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The Westray Story : NS Labour and Workforce Development


Prelude to the Tragedy: History, Development, and Operation

Chapter 2 Development of the Westray Project

The Arrival of Curragh
It seems that Curragh was interested in the Pictou coal project only if it was able to secure significant government support; Curragh seemed less interested in the merits of the project itself. And it was this mind-set that set the tone for the negotiations and developments to follow. [See page 33.]

The Final Deal
The arrogance and the tough negotiating stance of Curragh officials were probably rooted in their awareness of, and reliance on, the political backing for the project. [See page 44.]

Provincial Support
Donald Cameron, a Pictou County MLA, was totally committed to the concept of having a coal mine in that county. This commitment is laudable and represents the sort of activity expected of politicians. It is, perhaps, one of the most rewarding of their duties. Cameron, as minister of industry, trade and technology, continued with the same single-minded determination to work to ensure that Westray became a reality. In this context, he may have exceeded the limits of ministerial prudence and responsibility. He became an advocate of the project in much the same way that the promoters were in their dealings with the government of Canada. [See page 48.]

Take-or-Pay Agreement
The evidence is unequivocal that, by September 1988, the cabinet had not approved a take-or-pay agreement with Westray for 275,000 tonnes of coal per year. Although the issue may have been discussed in cabinet, there was no existing authority for the minister to confirm that the province was willing to enter into the agreement. In spite of this, Cameron, in his letter of 9 September 1988, committed the province to the take-or-pay agreement. That action on the part of the minister was clearly improper. Cameron may have felt secure that the negotiations, which were all that had been authorized by cabinet, would mature into formal approval for the agreement. It would appear that Cameron allowed his determination to cloud his judgment. The fact that the agreement received cabinet approval two years later in no way excuses Cameron's earlier unauthorized action. [See page 56.]

Opposition to the Take-or-Pay Agreement
The whole question of the take-or-pay agreement was fraught with difficulties. It was an unusual agreement in that it provided for a third party, the province, to commit public funds for the purchase of coal for which it had no immediate market. The agreement was roundly criticized as a bad deal for the province, and, moreover, the agreement was not really required in order to conclude the deal with Westray.

Cameron piloted this agreement through cabinet, which finally gave its approval. Although a minister is under no obligation to accept the advice of his or her departmental staff, the minister does at least have an obligation to consider that advice. The evidence is strong that Cameron did not give prudent and thoughtful consideration to the advice coming from his, and other, government officials. Notwithstanding the overwhelming opposition to the take-or-pay agreement, the political support for it became the final and decisive factor in pushing it through. [See page 60.]

Enforceability of the Take-or-Pay Agreement
The take-or-pay agreement executed by Curragh, Novaco, and the province was enforceable, notwithstanding a purported understanding between Cameron and Curragh officials that the agreement would never be exercised. To exercise the agreement for a given production year, the company had to choose to do so, well in advance, by a date specified in the agreement. The company would have to demonstrate at that time that the mine was capable of full production for the forthcoming year. Curragh indicated its intent to avail itself of the agreement when it requested an extension to that date, presumably to give itself time to get up to full production. Cameron's support for the agreement was based only on Curragh's word that the take-or-pay agreement would never be exercised. This attitude indicates startling naivety for a person of experience in the political milieu. If not naivety, it is another compelling example of Cameron's obdurate and single-minded determination to bring Westray to reality.

Having criticized Cameron for his conduct throughout the development stage of the Westray project, I must carefully note that my criticisms cannot be construed as evidence of any sort of complicity in the many defaults and oversights that led to the terrible event of 9 May 1992. There is no evidence that Cameron was ever told by his staff that the Westray mine was poorly or inadequately planned, poorly and unsafely operated, or operated in contravention of the Coal Mines Regulation Act and the Occupational Health and Safety Act. [See page 64.]

Chapter 3 Organization and Management at Westray

Organization and Management
The foremen and overmen at Westray had little or no opportunity to perform their duties as set out in the Coal Mines Regulation Act. They had little or no say in the day-to-day operation of the mine and were expected only to carry out the orders of Westray mine manager Gerald Phillips as delivered to them by him personally or through his underground manager, Roger Parry. [See page 80.]

Management at Westray was closed, and four of the senior staff — Gerald Phillips, Roger Parry, Glyn Jones, and Bob Parry — ran the mine with little or no input from others. Input was not sought, and when offered was usually disdainfully rejected. It is probable that Phillips, as vice-president and general manager, would be the most influential of the four. [See page 81.]

Qualifications — The Westray Managers
The evidence raises serious questions as to the qualifications of the mine manager and the underground manager at Westray. Gerald Phillips represented himself (at least in his resume) as having attained standing as a "mining engineer," and he listed several such positions held. This representation is clearly misleading.

Roger Parry was granted a provisional certificate by the director of mine safety, Claude White, even though there is no authority for such action. Parry's resume also listed employment as "underground manager" in Alberta, despite his having attained only the assistant underground mine manager certificate. [See page 87.]

Chapter 4 Training at Westray

Early Assessments of Training Needs
Westray management, from the chief executive officer down, paid little attention to the requirement for adequate training in underground coal mine safety and operations. The several training proposals produced by Westray seem to have been formulated to satisfy the inspectorate and the board of examiners while the company sent insufficiently trained persons into the mine. The record shows that the inspectorate did little to monitor compliance with the training proposals. [See page 104.]

Actual Training
The miners, supervisors, and underground tradesmen at Westray were not provided with adequate training in safe underground work practices. They went into the mine with little or no safety orientation. [See page 130.]

Lacking a proper appreciation for the special dangers inherent in underground coal mining, many of the tradesmen were prone to accede to directions to perform unsafe tasks or to take dangerous shortcuts in their work. [See page 131.]

Chapter 5 Working Underground at Westray

Dust Conditions
There is no question that management was aware that coal-dust accumulations underground at Westray were at hazardous levels. There is no question that management was aware, or ought to have been aware, that safe mining practice — as well as section 70(1) of the Coal Mines Regulation Act — requires operators to clear or treat coal dust to render it non-explosive. Notwithstanding the legislative requirement and the fact that management was cognizant of the hazard, management failed to order and enforce sufficient and systematic stonedusting underground at Westray. [See page 139.]

Gas Conditions
There is no question that management knew that the levels of methane underground at Westray were hazardous. Management was aware, or ought to have been aware, that, under section 72 of the Coal Mines Regulation Act, such conditions mandated the withdrawal of workers from the affected area. [See page 141.]

Roof Conditions
Westray management was preoccupied by problems of ground control. Management focused only on those safety issues, such as ground control, that directly interfered with immediate production of coal. Management's drive to produce and its failure to advocate safety in the workplace rendered any harmonization of production and safety difficult. Thus, Westray failed both to meet production demands and to address safety concerns. [See page 142.]

Hazardous and Illegal Practices
The many instances of hazardous and illegal practices encouraged or condoned by Westray management demonstrate its failure to fulfil its legislated responsibility to provide a safe work environment for its workforce. Management avoided any safety ethic and apparently did so out of concern for production imperatives. [See page 142.]

Twelve-Hour Shifts
Shifts at Westray for underground workers were 12 hours in length. In scheduling these shifts, Westray was in violation of section 128(1) of the Coal Mines Regulation Act. Twelve-hour shifts increase the risk of injury and accident to the workers because of their mental and physical fatigue. [See page 144.]

Tagging System
No effective system existed at Westray to keep track of the whereabouts of people underground. Management and supervisors failed to set up and enforce the use of an appropriate system for keeping track of who was underground and where they were. [See page 146.]

Storing Fuel and Refuelling Vehicles Underground
Westray management instructed that fuel be stored underground and that vehicles be refuelled underground. In so doing, Westray management acted in violation of section 69(6) of the Coal Mines Regulation Act and of its own codes of practice. These fuel storage and refuelling practices were illegal and hazardous. [See page 147.]

Torches Underground
The unsafe use of torches underground was a common practice at Westray. Management was aware of the practice, condoned the practice, and reprimanded those who condemned it. In so doing, management sent a clear message to the underground workers. Management's unsafe mentality was, in effect, filtering down to the Westray workforce. [See page 149.]

Methane Detection Equipment
Methane detection equipment at Westray was illegally foiled in the interests of production. [See page 150.]

Lockout System
No true system was in place at Westray for locking out the main conveyor belt, a standard procedure in underground coal mine operation. [See page 152.]

Unqualified Underground Personnel
Westray management sent underground both foremen with little or no coal mining experience and novice miners who were untrained and inadequately supervised. This practice can only be construed as a further example of Westray management's laxity in applying basic principles of coal mining safety. [See page 153.]

Non-flameproof Equipment Underground
Westray management failed to provide adequate instruction on the use, and the limitations imposed on that use, of non-flameproof equipment. By its example, Westray management condoned, and even encouraged, illegal use of this equipment underground. [See page 155.]

Cable Damage
Westray management seemed to condone the dangerous and haphazard practice of allowing temporary cable repairs to remain as permanent repairs. In so doing, management was in violation of section 85(2), rule 75, of the Coal Mines Regulation Act, which requires that such cables be properly vulcanized. [See page 157.]

Main Ventilation Fan
The main ventilation fan in any mine is fundamental to the safe operation of that mine and the safety of its underground workers. Notwithstanding, Westray management failed to instil any understanding of this fact in its workforce. On the contrary, workers were instructed to shut the fan down for maintenance without any provision for the safety of the workers. [See page 157.]

Environmental Monitoring System
The environmental monitoring system at Westray was not effective. Its problems were inherent not in the equipment, but in the manner in which it was installed and maintained. They can be summarized as follows:

  • Equipment was installed improperly and an incorrect transmission cable was used.
  • Initial difficulties were not resolved and the system was inoperative most of the time.
  • Maintenance and resolution of faults in the system were left to an engineer-in-training with no previous experience in coal mines or with this type of equipment.
  • That same engineer was allocated duties that conflicted between mine production and safety.
  • There were not sufficient monitoring stations in strategic locations, especially in the Southwest sections.
  • There was no scheduled maintenance or recalibration of gas sensors. [See page 163.]

Roof bolting in conditions such as those experienced at Westray clearly jeopardized the health of the workers who were "gassing out" on a continual basis. The issue of methanometers on roof bolters leads us directly to the adequacy of ventilation in mining headings. If the ventilation of the headings had been adequate, methane would be cleared before bolting began. Westray management's trivialization of methane in working areas illustrates a serious disregard for or a misunderstanding of proper ventilation. [See page 168.]

Westray management failed to provide properly maintained and appropriate equipment. Management thus failed in its fundamental and overriding responsibility to ensure that underground workers were able to do their work in a safe environment. [See page 168.]

Management-Worker Relations
Westray managers not only failed to promote and nurture any kind of a safe work ethic but actually discouraged any meaningful dialogue on safety issues. Management did so through an aggressive and authoritarian attitude towards the employees, as well as by the use of offensive and abusive language. Westray workers quickly came to realize that their safety concerns fell on deaf ears and that management's open-door policy was mere window dressing. [See page 176.]

Occupational Health and Safety Committee
Westray's joint occupational health and safety committee was ineffective. It never functioned as the Occupational Health and Safety Act envisaged, and for that management must bear responsibility. Management actively discouraged a safety mentality on the part of the workforce and failed to respond to safety concerns raised by committee members. [See page 183.]

Production Bonus System
It is clear from the evidence of the miners and from an outside expert's analysis of that evidence that the incentive bonus scheme based solely on productivity was not conducive to safety in the Westray workplace. [See page 187.]

Working Underground — Conclusion
The evidence before this Inquiry compels but one conclusion — the Westray operation defied the fundamental rules and principles of safe mining practice. Regardless of the theories, philosophies, and procedures that management espoused on paper, most notably in its employee handbook, it clearly rejected industry standards, provincial regulations, codes of safe practice, and common sense in the operation of the Westray mine. Management failed to adopt and effectively promote a safety ethic underground. Instead, management, through its actions and attitudes, sent a different message — Westray was to produce coal at the expense of worker safety.

Westray management, from the chief executive officer, Clifford Frame, and the mine manager, Gerald Phillips, down to the line supervisor, had a fundamental duty to instil in the underground worker a respect for safety beyond other considerations. Management could do this through training, by example, and with continued monitoring at all levels. In trivializing and ignoring safety concerns, Westray management was significantly derelict in its duty to the workforce and seemed actively to promote a disdainful and reckless attitude towards safe mining practices. [See page 188.]


The Explosion: An Analysis of Underground Conditions

Chapter 6 The Explosion

Sources of Ignition
The source of ignition that caused the methane accumulation to catch fire, most probably, was the cutting mechanism or picks of the continuous miner, which, when they struck either pyrites or sandstone, caused sparks of sufficient intensity to light the gas. The gas would be ignited in much the same way that the spark from the flint of a cigarette lighter will ignite the gas emitted from the lighter reservoir. [See page 197.]

The ignition caused a rolling methane flame to travel away from the working face of SW2-1 Road and also propagated into the Lefthander, consuming all the oxygen in the roadways and leaving deadly quantities of carbon monoxide in its place. The rolling flame moved to SW2-2 Cross-cut, where it followed SW2-B Road both inbye and outbye the cross-cut and continued as a rolling methane fire inbye SW2-2 Cross-cut towards the roof bolter at the face. The rolling flame did not develop into a methane explosion, although it did increase in intensity.

As the flame turned outbye SW2-2 Cross-cut, three factors combined to cause the flame to propagate into a methane explosion, which, in turn, generated a preceding shock wave: the boom truck located in the intersection, the auxiliary fan in the cross-cut, and the change of direction of the flame down SW2-B Road towards SW1-B Road. The resulting shock wave then created greater pressure and increased turbulence, which caused dust particles to become airborne — just in time for the extreme heat of the trailing methane explosion to generate a full-blown coal-dust explosion. It is probable that this coal-dust explosion started at or near the Stamler feeder-breaker located about 30 m down SW2-B Road outbye SW2-2 Cross-cut. The resulting coal-dust explosion then moved rapidly through the entire mine, causing death and devastation in a matter of a few seconds. [See page 206.]

Methane Layering
Methane layering, the result of inadequate ventilation, was permitted to propagate, virtually undetected, throughout the Southwest 2 section. It provided a rich source of fuel for any ignition source to feed upon. [See page 217.]

The Barometer
Westray mine management did not monitor the barometric pressure in any acceptable manner and neglected this significant factor in the maintenance of a safe and effective ventilation system. [See page 218.]

The Water Gauge
Westray mine management failed to provide a water gauge to monitor the ventilation conditions of the mine from the surface and, as a result of this omission, deprived the mine workforce of another significant safety-monitoring device. [See page 219.]

Auxiliary Ventilation Ducting
The combination of poor ventilation pressure, small ducting, lack of bratticing, and deficient ventilation controls made it almost impossible to clear methane from the working faces of the mine. Together, they are a further indication of incompetence or negligence in the safety planning and administration of the Westray mine. [See page 220.]

Management Response
During the period leading up to 9 May 1992, there was excessive untreated coal dust in the mine. Little or no effort had been made either to clean up that dust or to render it inert by the addition of sufficient stonedust. Mine management was aware of this problem, but failed to respond to complaints by employees or to the orders of 29 April 1992 from the Department of Labour. [See page 221.]

Methanometer Tampering The evidence indicates that there was tampering with the methanometer on the continuous miner in the Southwest section. The evidence does not support a finding that this tampering in any way caused the explosion. [See page 227.]

The Explosion — Conclusions
It is unfortunate that we are unable to state with complete certainty what caused the death of the 26 miners in the early morning of 9 May 1992. Failing that, we must analyse the known facts, and the opinions based on those facts, and arrive at the most probable cause of death. To support these findings, we relied on the anecdotal evidence of miners and mine rescuers, the photographic evidence gained as a result of the RCMP investigations, and the opinions, based on this evidence, of the several experts. The opinion evidence of Andrew Liney, Don Mitchell, and Malcolm McPherson, although not always in agreement on every issue, leads to the conclusion that the miners in the Southwest 2 section were overcome by carbon monoxide and died almost immediately. This conclusion is consistent with an intense methane fire that consumed all the oxygen, producing carbon monoxide among other products of combustion. It is also consistent with the findings of the chief medical examiner as set out above. The miners in the North mains and the Southwest sections most probably died of a combination of carbon monoxide poisoning and severe bodily injuries. They would have died instantaneously. This is consistent with a coal-dust explosion and the severe physical force exerted by the shock wave preceding the actual coal-dust conflagration.

Chapter 7 Ventilation

The Main Ventilation System at Westray
Generally, the regulating, control, and monitoring of the main airflow was inadequate and poorly planned. In some cases, the regulating devices contravened the requirements of the Coal Mines Regulation Act. In other cases, these devices were simply improperly constructed, as in the regulator in No. 2 Main between No. 9 and No. 10 Cross-cuts. [See page 243.]

Throughflow Ventilation: North and Southeast Sections
The ventilation system in the North Mains and Southeast sections of the mine was haphazard, reflecting little or no planning. Plastic stoppings were generally in a state of disrepair — increasing the leakage of air, promoting the recirculation of air, and decreasing the quality and flow of ventilation air. Faulty placement of auxiliary fans further decreased the flow and caused problems such as collapsed ducting, which remained in that state for unduly long periods. The placement of the auxiliary fans in these sections further diminished the airflow — to the extent that it was incapable of flushing liberated methane from the headings. The combined effect of all these deficiencies was to perpetuate poor air quality, the air circulating or recirculating within the sections at velocities too low to remove dangerous contaminants. Significantly, these conditions appear to have been tolerated, or even ignored, by a complacent or careless management. [See page 249.]

Throughflow Ventilation: Southwest Sections
The ventilation system in the Southwest section was consistently defective and inadequate. The ventilation system in the North Mains and the Southeast sections was also defective and inadequate. The defects included:

  • poorly constructed plastic stoppings, permitting air leakage of up to 55 per cent of the total airflow;
  • the broken anemometer (with no replacement on site), which prevented the taking of airflow measurements for two weeks;
  • low ventilation pressures and low airflows, which provided little or no air movement at the working faces where required to clear methane;
  • intake air directed past the two plastic stoppings inbye the SW1-3 Cross- cut, which were leaking quantities of methane from the abandoned areas into the active workings of the Southwest 2 section and contributing to the methane-layering problem; and
  • placement of conveyors in an intake airway, necessitating the movement of non-permissible vehicles in the return airways.

All these factors lead inexorably to the conclusion that Westray's management was either apathetic or, through incompetence, unaware of the implications of its actions and decisions in these crucial matters. [See page 256.]

Auxiliary Ventilation at Westray
The auxiliary ventilation system at the Westray mine was defective in several ways. Some of the more hazardous defects were:

  • It was ineffective in removing the methane from the working face.
  • The exhaust system of auxiliary ventilation (used in all but one location) was contrary to the Coal Mines Regulation Act and Westray's own Manager's Safe Working Procedures.
  • In most cases, the ventilation ducting was too small for the size of the auxiliary fans. This situation resulted in high resistance in the ducts and excessive suction, which caused collapsing of the ducts and loss of ventilating air to the working faces.
  • Poor airflow to the face permitted the accumulation of high levels of methane, which, in turn, caused the continuous miner to shut down until the methane was cleared and safe operating levels attained. To alleviate this gas accumulation and direct more intake air to the working face, miners would, on occasion, block the ventilation ducting serving the roof bolters — a reckless and foolhardy practice. [See page 264.]

Ventilation Planning for Westray Ventilation planning for the Westray mine did not address the requirements for a comprehensive system of fresh-air circulation and methane removal. The plan on which the ventilation was based was merely a brief outline in a feasibility study. A comprehensive engineering study by competent ventilation experts was not completed and documented before approvals were requested. The regulating agency, in this case the Department of Natural Resources, could not assess the efficiency or the safety of the ventilation system of the proposed Westray mine. [See page 271.]

Chapter 8 Methane

Methane Problems during Active Mining
At Westray, the machine-mounted methanometers and their automatic shut-off feature were regarded as a nuisance to be outwitted or eliminated, rather than as essential safety devices. The deliberate interference with the methanometers makes it clear that production of coal was to be maintained at all costs, and with blatant disregard for safety. [See page 292.]

Any of several situations could easily have resulted in an ignition of methane leading to a coal-dust explosion. It follows, therefore, that the incident that actually caused the ignition in the early hours of 9 May 1992 was not an aberration, but simply one more in a frightening series of events that, sadly, had become commonplace at Westray. [See page 292.]

The Explosive Environment
The problems associated with methane gas at the Westray mine originated with a failure to recognize the significance of the permeability of the Foord seam, and in not giving due consideration to the mining history of the Pictou coalfield. They ended with the explosion on 9 May 1992. Between those two points in time, there is a sad litany of causal factors relating to the emissions of methane at Westray and the attempts made to maintain coal production within poorly and incompetently managed ventilation systems. The following circumstances, which existed at various times and at various locations throughout the mine, coupled with the apparent management attitude of "coal production at any cost," provided the environment that would convert a spark at the continuous miner heading into a rolling methane fire and explosion:

  • failure to plan adequately for substantial emissions of methane or to take into account the historical evidence of such emissions;
  • continued mining in areas where pillars were crushing, hence producing higher quantities of gas;
  • falling barometric pressure for 42 hours prior to the explosion and the resulting increase in gas emission;
  • failure to maintain a barometer on the surface of the mine to track changes in atmospheric pressure;
  • insufficient ventilation in headings to dilute methane efficiently;
  • inadequate air velocities to promote mixing of the gas or to inhibit the formation of methane layers;
  • use of series ventilation, which resulted in a loss of air quality;
  • uncontrolled partial recirculation of air within the ventilation structure;
  • failure to keep auxiliary fans operating continuously;
  • failure to employ a degassing procedure before switching on an auxiliary fan when a flammable atmosphere had been observed in a heading, contrary to company guidelines;
  • inadequate ventilation ducting, which was allowed to fall into disrepair;
  • obstruction or constriction of ventilation ducting in headings being roof bolted, to keep the continuous miner from gassing out in adjoining headings;
  • travelling of intake air past the entrances to old workings — particularly the Southwest 1 workings, which were known to contain large volumes of methane and were improperly sealed;
  • relocation of machine-mounted methanometer monitor heads away from their correct location on the continuous miner jibs, thus defeating their purpose;
  • interference with the set points or readouts of continuous miner methanometers so that the machine would operate in higher concentrations of methane;
  • operation of a continuous miner with no machine-mounted methanometer;
  • operation of roof bolting equipment where methane layers existed to the extent that workers near roof level presented symptoms of oxygen deficiency;
  • failure to keep dust scrubbers operating at all times when a continuous miner was working;
  • use of compressed air equipment to remove methane from a roof cavity;
  • failure to provide roof bolting crews with the means of detecting methane;
  • failure to contain methane accumulation in an abandoned area by adequate seals, or to control it by adequate ventilation;
  • failure to detect and control a layer of methane issuing from an abandoned area;
  • inclined workings that promoted methane accumulations in the higher elevations without the necessary air velocity to disperse this accumulation;
  • falls of ground that left roof cavities in which methane could accumulate without any attempt to clear those cavities or fill them;
  • inclined entries that facilitated the upward progression of methane layers;
  • failure to check for methane layers or to provide the equipment necessary to perform such searches; and
  • an appalling lack of safety training and indoctrination, especially respecting new underground miners, on the general properties of methane and its propensity to rise to the roof and form layers that at some point would be explosive.

It should be understood that not all these conditions were necessary, at any one time, to provide the explosive environment that was present on 9 May 1992. They are all listed here to give some indication of the laxity, or the 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." [See page 304.]

The attitude of Gerald Phillips towards the methane problem is both difficult to understand and dangerous: difficult to understand because his early training in the United Kingdom would have trained him in the perils of dealing casually with methane; dangerous because his casual attitude permeated Westray management, creating and perpetuating a serious safety defect. Phillips, by his training and experience, must have known better.

Chapter 9 Dust

Summary of Dust Problems at Westray
Mine management, led by Gerald Phillips and Roger Parry, had the primary responsibility to keep the mine safe. With regard to coal dust, safety measures included:

  • removing coal dust from the mine;
  • ensuring that the mine floor, ribs, and roof were adequately stonedusted so as to render inert any remaining coal dust; and
  • regularly collecting and testing coal-dust samples to monitor combustibility.

Management was aware of these duties, as evidenced by the schemes set out in the Manager's Safe Working Procedures, yet it failed to discharge these responsibilities by ignoring its own procedures as well as the requirements of the Coal Mines Regulation Act. Westray management seemed to have adopted a cavalier attitude towards mine safety generally and the treatment of coal-dust hazards in particular. [See page 347.]

The Department of Labour inspectorate knew, or ought to have known, that management was continually out of compliance with even the most basic safety requirements of the act in respect to treatment of coal dust in the Westray mine.

In spite of the continued failure of mine management to comply with requests and demands respecting treatment of coal dust, the inspectorate made no effort to enforce those demands. This failure to enforce the law was painfully and tragically evident when the orders of 29 April 1992 were ignored, even though two of them required immediate action, and even though an inspector was at the mine site on 6 May 1992. The inspectorate was derelict in its responsibility to safeguard the welfare of the underground miners at Westray by failing to ensure compliance with the housekeeping and treatment requirements of the Coal Mines Regulation Act respecting coal dust. [See page 347.]

Chapter 10 Ground Control

Mining Conditions
The following combination of mining conditions made Westray a potentially difficult mine to develop and operate:

  • depth of coal in the mining area
  • thickness of the seam
  • relatively steep pitch of the seam
  • virtually unknown faulting in the mining area
  • poor roof quality
  • wide entries.

The cost of operating in such an adverse environment and the inherent uncertainties would suggest that the financial viability of the Westray project should have been in doubt from the very beginning. [See page 356.]

Lack of Continuity in Planning
In spite of several warnings of potentially serious ground control problems, the management of Westray proceeded with mine development without having completed verification of many of the tentative estimates contained in several feasibility studies. [See page 366.]

Ground Control Problems
Mining at Westray consistently encountered unexpected and adverse geological conditions. It is obvious that Westray managers were ill prepared to deal with these conditions, and, as a result, when they encountered an unexpected condition, they did not know how to deal with it. [See page 372.]

Southwest 1
Miners were chased out of the Southwest 1 section in March 1992 as a result of horrific ground conditions. This is a clear indication that Westray management had not yet learned to operate the mine safely and productively. Without adequate planning, management was confronting each problem on an ad hoc basis and was still searching for solutions up to the time of the explosion. [See page 377.]

External Expertise
Westray management, from the chief executive officer down, seemed unable to implement the advice of competent professionals. This incapacity discloses a serious defect in the Westray management mentality that is probably related to a combination of incompetence and inexperience.

Several basic points may be drawn from the Westray experience:

  • Comprehensive planning should be done as far in advance as possible so that problems may be anticipated and surprises kept to a minimum. This was not evident in the manner Westray attempted to deal with its ground control problems.
  • It seems almost axiomatic that an underground coal mine should retain the services of competent management and engineering personnel with proven experience and technical competence. Westray was significantly lacking in this regard. [See page 380.]

Impact of Ground Control on the Explosion
Perhaps the most serious effect of the ground control problems that burdened the Westray mine was not physical but mental. The adverse roof and rib conditions posed a continuous hazard and hampered production. Major falls week after week, daily overbreaks, and the ultimate loss of Southwest 1 must have constituted a serious threat to the mining crew and placed Westray management under considerable stress. It was probably obvious to everyone concerned that the very existence of the mine was in question. Senior managers were preoccupied with finding the solution to the ground control problems. As a result, attention was diverted from other major issues and hazards. Although it is impossible to quantify the contribution of such a major diversion to the disaster, it was likely significant.

Diversion of Attention
The entire ground control situation at the Westray mine is singularly significant in that it typifies the lack of planning, of competence, and of responsibility of senior Westray management. The response of Westray management to these continuing problems seemed to exacerbate them and divert attention from other serious safety concerns. In the result, the entire safety mentality at Westray deteriorated while management was consumed with its apparent inability to deal with ground control. [See page 382.]


The Regulators: Departmental and Ministerial Responsibility

Chapter 11 Department of Natural Resources

After the transfer of the inspectorate from the Department of Natural Resources to the Department of Labour in 1986, there was little or no communication between these departments even though communication and cooperation were essential for the proper conduct of their respective statutory regulatory duties. [See page 392.]

Duty to Ensure Safety
The various officials in the Department of Natural Resources either misunderstood or overlooked the overriding responsibility to ensure that Westray's mine plans were inherently safe. The department also failed, either through the Department of Labour inspectorate or through its own initiative, to ensure that any inherent safety concerns were being met by the company. [See page 401.]

Duty to Monitor for Compliance with Approved Plans
The transfer of the inspectorate from the Department of Natural Resources to the Department of Labour created serious gaps in the inspection and approval process, which neither department attempted to address. Officials in each department were satisfied to eschew any responsibility for these matters, assuming that the other department would fill the gaps. Those responsible for the regulation of Westray did not turn their minds to the issues until the mine blew up, at which time they were forced to seek some explanation for the failure of the regulatory regime. [See page 403.]

The Department of Natural Resources failed to accept responsibility for enforcing provisions of the Mineral Resources Act and to perform its regulatory role with the rigour required to ensure that Westray was running a safe and efficient operation. [See page 404.]

Geological Background
The strongly expressed position of Robert Naylor, a Department of Natural Resources geologist, that further geological work was required before the Westray project was approved, appears to have been well founded. It deserved more attention than it was accorded by more senior professionals in the department. By not addressing his concerns, Pat Phelan and Don Jones were remiss in their duty to take reasonable measures to ensure that the Westray mine plan would "result in efficient and safe mining." [See page 410.]

Westray Mining Proposal
The lack of a final mine plan was a significant factor in the overall planning of Westray. The department should have insisted that the company prepare a mine plan that addressed the issues of safe and efficient mining. [See page 410.]

Provincial Approval Process
The Department of Natural Resources issued a mining lease without satisfying the overriding provisions of section 90(1) of the Mineral Resources Act —namely, that "the project will result in efficient and safe mining." The department was wrong to do so. [See page 415.]

Submission and Review of Westray's Application
The review of the Westray application by the Department of Natural Resources was inadequate. The director of mining engineering infringed his own responsibilities by not maintaining the department's operating practices at a high level to keep pace with changing technology. Westray was a so-called high-tech mining operation, using mining techniques and equipment new to the Nova Scotia regulators. Before approving the Westray application, the department should have familiarized itself with this new technology in order to judge its suitability in the context of the Foord seam. The department's approach was not acceptable, and the expressed view that the application met the basic requirements of the legislation cannot rationalize that approach. [See page 416.]

Tunnel Realignment 1
Westray Coal failed to advise the Department of Natural Resources of its first tunnel realignment. When the department learned of the change and informed the company of the proper channels to be followed, the company proceeded to request departmental approval. Although the department appeared to express valid concerns about the realignment, the record indicates that the department approved the change without the company's first having addressed those concerns. [See page 422.]

Extent of the Department's Responsibility
The Department of Natural Resources had a statutory duty to ensure that the mine plans provided for safe and efficient mining. In light of the inadequacy of the mine plans submitted by Westray and the ineffectual reviews of these plans by the department, it was in breach of this "safety" responsibility. [See page 445.]

Monitoring for Compliance with Approved Plans
It is highly probable that officials of the Department of Natural Resources knew of the unapproved changes to the mining plan at Westray but declined to take any action to ensure compliance with the legislation. [See page 448.]

The Department of Natural Resources failed to monitor the Westray mine operation to ensure that the mining permit holder was conducting the mining operations at Westray "in conformity with the approved mining plan as revised from time to time." [See page 448.]

Chapter 12 Department of Labour

Mine Inspection Division
The training and experience of the inspectors responsible for Westray were inadequate. Their performance was also diminished by a lack of guidance and supervision. Claude White, the director of mine safety, did not do his job of monitoring the system and ensuring that any difficulties were corrected. [See page 463.]

The inspectorate did not routinely review Westray's mine plans. A review of approved plans might have revealed potential safety problems that were not obvious during inspections. Competent review by regulators might have moved the company to consider changes more carefully. [See page 467.]

Albert McLean was not competent to perform all the duties of a mining inspector or to enforce routinely the provisions of the Coal Mines Regulation Act. Even in those areas where he should have had competence, he failed to perform his duties with diligence or concern. His performance was unacceptable, and this fact ought to have been obvious to his supervisors. His supervisors ignored or glossed over his inadequacies and made no effort to supervise, train, or direct him, or to monitor his activities at Westray.

John Smith was qualified for his position as electrical-mechanical inspector. In those areas he seemed to perform with some competence. He did not perform his duties with the aggressiveness and vigour needed to offset the attitudes and laxity of Westray management.

Neither Smith nor McLean was given a clear indication of his duties and responsibilities. Both Smith and McLean followed the version of the internal responsibility system as determined by Jack Noonan and promoted by Claude White.

By and large, the performance of Smith and McLean as mine safety inspectors at Westray was inadequate and did little to convey to an aggressive and disdainful Westray management that safety was paramount and that non-compliance with safety rules and regulations would not be tolerated. [See page 468.]

Perception of Mandate
Jack Noonan erred in advocating his version of the internal responsibility system (IRS), and in claiming that inspectors could enforce the Coal Mines Regulation Act properly while following directives based on his version of the IRS. [See page 468.]

Department of Labour and Internal Responsibility
Jack Noonan, as executive director of occupational health and safety, held a perspective of the internal responsibility system inconsistent with usage in other jurisdictions and with the statutory obligations of the inspectorate. This passive and apathetic approach sent two messages to those in the inspection service: (1) that health and safety were primarily the responsibility of employer and miner; and (2) that the inspectors' role was one of training and persuasion, to be undertaken usually in response to the initiative of management or workers. For whatever reason, Noonan virtually abdicated any leadership role and must bear substantial responsibility for the failures of the inspectorate. [See page 471.]

Internal Responsibility in Nova Scotia
It is abundantly clear that the provincial inspectorate used the concept of the internal responsibility system to divert attention from its own responsibilities. It is not so clear whether this was done as a matter of practice or after the fact to justify many of the deficiencies of the inspectorate, which only became apparent after the explosion of 9 May 1992. [See page 477.]

The Inspectorate at Westray: Applying the Regulatory Regime
The Westray joint occupational health and safety committee was given little assistance or encouragement from either the company or the inspectorate. The company clearly did not want an effective committee. The inspectorate, operating under Noonan's strange interpretation of internal responsibility, adopted a passive and non-interventionist approach, ensuring that the committee would be ineffectual. [See page 483.]

Pattern of Inspections
The inspectorate normally gave Westray management notice of its impending inspections. By so doing, the inspectors could not be assured that the conditions they encountered truly reflected the regular condition of the mine. [See page 488.]

Department of Labour inspectors were regularly accompanied by management on their inspections. One consequence was to discourage the miners from discussing conditions with the inspectors. Workers underground did not have open communication with the inspectors. [See page 489.]

The inspectorate relied on Westray management for guidance and choice of inspection routes. Such reliance led to careless inspection and ignorance of the true state of operations underground at Westray. [See page 489.]

Records of Inspections
The department's own records of dealings with Westray were sometimes altered. The editing removed some references to potentially embarrassing matters. In one instance, for example, references to extended deadlines for producing stonedusting and dust sampling plans were changed.

Claude White's explanations for the altering of departmental records were not credible. The altering of official minutes made it more difficult to follow up on important safety matters that were central to the Department of Labour's mandate. [See page 491.]

The Carl Guptill Saga
The inspectorate's actions in the Carl Guptill incident were a disservice to a miner with a legitimate complaint, and a clear message to other members of the Westray workforce that the inspectorate was not going to support them in any safety-related confrontation with the management. The significance of this incident ought not to be understated. It is clear: (1) that the Department of Labour did not investigate all the complaints raised by Guptill; (2) that department officials, in the cursory investigation conducted, relied on statements prepared by the company without sufficient verification; (3) that department officials revealed the name of the complainant to the company; and (4) that references to the complaint were removed from meeting minutes in an apparent effort to avoid confrontation with the company. [See page 498.]

Extent of the Department's Responsibility
Claude White is a professional and experienced mining engineer. His job was to see that the mine inspectorate enforced the Coal Mines Regulation Act and the Occupational Health and Safety Act. He failed to do so. [See page 500.]

The inspectors' handling of the equipment permits was inadequate. They made errors in paperwork and communicated poorly among themselves. They permitted Westray management to intimidate them and ignored the concerns of the miners and the input of the safety committee. They left the enforcement of the conditions for equipment use with Westray officials. [See page 501.]

The Department of Labour in general, and the inspectorate in particular, was markedly derelict in meeting its statutory responsibilities at the Westray mine. This company demonstrated a disdain for any regulatory regime, whether the regime concerned the safe design of the mine or the safe operation of that mine. The inspectorate had its own duties to carry out, as enumerated in the legislation, and it failed to do so. It must be profoundly unsettling to the people of Nova Scotia to realize that the department's safety inspectorate is so demonstrably apathetic and incompetent.

The Department of Labour was ill prepared for the task of regulating Westray. The inspectorate was untrained, poorly supervised, and improperly motivated. No efforts were made, through either training or motivation, to develop a competent inspectorate capable of monitoring a safety program at Westray. Even those sections of the Coal Mines Regulation Act that could have been of benefit to the Westray worker were largely ignored. By and large, through incompetence and apathy, the inspectorate of the Department of Labour did a disservice to the Westray miners and the people of Nova Scotia. [See page 506.]

Chapter 13 The Politicians and Ministerial Responsibility

Political Involvement in the Westray Project
The take-or-pay agreement between the province and Westray was a legal and enforceable contract. Donald Cameron was clearly in error when he so firmly stated that the province would never be called on to honour it. [See page 515.]

Ministerial Responsibility and the Transcript Evidence
Donald Cameron, both as cabinet minister and as premier, did not have a clear understanding of his role or that of cabinet respecting the acceptable level of political support for projects or the relationship between the minister and his department in dealing with such projects. [See page 522.]


The Aftermath: Rescue Efforts and The Inquiry

Chapter 15 Rescue Efforts

Observations of the Rescuers
Although the Westray mine-rescue teams and the teams from other parts of Nova Scotia and from New Brunswick were well trained and proficient in the performance of their rescue duties, the company was ill prepared for any disaster, let alone one of the magnitude of 9 May 1992. The company lacked a cohesive disaster plan, including a call-out list and an emergency procedures manual. [See page 559.]

The mine-safety personnel from the Department of Labour seemed to have a rather ill-defined role in the rescue operation, and director of mine safety Claude White seemed to play only a peripheral role in the operation. [See page 560.]

There appeared to be a shortage of self-contained breathing devices on site, which resulted in some delay while self-contained self-rescuers were brought in from elsewhere. There was a lack of the safety tools and testing devices essential to reduce the hazards of post-explosion rescue attempts. [See page 560.]

Community groups, volunteer medical emergency persons, volunteer firefighters, the telephone company, the RCMP, and other support groups responded with admirable haste and dedication. A more precisely defined role and more efficient on-site organization could have assisted these support groups in carrying out their respective tasks more productively. [See page 560.]

Published on the authority of the Lieutenant Governor in Council by the Westray Mine Public Inquiry.

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© Province of Nova Scotia 1997
Permission is hereby given by the copyright holder for any person to reproduce this report or any part thereof.
ISBN 0-88871-468-8