Systematically analyses mine disasters and fatal incidents in five countries (Australia, Britain, Canada, New Zealand and the USA) since 1992. It finds that there are 10 pattern causes which repeatedly recur in these incidents, namely:
- engineering, design and maintenance flaws,
- failure to heed warning signs,
- flaws in risk assessment,
- flaws in management systems,
- flaws in system auditing,
- economic/reward pressures compromising safety,
- failures in regulatory oversight,
- worker/supervisor concerns that were ignored,
- poor worker/management communication and trust, and
- flaws in emergency and rescue procedures.
The majority of incidents entailed at least three of these pattern causes and many exhibited five or more. The book also demonstrates these pattern deficiencies are not confined to mining but can be identified in other workplace disasters including aircraft crashes, oil-rig explosions, refinery and factory fires, and shipping disasters. The book also examines why pattern causes have proved so resistant to intervention by governments while also identifying instances where lessons have been learned. The book concludes by proposing an agenda for change that will address pattern causes and contribute to safe and productive work environments.