Human Error Blamed for Westray Mine Disaster

Westray management failed in their primary responsibility
Bureaucracy infested with apathy and complacence

Human Error Blamed for Mine Disaster

Responsibility Lies With Mine Management
and Government Bureaucrats

This article appeared in
The Toronto Star
Tuesday, 2 December 1997

It is a story of incompetence, of mismanagement,
of bureaucratic bungling, of deceit, of ruthlessness,
of coverup, of apathy, of expediency and of cynical
indifference. It is a tragic story.
— Justice Peter Richard

STELLARTON, N.S. (CP) — The underground explosion that killed 26 men in the Westray coal mine was the predictable and preventable result of human failure at almost every turn, says a report on the 1992 disaster.

In a hard-hitting, name-naming analysis released yesterday, Justice Peter Richard says the "clear hierarchy of responsibility" lies with mine management and government bureaucrats.

"It is a story of incompetence, of mismanagement, of bureaucratic bungling, of deceit, of ruthlessness, of coverup, of apathy, of expediency and of cynical indifference," Richard says. "It is a tragic story."

The Nova Scotia government immediately announced a cabinet committee to respond to the report and its 74 recommendations.

"We want to have our response out before Christmas," said Public Works Minister Don Downe, who chose his words carefully while families of the dead miners talked about compensation. Downe will chair the committee.

Most of the widows and other relatives who waited 5½ years for the report were not disappointed. They had wanted accountability and they got some from the Nova Scotia Supreme Court judge.

"We knew all along that this accident didn't have to happen," said widow Genesta Halloran. "I want these recommendations to apply to all workplaces in the province of Nova Scotia, not only coal mines."

No one — except the miners themselves — escaped criticism in Richard's four-volume report titled The Westray Story: A Predictable Path to Disaster.

The coal-dust explosion, triggered by a spark and methane-gas fire at the coal face, "was not the result of a single definable event or misstep," he said.

"Only the serenely uninformed (the wilfully blind) or the cynically self-serving could be satisfied with such an explanation ... Management failed, the inspectorate failed and the mine blew up."

But Richard does single out Westray management and its "uncompromising and abusive" owner, Clifford Frame, as ultimately responsible for conditions at the Pictou County colliery.

"The fundamental and basic responsibility for safe operation of an underground coal mine, and indeed of any industrial undertaking, rests clearly with management," he wrote.

"Westray management failed in this primary responsibility, and the significance of that failure cannot be mitigated or diluted simply because others were derelict in their responsibility."

Those others include the Nova Scotia labour department, which Richard says was infested with "apathy and complacence."

"The unacceptable performance of Claude White and Albert McLean in the conduct of their duties as mine-safety inspectors and regulators, coupled with their demeanour at the inquiry hearings, must surely have destroyed any confidence (Nova Scotians) might have had in the ... safety inspectorate."

McLean has been on leave since he testified. White was demoted to a consultant's job. Richard recommends the two be fired.

Frame, in a statement released late in the day, said: "There seems to be no doubt that mistakes occurred in the mine 5½ years ago and that human error produced the conditions that caused the disaster.

"I deeply regret that mistakes were made," he said, adding he will "forever grieve" the dead miners.

Labour wasn't the only government department to fall down on the job, Richard says.

He cites natural resources for "its hands-off attitude, its general indifference to the quality of mine planning" and uncaring attitude toward safety.

"Natural resources failed to discharge its duties in a creditable manner," Richard says. "The general attitude of wilful blindness pervaded the department's dealings with Westray.

"Thus, the stage was set for Westray management to maintain an air of arrogance and cynicism, knowing that it was not going to be seriously challenged."

Richard says there is no evidence former premier Donald Cameron, in whose area the mine was built, was ever told by staff that Westray was poorly planned and unsafely run. But he says the politician did act improperly in committing the province to a 1988 agreement before it was approved by cabinet.

Cameron "may have exceeded the limits of ministerial prudence and responsibility" in so fervently pursuing the mine while industry minister.

"He became an advocate for the project in much the same way that the promoters were in their dealings with the government of Canada."

Richard notes Cameron took the word of the mine's Toronto-based owner, Curragh Inc., at face value during negotiations instead of securing written commitments.

This attitude indicates startling naivete for a person of experience in the political milieu. If not naivete, it is another compelling example of Cameron's obdurate and single-minded determination to bring Westray to reality."

Cameron, ex-premier John Buchanan and former labour minister Leroy Legere had "disparate understandings of their roles as ministers of the crown," he says.

"The fact that they had such an imperfect understanding of the nature of their responsibilities suggests that a formal clarification of constitutional responsibilities is required."

Guidelines to ministers are among Richard's extensive recommendations, many of which relate to the technicalities of mine operations and monitoring.

"Sometimes the best training is the school of hard knocks," said the area's former MP, Elmer MacKay. "The people who are administering ... political decisions have to do the best they can based on what they know."

Frame refused to testify before the inquiry. Richard says Ottawa and the province should study the accountability of corporate bosses for "wrongful or negligent acts of the corporation" with an eye to legislating it.

Ken Teasdale, who lost his son-in-law in the blast, thanked Richard for "aspects" of his report. However, he lamented the fact the judge deemed the fate of more than $100 million in government funding to the mine outside his mandate.

"Donald Cameron indicated he wanted no stone unturned" when he commissioned the inquiry six days after the explosion, said Teasdale. "He wanted everything to be done to uncover what went wrong.

"He even went so far as to state that your mandate was very broad and if you needed any further broadening of your mandate all you needed to do was ask."

Few relatives or ex-miners said the report helped them put the tragedy behind them. A criminal case is still pending against mine managers Gerald Phillips and Roger Parry and there was talk yesterday of a lawsuit against the province for compensation.

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