Shifting the Cultural Paradigm for the Prevention of Catastrophic and Fatal Events

The relative infrequency of fatalities and other serious events can give them an appearance of being random, of being beyond any reasonable degree of anticipation and prevention. In fact, the vast majority of these events result from exposures that are identifiable, measurable, and manageable. The lessons of prominent incidents, such as the Space Shuttle Columbia, OxyÆs Piper Alpha, Esso Longford, BP Texas City, Massey Mine, as well as lessons from single fatality events, is that alongside the proximate causes of each incident, there also coexisted an underlying fabric of systems, mechanisms, and culture that allowed risk in the workplace to persist and often to become normalised. All of these ingredients of the organisationÆs safety fabric lend themselves to the influence and intervention of senior leaders. The difficulty is that traditional injury prevention paradigms are not sufficient for addressing the precursors that lead up to catastrophic and fatal events. A recent study of such events, led by Dr Thomas Krause concluded that the descriptive aspect of HeinrichÆs safety triangle is useful, but that the predictive aspect is not. The study surfaced reasons why a reduction in less serious injuries does not necessarily correspond to a proportionate reduction in catastrophic and fatal risks. This presentation expands on the findings to include the concept of exposure to the event potential linked to precursor events and the framework for leading an organisation to be both cognisant and effective in eliminating such events.CITATION:Russell, R, 2012. Shifting the cultural paradigm for the prevention of catastrophic and fatal events, in Proceedings International Mine Management 2012, pp 91-96 (The Australasian Institute of Mining and Metallurgy: Melbourne).