MINES 12,600

NUMBER OF FATALITIES
60

FATALITY RATE
0.0185

ALL INJURY RATE
3.94

ALL U.S. INDUSTRY FATALITY RATE 0.0038

MINING DISASTER INCIDENTS AND FATALITIES,

1900-2010

MINE DISASTERS: 2001-2010

YEAR

MINE NAME

LOCATION

TYPE OF
DISASTER

MINERAL
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,KEN
TUCKY

EXPLOSION

COAL

2007

CRANDALL
CANYON

HUNTINGTON,
UTAH

GROUND FALL COAL

[FACE OR RIB]

2010

UPPER BIG
BRANCH

MONTCOAL, WEST
VIRGINIA

EXPLOSION

COAL

29

TOTAL NUMBER OF REPORTED

FIRES [1990-2007] = 1601

Reported fires for the U.S. mining industry

from 1990 to 2007
http://www.cdc.gov/niosh/mining/pubs/pdfs/tsomf.pdf

MANDATORY DUST STANDARDS WERE

INTRODUCED IN 1969 AND REVAMPED IN LATER
YEARS. THE INCREASE IN PREVALENCE IN
RECENT YEARS IS OF CONCERN.

Percentage of miners with CWP by tenure in mining,

CWXSP, 1970-2006

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.

BAD NEWS
ALL ACCIDENTS CAN
HAPPEN

GOOD NEWS
ALL ACCIDENTS CAN
BE PREVENTED

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 DETECTABLE
2. DISASTER PREVENTABLE
3. HUMAN ERRORS DOMINANT
4. NON-TECHNICALFACTORS EVIDENT
ORGANIZATIONAL FACTORS
NOT 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 CANT 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 SYSTEMS
1. TECHNICAL SAFETY
2. OCCUPATIONAL SAFETY
3. 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 systems 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

EXAMPLES OF LEADING INDICATORS

BHP BILLITON

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 INDICATORS

BHP 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

LEARNING CURVES FOR DISASTER

CONTROL

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

UNDERGROUND COAL EVENTS 20032007

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

CONCEPT OF PRECURSOR EVENTS FORETELL

POSSIBLE FUTURE EVENTS
SOURCE: MSHA, 2008, PERSONAL COMMUNICATION

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 Schellings 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
Systems

API 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

Knowledge

Habit

Skills

How to do things

Desire

Want to do things

Internalized principles and patterns of behavior

From Stephen Coveys The 7 habits of Highly Effective People

ATTITUDE

ATTITUDE IS A WAY OR
METHOD OF DOING
THINGS WHICH SHOWS
ONES NATURE OR
TENDENCY

GOOD ATTITUDE

RIGHT ATTITUDE

POSITIVE ATTITUDE

BAD ATTITUDE

NEGATIVE ATTITUDE

ATTITUDE IMPACTS OUTCOME

I CANT
I WONT
I WISH I COULD
I WANT TO
I CAN
I WILL

FAILURE

SUCCESS

GREATER THE POSITIVE ATTITUDE,

GREATER THE CHANCES OF SUCCESS

ARE THERE BETTER METHODS?

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

Desire:
Yearning
Thirst
Aspire
Love
Want to

Organization:
Corporate
Division
Plants
Units

Policies and procedures

Guidelines and manuals

Norms
Culture

Individuals:
Executives
Managers
Supervisors
Workers

Education and training

Experience

Attitude
Motivation intrinsic/extrinsic

KNOWNS, UNKNOWNS AND

UNKNOWN UNKNOWNS
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 CERTAIN
B. NEVER ASSIGN A ZERO PROBABILITY
C. SEEK CONTINUOUS PROCESS IMPROVEMENT AND
D. SUPPORT RESEARCH AND DEVELOPMENT TO
INCREASE RELIABILITY OF DATA, ASSUMPTIONS,
MODELS AND ANALYSIS

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

ACT

PLAN

CHECK

DO

Use PDCA processes and procedures as a part of integrated

management system for continuous improvement.