A report by an investigating commission has just been handed down , which,
among other things, highlights a need for training to prevent a
recurrence.
I have grave concerns that the outcome could well be mandatory training on
complex technical issues which are beyond the capacity of the trainees to
influence.
Reading the report and from personal interviews with some of those
involved I was reminded of the movie, The China Syndrome.
While it is true that there was some shortage of technical knowledge about
the contributors to the disaster some of the contributors appear to me
have been:
Supervisors responsible for carrying out safety inspections failed to make
reports on the conditions in the mine
People at all levels adopted an attitude of "It will be OK!"
Alarms on a monitoring system were switched off because they were annoying
Supervisors left the mine early, before making contact with the oncoming
shift.
I was also reminded of the Boiling Frog Syndrome - a rather cruel
experiment in which a frog placed into a pot of boiling water will show
discomfort and attempt to escape, while a frog placed in a pot of normal
water which is then slowly heated will remain at peace with the
environment. In this case the degree of danger present normally may
increase incrementally and not be noticed.
These opinions are mine, and are an oversimplification, because the
inquiry lasted three months, the report took nine months to write and much
of my information is from summary reports and personal discussions.
I worked for the company that operated the mine for over twenty years,
including 10 in management positions and I believe that the company's
executives are totally committed to safety. I believe that the problem is
with the attitude of operators, first level supervisors and middle
management.
The Australian coal industry is strongly unionised and all supervisory and
management positions are held by people who have government mandated
qualifications. It is hard to believe that they achieved these
qualifications without sufficient knowledge about the contributors to this
explosion.
On the basis that the best opportunity for massive attitude change in
after a trauma, I am seeking information from other change agents on
experiences that they may have had in achieving a dramatic attitude change
in comparable circumstances.
While you may choose to contact me directly, especially if your reply has
confidential information (which I will treat with respect) I would like to
see a discussion generated on the list as I believe that it has messages
not only for mining, but also road safety, forestry, construction and
similar dirty hands industries.
I have cross posted this plea to another list, and ask for your
understanding if you receive it more than once.
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Host's Note: See also the earlier thread:
Linkname: Learning-Org Aug 1995: A Safety Case LO2304
URL: http://world.std.com/~lo/95.08/0016.html
begun by Goef Fountain. (Web browser is the best way to see this.)
-- Rick Karash, rkarash@karash.com, host for learning-org
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-- ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^ If you're not having, then maybe you are not doing it right or maybe you are just doing the wrong thing.John Sleigh Making Learning Fun PO Box 1059 Potts Point NSW 2011 AUSTRALIA jsleigh@mail.enternet.com.au ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^