The conclusions below are additional to the observations and comments made throughout the Report.
As the evidence emerged during this Inquiry, it became clear that many persons and entities had defaulted in their legislative, business, statutory, and management responsibilities. There is always the danger that when so many are implicated and bear some degree of responsibility the principal focus may be somewhat diminished by the sheer multiplicity of defaults. In the case of Westray, there is a clear "hierarchy" of responsibility for the environment that set the stage for 9 May 1992 — and we ought not to lose sight of this hierarchy.
The fundamental and basic responsibility for the safe operation of an underground coal mine, and indeed of any industrial undertaking, rests clearly with management. The internal responsibility system merely articulates this responsibility and places it in context. Westray management, starting with the chief executive officer, was required by law, by good business practice, and by good conscience to design and operate the Westray mine safely. 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.
The Department of Labour through its mine inspectorate must bear a correlative responsibility for its continued failure in its duty to ensure compliance with the Coal Mines Regulation Act and the Occupational Health and Safety Act. Indeed, the many and varied faults of Westray management and its derelict attitude towards safety should have prompted the Department of Labour inspectorate to adopt a firm and uncompromising position on strict compliance. Instead, the evidence indicates that the demeanour of the inspectorate was one of apathy and complaisance.
With its "hands-off" attitude, its general indifference to the quality of mine planning, and its lassitude about any safety responsibility, the Department of Natural Resources failed to discharge its duties in a creditable manner. 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.
Much has been said throughout this Inquiry about the inadequacy of the Coal Mines Regulation Act. As outdated and archaic as the present act is, it is painfully clear that this disaster would not have occurred if there had been compliance with the act.
If the "floor, roof and sides of the road and the working places" 1 had been systematically cleared so as to prevent the accumulation of coal dust;
If the "floor, road and sides of every road" 2 had been treated with stonedust so that the resulting mixture would contain no more than 35 per cent combustible matter (adjusted downward to allow for the presence of methane); and
If the mine had been "thoroughly ventilated and furnished with an adequate supply of pure air to dilute and render harmless inflammable and noxious gases," 3 then . . .
. . . the 9 May 1992 explosion could not have happened, and 26 miners would not have been killed.
Compliance with these sections of the Coal Mines Regulation Act was the clear duty of Westray management, from the chief executive officer to the first-line supervisor. To ensure that this duty was undertaken and fulfilled by management was the legislated duty of the inspectorate of the Department of Labour. Management failed, the inspectorate failed, and the mine blew up.
In the opening statement to this Report on pages vii—ix, I comment that the Westray story is a "complex mosaic of actions, omissions, mistakes, incompetence, apathy, cynicism, stupidity, and neglect." It seems fitting that I ought now, in this conclusion to the Report, revisit this comment and relate it to the extensive evidence that has been summarized in the preceding pages. The following questions are posed, in a somewhat rhetorical manner, to underscore the proposition that the Westray story is, indeed, a "complex mosaic."
What if — Clifford Frame, as Westray's chief executive officer, had acknowledged that the motivation for mine safety begins at the top? What if he had sent a clear message to Westray management that a safe working environment was paramount?
What if — Gerald Phillips, Roger Parry, Glyn Jones, and other Westray managers, with a clear directive from the chief executive officer, had conscientiously directed compliance with the Manager's Safe Working Procedures?
What if — the Coal Mines Regulation Act had been applied and enforced by the inspectorate of the Department of Labour? Would it have made a difference if the executive director of occupational health and safety had even read the act?
What if — the public servants at the Department of Natural Resources had fulfilled their legislative responsibilities and determined, before issuing mining permits, that the mine plans submitted by Westray assured "safe and efficient" use of the resources and then followed up to determine that Westray was mining in accordance with those plans?
What if — the Westray miners, at the certification vote on 5 and 6 January 1992, had voted in favour of the application of the United Mine Workers of America to represent them as the bargaining agent under the Nova Scotia Trade Union Act?
What if — Department of Labour inspector Albert McLean, while at Westray on 6 May 1992, had returned underground to evaluate the company's progress in complying with the several oral and written orders issued during the inspectors' visit of 29 April 1992?
Published on the authority of the Lieutenant Governor in Council by the Westray Mine Public Inquiry.
© Province of Nova Scotia 1997
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