Conversations from the Coalface: Positive Asymmetry and the Culture of Silence that Surrounds the Pike River Mine Tragedy

<p>Charles Perrow (1999) once famously noted ‘Where body counting replaces social and cultural values and excludes us from participating in decisions about the risks that a few have decided the many cannot do without, the issue is not risk, but power.’ This dissertation explores positive asymmetry (Cerulo 2006) and the culture of silence that surrounds Pike River Mine disaster that killed 29 men on the West Coast of Aotearoa/New Zealand on 19 November 2010. This asymmetry involves habitual ways of thinking and behaving which increase the propensity to ignore an approaching worst case scenario in order to meet intended outcomes. Increasingly lauded in ‘get rich quick’ cultures, positive asymmetry can be lethal in mining and other hazardous workplaces where there is pressure to meet demands of the market that override pre-existing flaws in systems and culture, and it is often accompanied by practices of eclipsing (acts of banishing, physical seclusion, shunning) clouding (impressionism, shadowing) and recasting (rhetorical, prescriptive behaviours). There is a culture of silence that accompanies this cognitive symmetry in relation to the case of Pike River Mine which existed from its early development and continues years after the fatalities in a culture of socially organised denial; which is one in which there is a collective distancing among individuals due to norms of emotion, conversation and attention (Norgaard 2011). What happened at Pike River Mine was not the result of an attention deficit model. There was plenty of information. The mine had some good safety systems. They were not utilised. So what was going on? In this thesis, I look to the James Reason Model of Accident Causation used before the Royal Commission of Inquiry into the disaster and argue that although this does well to describe risk and to illustrate accident causation as a failure of organizational systems, it cannot as a structural model possibly describe the cultural logic and power dynamics which lay beneath the competition driving decision-makers within these systems. Pike River Mine was a case of deliberate risk and hibernating beneath that risk was (and still can be) a base of unchecked power. It follows that any ‘errortolerant’ systems we design for safer workplaces will only work insofar as there is an ‘error-intolerant culture’ inside the industry. Pike River Mine was not an isolated incident and if we fail to look to the power that lay behind that deliberate risk taking, there will be more ‘Pikes’ to come. There exists a triple helix to this tragedy consisting of power, risk and asymmetry. In practising vigilance, we need to look to the junction of these three, for therein lies the perfect storm of conditions for future human tragedy and financial disaster in whichever industry chooses to practice it.</p>

Conversations from the Coalface: Positive Asymmetry and the Culture of Silence that Surrounds the Pike River Mine Tragedy

<p>Charles Perrow (1999) once famously noted ‘Where body counting replaces social and cultural values and excludes us from participating in decisions about the risks that a few have decided the many cannot do without, the issue is not risk, but power.’ This dissertation explores positive asymmetry (Cerulo 2006) and the culture of silence that surrounds Pike River Mine disaster that killed 29 men on the West Coast of Aotearoa/New Zealand on 19 November 2010. This asymmetry involves habitual ways of thinking and behaving which increase the propensity to ignore an approaching worst case scenario in order to meet intended outcomes. Increasingly lauded in ‘get rich quick’ cultures, positive asymmetry can be lethal in mining and other hazardous workplaces where there is pressure to meet demands of the market that override pre-existing flaws in systems and culture, and it is often accompanied by practices of eclipsing (acts of banishing, physical seclusion, shunning) clouding (impressionism, shadowing) and recasting (rhetorical, prescriptive behaviours). There is a culture of silence that accompanies this cognitive symmetry in relation to the case of Pike River Mine which existed from its early development and continues years after the fatalities in a culture of socially organised denial; which is one in which there is a collective distancing among individuals due to norms of emotion, conversation and attention (Norgaard 2011). What happened at Pike River Mine was not the result of an attention deficit model. There was plenty of information. The mine had some good safety systems. They were not utilised. So what was going on? In this thesis, I look to the James Reason Model of Accident Causation used before the Royal Commission of Inquiry into the disaster and argue that although this does well to describe risk and to illustrate accident causation as a failure of organizational systems, it cannot as a structural model possibly describe the cultural logic and power dynamics which lay beneath the competition driving decision-makers within these systems. Pike River Mine was a case of deliberate risk and hibernating beneath that risk was (and still can be) a base of unchecked power. It follows that any ‘errortolerant’ systems we design for safer workplaces will only work insofar as there is an ‘error-intolerant culture’ inside the industry. Pike River Mine was not an isolated incident and if we fail to look to the power that lay behind that deliberate risk taking, there will be more ‘Pikes’ to come. There exists a triple helix to this tragedy consisting of power, risk and asymmetry. In practising vigilance, we need to look to the junction of these three, for therein lies the perfect storm of conditions for future human tragedy and financial disaster in whichever industry chooses to practice it.</p>

Causation of Metro Operation Accidents in China: Calculation of Network Node Importance Based on DEMATEL and ISM

Continuous metro-operation accidents lead to serious economic loss and a negative social impact. The accident causation analysis is of great significance for accident prevention and metro operation safety promotion. Network node importance (NNI) evaluation has been widely used as a tool for ranking the nodes in complex networks; however, traditional indicators such as degree centrality (DC) are insufficient for examining accident networks. This study proposed an improved method by integrating decision making trail and evaluation laboratory (DEMATEL) and interpretive structural modeling (ISM) into traditional NNI evaluation, where the key nodes are determined by both the nature of the accident network topology and the contribution of the nodes to accident development. Drawing on this method, 32 accident causal factors were identified and prioritized on the ground of 248 accident cases. It was found that 14 important factors related to staff (e.g., “driver noncompliance”), environment (e.g., “extrinsic nature disturbance”), passenger (e.g., “passenger sudden illness”), and machine (e.g., “track failures”) should be given priority in safety management due to their significant tendency of causing metro accidents. Theoretical and managerial implications were discussed to provide useful insights into the understanding of the causation of metro accidents and form a basis for metro managers to develop targeted safety countermeasures related to metro operation. The proposed hybrid method is proven effective in investigating accident networks involving sequential and casual relationships and revealing factors with high possibility to increase accidents.

Analysis of Port Accidents and Calibration of Heinrich’s Pyramid

Academics and the maritime industry have used the Heinrich Pyramid for decades to justify overall safety theory, risk assessments, and accident prevention strategies. Most use Heinrich’s original severity ratios (1:29:300) for accident causation development in a factory setting. However, to use the Pyramid effectively and mitigate risks/hazards, it must be calibrated to represent specific industry reality. This paper, for the first time, focuses on calibration of Heinrich’s Pyramid to maritime accident data, using databases from the Marine Accident Investigation Branch of the Department for Transport. This research clusters five years (2013–2017) of accident data, using K-Means clustering on categorical variables and severity levels of accidents, similar logic to Heinrich’s analysis. This approach and descriptive statistics provide new ratios between accident severity classifications for casualties with a ship (CS) and occupational accidents (OAs) separately. Results show that the data do not appear to fall into Heinrich’s Pyramid shape and yield a vastly different and lower ratio to that of Heinrich’s. Especially concerning was that Very Serious and Serious accidents occurred at a 1:5 ratio for CS and 4:1 for OA, very different from Heinrich’s 1:29. Although these results calculated a new ratio, it may not represent reality owing to accident reporting requirements under UK law, a lack of an agreed taxonomy of risk and hazard definitions, and likely underreporting of less severe accidents. This is proven because, in 2017, CS data became pyramid shaped, after a decrease in the number of accidents and a 17% increase in near-misses.

DEEP SCOPE: A Framework for Safe Healthcare Design

Thinking in patient safety has evolved over time from more simplistic accident causation models to more robust frameworks of work system design. Throughout this evolution, less consideration has been given to the role of the built environment in supporting safety. The aim of this paper is to theoretically explore how we think about harm as a systems problem by mitigating the risk of adverse events through proactive healthcare facility design. We review the evolution of thinking in safety as a safety science. Using falls as a case study topic, we use a previously published model (SCOPE: Safety as Complexity of the Organization, People, and Environment) to develop an expanded framework. The resulting theoretical model and matrix, DEEP SCOPE (DEsigning with Ergonomic Principles), provide a way to synthesize design interventions into a systems-based model for healthcare facility design using human factors/ergonomics (HF/E) design principles. The DEEP SCOPE matrix is proposed to highlight the design of safe healthcare facilities as an ergonomic problem of design that fits the environment to the user by understanding built environments that support the “human” factor.

Causality-Network-Based Critical Hazard Identification for Railway Accident Prevention: Complex Network-Based Model Development and Comparison

This study investigates a critical hazard identification method for railway accident prevention. A new accident causation network is proposed to model the interaction between hazards and accidents. To realize consistency between the most likely and shortest causation paths in terms of hazards to accidents, a method for measuring the length between adjacent nodes is proposed, and the most-likely causation path problem is first transformed to the shortest causation path problem. To identify critical hazard factors that should be alleviated for accident prevention, a novel critical hazard identification model is proposed based on a controllability analysis of hazards. Five critical hazard identification methods are proposed to select critical hazard nodes in an accident causality network. A comparison of results shows that the combination of an integer programming-based critical hazard identification method and the proposed weighted direction accident causality network considering length has the best performance in terms of accident prevention.