Looking At Old Practices With A Fresh Eye
Two professors and 21 students at West Virginia Wesleyan University recently conducted an exercise in “content analysis” on 10 years’ worth of MSHA fatal accident investigation reports.
Content analysis is a method of looking closely at the vocabulary, concepts, specific facts and world view in a body of writing. It uses a coding system and computers. Content analysis – in its more precise way -- can get at some of the same issues as good old-fashioned “critical thinking.” Marketers, political analysts and historians, among others, have found it useful.
The West Virginia Wesleyan group came to its task with no special expertise in mining, but willing to spend time and develop their understanding. Their thoughts deserve consideration.
Some of the group’s ideas have been raised before in the mining industry. In other cases, their fresh eye may have given them an advantage. It must be said that on a few points, their conclusions went beyond their evidence. That, however, does not invalidate all that they have to say.
“The accident reports do not have a consistent format nor do they contain consistent information,” the group reported. MSHA might respond that the format was evolving but is now consistent, which would be true of the overall outline. But lack of consistency in specific information is glaring to anyone who regularly uses these documents.
One small example: most reports mention the victims’ training, at a minimum to say if it met federal requirements. Yet the report on a roof bolter’s death at the Long Branch Energy #18 Tunnel mine this February (as covered in this issue) was silent on the subject. Did the investigators obtain this information? If not, why not? Did they omit the information as unimportant? Or could there have been another reason to withhold it? Did MSHA do its investigative job thoroughly? The reader can’t tell. And anyone trying to study training in relation to fatalities is doomed to frustration.
The group recommends a “template” to ensure consistent information. This excellent idea might best be carried out by a standard form in an appendix to the report. Narrative sections could cover what is essential to understand the particular accident – potentially a different fact set in each case. More details would be there for those who need or want them. As the study group recommended, information that could not be collected should be noted.
This approach also could advance another recommendation: to increase the educational usefulness of the reports.
One challenge to report writers is the many functions a fatality report will serve. The report must document the basis for enforcement actions, identify root causes, demonstrate the thoroughness of the investigation process, help prevent similar accidents through education, provide some closure for families, assist in identifying more general safety needs, and finally serve as a historical record.
All these purposes are important. The core of the report needs to be a clear, precise and thoughtful narrative of the accident, its background, and the critical findings of the investigation. With comprehensive details included in a separate form-style appendix, all these functions can be served even better than at present.
As the study group noted, some categories used to classify accidents need revision. “Powered haulage” is a case in point. What can we learn from lumping together accidents involving haul trucks, conveyor belts, mantrips and surface railroads? While carefully separating these from accidents involving bulldozers and loaders (“machinery”)? And who remembers when the “powered” part of the term was necessary? “Non-powered haulage” – the mine mule – is long gone.
The study group also crunched the data in an effort to find “specific patterns and go beyond hunches and anecdotes that are part of the mining industry.” While some of their findings were no surprise, a few were.
For instance, who would have predicted that the highest peak in fatal accidents would occur about 2 hours into a shift? And while the students felt that almost 40 percent of all fatal accidents resulted from “action of individual miner,” they counted even more as attributable to management: “action of supervisor,” “action of miner and supervisor,” or “operator/management malfeasance.”
With Kentucky and West Virginia at the top of the count and identical in the number of fatal accidents, the students also pointed out that West Virginia had a much worse problem with roof falls and Kentucky with haulage accidents.
The MSHA reports contain much useful information that, in some cases, has been underutilized. This study is a start, and -- it’s to be hoped – can lead to more.
In tabulating deaths according to the victim’s age, the group noted that their data would mean more if they knew how many working miners there are in each age group. The last demographic survey of the mining industry was in 1986. NIOSH reportedly is working on such a survey now. Results cannot come too soon.
The group made a few unwarranted inferences. For instance, to conclude that “Equipment operator is the most dangerous mining operation,” you would strictly speaking have to compare the percentage of miners who are equipment operators with the percentage of fatalities involving them. But even without that, if equipment operators are the most frequent job category among fatal accident victims, it certainly makes sense to give special emphasis to that occupation.
More puzzling is a claim that “…the fact that only sixteen percent of the fatal coal mine accidents had no violations indicates there is a problem with safety enforcement and follow through in America’s coal mines. Prevention of accidents through code enforcement does not appear to be a priority of either MSHA or the coal industry.”
It would be surprising if many fatal accidents occurred without any safety violations to cause them. And while lax enforcement does sometimes exist, a broad-brush conclusion about MSHA and the whole industry – from these data -- does not follow.
One comment to add the students', based on personal experience in summarizing these reports for the last couple of years for Mine Safety and Health News. The “root cause analysis” in the reports is often too general to be informative. It may simply say that management didn’t conduct a hazard analysis, had no process in place to address a particular hazard or failed to enforce its own process. A deeper inquiry into the whys and wherefores of these omissions would be more meaningful.
The West Virginia Wesleyan project also has created a database available for others’ analysis while giving the students experience with a practical project for an important goal. Credit goes as well to West Virginia Governor Joe Manchin and state Sago investigation director Davitt McAteer, who instigated the project.
It’s to be hoped that someone may undertake a similar project for fatalities involving metal and nonmetal miners, who – unknown to most – accounted for even more on-the-job deaths in the past 10 years than the coal mining industry.
Content analysis is a method of looking closely at the vocabulary, concepts, specific facts and world view in a body of writing. It uses a coding system and computers. Content analysis – in its more precise way -- can get at some of the same issues as good old-fashioned “critical thinking.” Marketers, political analysts and historians, among others, have found it useful.
The West Virginia Wesleyan group came to its task with no special expertise in mining, but willing to spend time and develop their understanding. Their thoughts deserve consideration.
Some of the group’s ideas have been raised before in the mining industry. In other cases, their fresh eye may have given them an advantage. It must be said that on a few points, their conclusions went beyond their evidence. That, however, does not invalidate all that they have to say.
“The accident reports do not have a consistent format nor do they contain consistent information,” the group reported. MSHA might respond that the format was evolving but is now consistent, which would be true of the overall outline. But lack of consistency in specific information is glaring to anyone who regularly uses these documents.
One small example: most reports mention the victims’ training, at a minimum to say if it met federal requirements. Yet the report on a roof bolter’s death at the Long Branch Energy #18 Tunnel mine this February (as covered in this issue) was silent on the subject. Did the investigators obtain this information? If not, why not? Did they omit the information as unimportant? Or could there have been another reason to withhold it? Did MSHA do its investigative job thoroughly? The reader can’t tell. And anyone trying to study training in relation to fatalities is doomed to frustration.
The group recommends a “template” to ensure consistent information. This excellent idea might best be carried out by a standard form in an appendix to the report. Narrative sections could cover what is essential to understand the particular accident – potentially a different fact set in each case. More details would be there for those who need or want them. As the study group recommended, information that could not be collected should be noted.
This approach also could advance another recommendation: to increase the educational usefulness of the reports.
One challenge to report writers is the many functions a fatality report will serve. The report must document the basis for enforcement actions, identify root causes, demonstrate the thoroughness of the investigation process, help prevent similar accidents through education, provide some closure for families, assist in identifying more general safety needs, and finally serve as a historical record.
All these purposes are important. The core of the report needs to be a clear, precise and thoughtful narrative of the accident, its background, and the critical findings of the investigation. With comprehensive details included in a separate form-style appendix, all these functions can be served even better than at present.
As the study group noted, some categories used to classify accidents need revision. “Powered haulage” is a case in point. What can we learn from lumping together accidents involving haul trucks, conveyor belts, mantrips and surface railroads? While carefully separating these from accidents involving bulldozers and loaders (“machinery”)? And who remembers when the “powered” part of the term was necessary? “Non-powered haulage” – the mine mule – is long gone.
The study group also crunched the data in an effort to find “specific patterns and go beyond hunches and anecdotes that are part of the mining industry.” While some of their findings were no surprise, a few were.
For instance, who would have predicted that the highest peak in fatal accidents would occur about 2 hours into a shift? And while the students felt that almost 40 percent of all fatal accidents resulted from “action of individual miner,” they counted even more as attributable to management: “action of supervisor,” “action of miner and supervisor,” or “operator/management malfeasance.”
With Kentucky and West Virginia at the top of the count and identical in the number of fatal accidents, the students also pointed out that West Virginia had a much worse problem with roof falls and Kentucky with haulage accidents.
The MSHA reports contain much useful information that, in some cases, has been underutilized. This study is a start, and -- it’s to be hoped – can lead to more.
In tabulating deaths according to the victim’s age, the group noted that their data would mean more if they knew how many working miners there are in each age group. The last demographic survey of the mining industry was in 1986. NIOSH reportedly is working on such a survey now. Results cannot come too soon.
The group made a few unwarranted inferences. For instance, to conclude that “Equipment operator is the most dangerous mining operation,” you would strictly speaking have to compare the percentage of miners who are equipment operators with the percentage of fatalities involving them. But even without that, if equipment operators are the most frequent job category among fatal accident victims, it certainly makes sense to give special emphasis to that occupation.
More puzzling is a claim that “…the fact that only sixteen percent of the fatal coal mine accidents had no violations indicates there is a problem with safety enforcement and follow through in America’s coal mines. Prevention of accidents through code enforcement does not appear to be a priority of either MSHA or the coal industry.”
It would be surprising if many fatal accidents occurred without any safety violations to cause them. And while lax enforcement does sometimes exist, a broad-brush conclusion about MSHA and the whole industry – from these data -- does not follow.
One comment to add the students', based on personal experience in summarizing these reports for the last couple of years for Mine Safety and Health News. The “root cause analysis” in the reports is often too general to be informative. It may simply say that management didn’t conduct a hazard analysis, had no process in place to address a particular hazard or failed to enforce its own process. A deeper inquiry into the whys and wherefores of these omissions would be more meaningful.
The West Virginia Wesleyan project also has created a database available for others’ analysis while giving the students experience with a practical project for an important goal. Credit goes as well to West Virginia Governor Joe Manchin and state Sago investigation director Davitt McAteer, who instigated the project.
It’s to be hoped that someone may undertake a similar project for fatalities involving metal and nonmetal miners, who – unknown to most – accounted for even more on-the-job deaths in the past 10 years than the coal mining industry.
posted by Kathy Snyder at 5:11 PM
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