Stupidity Blew Up Westray
Incompetent regulators and arrogant management
Stupidity Blew Up Westray
Judge says explosion that killed 26 was sparked
by failures of bosses and bureaucrats
by Kevin Cox
This article appeared in
The Globe and Mail
Tuesday, December 2, 1997
A deadly mixture of coal dust and methane killed 26 men in the Westray coal mine in 1992, but the tragedy was caused by a combination of government regulators' incompetence and company managers' arrogant disregard for safety, the judge who conducted a public inquiry says.
"The Westray story is a complex mosaic of actions, omissions, mistakes, incompetence, apathy, cynicism, stupidity and neglect," Mr. Justice Peter Richard said of the way the mine was established and operated. "Some well- intentioned but misguided blunders were also added to the mix."
The commissioner's report on the ill-fated mine, which received $100-million in public financing, accepts the testimony of dozens of former Westray miners who said they worked in a dangerous underground facility where both managers and provincial inspectors ignored their concern about crumbling roofs, high methane levels and deep drifts of coal dust.
Employees who did complain were threatened with dismissal.
The report, titled The Westray Story: A Predictable Path to Disaster, said the tragedy could have been prevented if provincial mine inspectors had forced mine managers to follow the rules about ventilation to prevent buildups of explosive methane gas and if they had enforced orders to clean up layers of coal dust.
Judge Richard released the report of the $4.98-million inquiry at the Nova Scotia Museum of Industry, which overlooks the mine site where the shattered mine portal and large blue towers still stand as they did when the explosion occurred in May 9, 1992.
He said he could not blame any one or two individuals for the deaths of the men. Instead, throughout 751 pages he lashed out at a wide array of mining executives and managers, including former mine-company chief Clifford Frame, mine manager Gerald Phillips, former premier Donald Cameron and several provincial mine inspectors and supervisors.
The judge makes 74 recommendations including a call for a complete overhaul of the provincial Department of Natural Resources, which he said showed "willful blindness" in not warning of the hazards during the establishment of the mine. He also called for a revamping of the Department of Labour, whose inspectors were described as incompetent and inadequately trained in detection of hazardous conditions.
Judge Richard said Nova Scotians have lost confidence in both departments because of the incompetence of the officials.
He wants several of the bureaucrats removed, including provincial mine inspector Albert McLean, who found dangerous levels of coal dust at the mine on April 29, 1992, but did not follow up his report to see whether the company had dealt with the problem.
Public Works Minister Donald Downe said yesterday that the province is preparing a written response to the report and will make the document public before Christmas.
The report also criticizes Mr. Cameron, who as Progressive Conservative premier was a major promoter of the mine, for pushing the project forward with "obdurate and single-minded determination."
The judge, who recommended that guidelines be established for Nova Scotia cabinet ministers, said that Mr. Cameron did not understand his own role with respect to the mine. The judge said the premier failed to see what acceptable political support for the project should be.
But the report concluded that Mr. Cameron was not personally aware of dangerous conditions at the mine.
Judge Richard concluded that the mine managers were aware that an explosive environment was building at the mine in the days before the blast, yet were so intent on producing coal that they ignored the increasing concentrations of methane and the thick layers of coal dust.
Judge Richard listed 27 problems in the Westray mine just prior to the blast, including inadequate ventilation, lack of methane-detection devices and "an appalling lack of safety training and indoctrination" of miners.
He said he made the list to "give some indication of the laxity, or incompetence or the apathy, or the carelessness that seemed to permeate Westray management and in turn to have a negative effect on the underground workers who were lulled into a sense of 'it can't be all that bad'"
He said that it is difficult to understand the attitude of the mine manager, Mr. Phillips, who along with underground manager Roger Parry is facing charges of criminal negligence and manslaughter in the deaths of the miners, in failing to deal with the serious problem of methane buildups in the mine.
The judge said Mr. Phillips, a veteran mine manager, must have been aware of the danger of the methane buildup but didn't take action.
"His casual attitude permeated Westray management, creating and perpetuating a serious safety defect. Phillips, by his training and experience, must have known better," the report said.
The judge said that Mr. Frame, the former head of mine owner Curragh Inc. who refused to testify at the inquiry hearings and defied legal attempts to compel him to do so, was only a promoter for the project and failed to ensure that a safe working environment was in place when the mine opened in the fall of 1991. The judge also announced at the news conference yesterday that the inquiry has abandoned its attempts to compel Mr. Frame and another former Curragh executive, Marvin Pelley, to testify.
The judge said he relied on the testimony of miners and documentation about Westray to put together the report.
The report also rejected suggestions made to reporters by Mr. Phillips and Mr. Frame and made to the commission by Mr. Cameron that miners who tampered with methane-detection devices in the days before the explosion so they could keep producing coal had some responsibility for the tragedy.
In words that brought some comfort to the almost 30 former miners and relatives of the dead miners who attended the news conference yesterday, Judge Richard concluded that while the tampering with the methane meters was "dangerous and foolhardy," the tragedy was actually caused by "dismally inadequate" ventilation that failed to dilute the explosive levels of methane.
Last night Mr. Frame issued a statement that attributed the tragedy to "human error."
"There seems to be no doubt that mistakes occurred in the mine that day five and a half years ago and that human error produced the conditions that caused the disaster. I deeply regret that mistakes were made," the statement said.
According to the inquiry's report, the cause of the tragedy was simple. "Management failed, the (Department of Labour) inspectorate failed and the mine blew up," the report said.
That was scarcely news to the assembled former miners and relatives of the dead.
"I wouldn't call it closure by any means but it is a steppingstone in the process," said Alan Martin, whose brother Glenn died in the explosion. "If we can convince the government to do something rather than cover their butts then we are going to save lives down the line, that's what this is all about. My brother's dead and he's not coming back."
Genesta Halloran, whose husband John died in the mine, was pleased the report absolved the miners of blame in the tragedy.
"This is sort of a good Christmas present as long as they can tell us that it (the explosion) was preventable and it wasn't the miners' fault, then we can look at the recommendations.
But Melvin Skinner, who drove to work with three of the Westray miners who died that day and won a medal of bravery for his efforts during the unsuccessful rescue effort, found little comfort in the four-volume report.
"I knew five and a half years ago that the place blew up and 26 guys died because it was unsafe and the managers didn't manage it properly," he said. "All this does five years later is put it down in black and white for me with some nice colour pictures. That does absolutely nothing for that woman there with three kids whose husband died down there."
Westray: Aftermath of a Tragedy
- 1992 May 9: Explosion wrecks Westray coal mine in Plymouth, N.S., killing 26 miners.
- May 15: Province appoints Justice Peter Richard of Nova Scotia Supreme Court to run wide-ranging Westray inquiry.
- May 21: RCMP launch criminal investigation.
- Oct. 5: Nova Scotia Labour Department lays 52 non-criminal charges of unsafe practices against Westray owner Curragh Inc. and four managers.
- Dec. 10: Prosecution drops 34 of 52 safety charges to avoid prejudicing RCMP
- 1993 Jan. 6: Province permits Westray to flood sections of mine for safety reasons, making some tunnels inaccessible for evidence-gathering.
- March 3: Prosecution stays remaining 18 safety charges to avoid jeopardizing rights in criminal investigation.
- April 20: RCMP lay charges of manslaughter and criminal negligence causing death against Curragh and managers Gerald Phillips and Roger Parry.
- July 20: Provincial court quashes manslaughter and negligence charges, saying they lack detail.
- July 23: RCMP file new charges of criminal negligence and manslaughter against Curragh and managers Phillips and Parry.
- 1994 April 18: Inquiry lawyer John Merrick argues before Supreme Court of Canada that delaying inquiry until trials are over could cost lives.
- 1995 Feb. 6: Trial begins in Pictou, N.S.
- May 4: Supreme Court rules inquiry can proceed before trial ends.
- June 9: Trial proceedings stayed on grounds prosecution did not adequately disclose evidence.
- Nov. 6: Inquiry hearing begin.
- Dec. 1: Nova Scotia Court of of Appeal quashes stay of criminal trial.
- Dec. 21: Phillips and Parry ask Supreme Court of Canada to overturn new trial order.
- 1996 July 22: Westray inquiry concludes with lawyers' summations after 76 days of
testimony; attempts to subpoena Curragh bosses continue. 1997
- March 20: Supreme Court of Canada upholds new trial order.
- July 17: Ontario court rules former Westray owner Clifford Frame and former president Marvin Pelley, both Ontario residents, must testify before the inquiry. Frame and Pelley's appeal is to be heard in February.
- Dec. 1: Justice Peter Richard's report released, blaming bureaucratic bungling, incompetent mine managers and pushy politicians for the mine disaster. Released without testimony from Frame and Pelley.
Go To: Westray Scrapbook Fifty clippings about the Westray coal mine disaster
Go to: Main Westray Coal Mine Disaster page
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