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The Westray Story : NS Labour and Workforce Development


Prelude to the Tragedy: History, Development, and Operation

Chapter 3 Organization and Management

Provisional certification
1 No provisional mining certificates should be issued in any circumstance. The process of granting certification based on status in other jurisdictions must be refined to ensure that qualifications are consistent with provincial requirements. The burden should be on the applicant to establish that his or her qualifications are sufficient to support the requirements for the certification sought. Any person granted certification based on status in another jurisdiction should be required to be examined in Nova Scotia for such certification at the earliest reasonable time. [See page 87.]

Job descriptions
2 Every position in a mine should have a written job description setting out the duties and responsibilities of that position, with particular reference to safety. Each employee should be provided with a copy of his or her job description. A copy of all job descriptions should be prominently displayed in an area frequented by employees. [See page 87.]

Chapter 4 Training at Westray

The key to any successful regulatory regime is compliance, and the key to compliance is enforcement. As has been so graphically illustrated in the Westray experience, regulations, no matter how effective on paper, are worthless when they are ignored or trivialized by management and when their enforcement is in the hands of an apathetic and insensitive inspectorate. The recommendations that follow are neither innovative nor unique. They merely present a minimal outline of the basics to ensure that workers are "safety trained."

Role of the regulator
3 One regulatory organization (such as the Department of Labour or a board of examiners) should be responsible for certifying workers in underground coal mines in Nova Scotia. [See page132.]

4 Before approving the start-up of any underground coal mine, the regulator should review and amend the standards of certification to ensure the following:

(a) Standards of certification fit the mining methods and technology of the proposed mine.
(b) All positions in the mining operation are filled by people with the qualifications and experience necessary to do their jobs safely.
(c) The system of certification applies to every person required to work underground. Categories of certification should include (at a minimum) coal miner, electrical tradesperson, mechanical tradesperson, surveyor, engineer, mine rescue person, and the various levels of supervisors and managers.
(d) Trainers have the necessary qualifications and experience. [See page 132.]

5 The regulator should establish a model curriculum consistent with established standards and practices in the coal mining industry. [See page 132.]

Role of the mine operator
6 The mine operator should be required to have in place a training program, approved by the regulator, for every position in the workplace. The mine operator's training proposal must:

(a) conform to or be more rigorous than the model curriculum;
(b) show when, how, and what training will be done;
(c) incorporate annual refresher training and safety education;
(d) provide for adequate orientation to the mine for all new employees, including those with experience in coal mines; and
(e) include complete and sufficient training for operators of individual pieces of mining equipment prior to their being assigned operating positions. [See page 133.]

Role of the mine operator and the regulator
7 The mine operator should be required to keep training and work history records for applicants for certification. The regulator should:

(a) check applicants' records, making sure that training is taking place; and
(b) test applicants for certification in a manner that establishes whether underground workers are trained sufficiently to work safely. [See page 133.]

Role of the joint occupational health and safety committee
8 The mine's joint occupational health and safety committee should periodically review training standards, policies, and programs to make sure that they adequately reflect changing technology and mining conditions and practice within the mine. [See page 133.]

Chapter 5 Working Underground at Westray

Incentive plans
9 Incentive bonuses based solely on productivity have no place in a hazardous working environment such as an underground coal mine. Such schemes should be replaced, where practical, by safety incentives that include three principles:

(a) The incentive plan should be developed cooperatively with the employees to whom it will be addressed.
(b) Both group safety performance and individual safety performance should be rewarded.
(c) All employees, whether underground or on surface — workers, supervisors, and middle managers — should be included.

If properly instituted, such a safety incentive plan may well have its own productivity rewards. [See page 188.]


The Explosion: An Analysis of Underground Conditions

Chapter 7 Ventilation

Overriding principles
10 The overriding principle in mine ventilation must be that the mine is properly ventilated at all working times. It is the primary duty of the mine manager to ensure this proper ventilation.

(a) All active working places should be ventilated by a current of fresh air containing not less than 19.5 per cent by volume of oxygen and not more than 0.5 per cent by volume of carbon dioxide.
(b) Each working face should receive fresh air of sufficient volume and velocity to dilute and render harmless all noxious or flammable gases and maintain all working and travelling areas in a safe and fit condition. [See page 276.]

Ventilation plan
11 No mine should start up without a comprehensive ventilation plan approved by the regulator. The ventilation plan should be subject to at least an annual update, and any changes in the interim should be subject to approval by the regulator. [See page 276.]

12 The ventilation plan should contain details of the system proposed, or of amendments to the existing approved system, and should indicate:

(a) the limits of the mine property and any adjacent workings, as well as any abnormal conditions;
(b) the location and detailed specifications of all surface fans and all surface openings;
(c) the direction, velocity, and volume of air at each mine opening;
(d) all underground workings, including location of all stoppings, overcasts, undercasts, regulators, doors, and seals;
(e) the method of sealing worked-out areas, provisions for air sampling behind any such seals, and the manner in which such sealed areas will be vented into return air passages (ensuring that no intake air is or could be passing any sealed-off area);
(f) the location of all splits and the volume of fresh air entering each split and of return air at each cross-cut in a room-and-pillar mine and at each working face; and
(g) the locations for the measurement of air in the mine to ensure the proper ventilation at all times. [See page 276.]

13 The mine operator should employ or retain the services of a qualified ventilation engineer to assist in the preparation of all ventilation plans or amendments to such plans. The ventilation engineer should sign any ventilation plans or amendments before they are submitted to the regulator. [See page 277.]

14 The regulator may submit plans or amendments to a qualified mine ventilation engineer for review, and any fee for such review should be the responsibility of the mine operator. The regulator may require modifications to the plan in the interests of safety. [See page 277.]

15 The regulator, in consultation with a qualified ventilation engineer, should draft regulations dealing with main fans and auxiliary fans. These regulations should include:

(a) details of the design, installation, operation, maintenance, and inspections of such fans; and
(b) requirements for instrumentation, the recording of data from such instrumentation, and the filing of this data with the regulator. [See page 277.]

16 No booster fan should be installed underground without the approval of the regulator. [See page 277.]

17 Every main ventilating fan should be mounted above ground in a fireproof fan house located at a safe distance from any mine opening and offset from any such openings or connections. The fan house should be equipped with a weak wall or explosion door located in a direct line with any possible explosion forces. Every main fan should be equipped with an audible alarm that sounds automatically if the fan stops or slows down. [See page 277.]

18 Where any fan used in ventilating a mine stops for any reason, the area affected should be immediately evacuated. No auxiliary fan should be restarted until a qualified person has inspected the area and found it to be safe and free of gas. The area should not be re-entered until the ventilation has been restored to the required level and the area has been found to be safe and free of gas by a qualified person. If any fan remains stopped for more than 30 minutes, the mine operator should report the relevant circumstances to the regulator. [See page 277.]

Equipment and materials
19 The regulator, in consultation with a qualified ventilation engineer, should draft regulations dealing with requirements for ducting, brattice, stoppings, locations of measuring devices, and sealing of abandoned sections of the mine. All brattice cloth, ducting, and materials used for constructing stoppings should be of fire-resistant material. [See page 277.]

20 Equipment used to ventilate an underground coal mine should be of a type approved by the regulator and should be installed in an approved manner. Equipment, materials, or procedures not previously approved may be approved if the regulator is satisfied that the same measure of protection is provided to the underground worker. [See page 277.]

Operation of the ventilating system
21 Unless specifically approved in writing by the regulator, no more than one mechanized coal mining unit should operate in each ventilation split. Each split should be provided with a separate supply of fresh air. [See page 278.]

22 Ventilating air should not be recirculated without the written consent of the regulator. [See page 278.]

23 The mine operator should employ a qualified mine ventilation technician to be responsible for the operation and maintenance of the ventilation system. The ventilation technician should measure the airflow and sample the air quality in the mine at approved intervals of at least once a month for the whole mine and weekly for working areas. The results of ventilation and air quality tests should be recorded and a copy of such record should be filed with the regulator. [See page 278.]

Air quality
24 Workers should be removed from any area in a mine where the concentration of dust or noxious gases in the air exceeds the standards set out by the American Conference of Governmental Industrial Hygienists (ACGIH). [See page 278.]

25 Devices used for testing air quality, velocity, and volume should be of a type certified and approved for such use by the Canada Centre for Mineral and Energy Technology (CANMET), the Approval and Certification Center of the Mine Safety and Health Administration (MSHA), the Canadian Standards Association (CSA), or other such equivalent testing body. [See page 278.]

Chapter 8 Methane

Methane is an integral part of coal and coal mining, a by-product of the natural geological and decaying forces that caused the coal to form. My recommendations address issues of monitoring and control, as well as degasification. With respect to the former, the U.S. ventilation requirements, set out in Part 75 of Title 30, Mineral Resources, of the Code of Federal Regulations [30 CFR 75], provide an excellent reference point. I have been greatly influenced by their specificity, which I have considered in the context of the terms of reference of this Inquiry as set out in the Order in Council.

Monitoring and control: Basic requirements
26 The level of methane in an air intake to the working face of the mine should not exceed 0.5 per cent by volume.

(a) If the methane level exceeds 0.5 per cent by volume, the ventilation technician or other qualified person must take steps to adjust the ventilation system to dilute the methane to acceptable levels.
(b) If the methane level in any part of a mine reaches or exceeds 2 per cent by volume, all workers must be evacuated from the affected area.
(c) The airflow throughout the mine, including the mine face, should be such that methane will be diluted to a level below 0.5 percent by volume, as measured at least 30 cm from the roof or ribs.
(d) The velocity of air throughout the mine should be sufficient to prevent the formation of methane layers. [See page 313.]

Monitoring and control: Measuring methane
27 Each crew at the working face of a mine should include a person trained in the use of a methanometer. This person should carry, while in the mine, an approved device or devices capable of testing for both methane and oxygen, and capable of testing at the roof and in roof cavities for layering. [See page 313.]

28 The mine operator should provide suitable testing and calibrating facilities on the mine surface. Methanometers should be tested for accuracy before each shift and calibrated as required. [See page 313.]

29 If the locked flame safety lamp is used at all, it should be handled only by persons who have received adequate training in its assembly and operation. No lamp should be reignited underground unless the methane content in the ambient air is 0 per cent, as determined by a methanometer. [See page 313.]

Mining equipment
30 If the methane level in the area reaches or exceeds 1 per cent by volume, any electrically operated equipment in use should be shut down, and any shotfiring being carried out should be discontinued.

(a) In addition to other safety devices, any electrical equipment operating at the mine face or in reasonable proximity, as established by the regulator, should be equipped with a methane-monitoring device capable of continually monitoring the methane content of the air.
(b) If the methane content exceeds 1 per cent by volume, the methane monitoring device should automatically shut down the electrical equipment.
(c) The electrical equipment should not be re-energized until a qualified person certifies that the methane content in the air has been diluted to a safe level. (30 CFR sets out this requirement as it applies to mines under the jurisdiction of the U.S. Mine Safety and Health Administration.)
(d) The methane monitors installed on electrical equipment should be kept operative at all times and tested weekly for accuracy. Sensors should be affixed to the equipment as close to the working face as practicable. [See page 313.]

31 The operation of mobile diesel-powered equipment underground should be regulated to ensure that the health and safety of the workforce is not endangered or impaired by such operation. [See page 314.]

Atmospheric monitoring system
32 The regulator may require, as part of the mine development plan, a plan for the installation of a remote system for monitoring the mine atmosphere, with appropriate audible alarms and recording devices. Such a monitoring plan should include the provision that a qualified person must be at the remote monitoring station at all times that the mine is operating. [See page 314.]

33 As a prerequisite to the resumption of underground coal mining at Westray or elsewhere in the Pictou coal basin, the province should require the completion of a study into the safety and economic factors involved in drainage of the coalbed methane in the mining area concerned. [See page 314.]

34 Every mine development plan should include complete details of any program or process designed to drain methane from the coal seam before, during, and after mining. The regulator could waive this requirement if satisfied that the program or process would be impractical and that general mine safety would not be compromised. [See page 314.]

Chapter 9 Dust

Coal dust is a major health and safety hazard in underground coal mines. When the hazard of methane is combined with excessive and untreated coal dust, the potential for disaster, as tragically demonstrated at Westray, is very real.
In Nova Scotia, section 70(1) of the Coal Mines Regulation Act requires that the floor, roof, and sides of the road and the working places in a mine "shall be systematically cleared so as to prevent, as far as practicable, the accumulation of coal dust. . . ." Section 345 of the Alberta Coal Mines Safety Regulations requires that "[b]efore a part of a road is dusted for the first time with rock dust, it shall be cleaned as thoroughly as possible of all combustible dust." The U.S. regulations go into greater detail respecting this "housekeeping" function.

The first line of defence in the battle to neutralize the coal dust seems to be good, old-fashioned housekeeping.

35 Every coal mine operator should prepare a program for the regular clean- up and removal of coal dust and other combustibles from the floor, roof, and ribs of roadways and work areas in the mine. A copy of the program should be filed with the regulator, who may require changes in the clean-up program if it does not comply with accepted industry standards. [See page 348.]

Wetting coal
It is prudent that all areas close to the working face and areas in which coal is transferred from one device to another be wetted so as to maintain the coal dust in an incombustible state. Such areas are the cutting surface of the face, the location of the transfer of the coal to the conveyor, and transfer points from one conveyor to another. It is not practical to stonedust these areas.

36 Sufficient water should be provided in the mine to ensure that an adequate supply is available to wet the coal being mined and transported within the mine.

(a) All coal-cutting picks should be equipped with water-spray jets of sufficient number and size to ensure that the areas of the coal face being worked are maintained in a damp condition so as to render any coal dust incombustible.
(b) All transfer points where coal is moved from one mode of transport to another should be equipped with water-spray devices sufficient to render any coal dust incombustible. [See page 349.]

My research on barriers — stonedust or water, passive or triggered — has led me to conclude that their use is somewhat problematic, especially in room-and-pillar mining. Barriers may, in some circumstances, serve as supplemental explosion suppressors, but they ought not to be seen as diminishing the need for adequate stonedusting.

37 The Department of Labour and the Department of Natural Resources should consider active research in the development and use of passive and triggered stonedust and water barriers for the drives and entries of underground coal mines. This research should be aimed at the development of such techniques for use in room-and-pillar mining operations.
If the development of barrier technology indicates that substantial safety benefits may accrue, the regulator could order a mine operator to install water or stonedust barriers in the mine. [See page 349.]

After basic "housekeeping," the most widely accepted method of controlling coal dust is to render it inert by mixing it with finely ground incombustible rock, such as limestone or dolomite. It would seem from our review that stonedusting requirements in the Coal Mines Regulation Act are not far off the mark from any industry standard. Nevertheless, a discrepancy between the legislative requirements and the actual practice occurred and has persisted.

38 All underground areas of a coal mine should be stonedusted to within 12 m of the working face and all cross-cuts less than 12 m distant from the face should be stonedusted. This would not apply to those areas within the mine containing sufficient moisture to render the coal dust incombustible or for which the regulator, after examination, has granted exemption. [See page 349.]

39 A mine operator should file with the regulator a copy of the stonedusting program for the mine, including the method and frequency of testing; the type of testing equipment used; the type and number of dust-spreading machines used; the frequency of dusting; and the location and quantity of stonedust stored in the mine for emergencies (as opposed to normal usage). [See page 350.]

40 The material used for stonedusting should be of a type approved by the regulator for that purpose and should meet accepted industry standards as to size, composition, and incombustibility. [See page 350.]

41 Dust samples should be taken at least once a week using a method approved by the regulator for that purpose. Samples should be taken according to a regularly updated and approved plan. The regulator may require additional testing and may grant exemptions, providing that the overall safety of underground workers is not compromised. [See page 350.]

Chapter 10 Ground Control

External expertise
42 Consultants, when required, should be selected carefully to ensure that their background and expertise are consistent with the specific requirements of the problem to be analysed. Any conflicts in the advice from these consultants ought be resolved through discussion and, if necessary, through further advice. Conflicts in technical advice must be resolved, not ignored. [See page 380.]

Legislation and Regulations
43 A legislative regime should be put in place to ensure regulatory involvement in all areas of ground control in which safety is a consideration. The regime should encompass planning approval, materials and equipment certification, and any other aspect of ground control having safety implications. [See page 383.]

44 The regulations should specify the following at a minimum:

(a) Ground control plans and any revisions to those plans should be prepared by the mine operator and submitted to the regulator for approval prior to the implementation of any such plans.
(b) The ground control plan should show the existing geological conditions and the mining system to be used. The plan should also indicate any unusual hazards and outline the manner in which these will be handled.
(c) Approved plans should be available to miners and other underground workers and should be posted in the mine at the area affected by the plan.
(d) What the plan is required to specify should be set forth by the regulator from time to time, and should include:

(i) a columnar section of mine strata;
(ii) planned width of openings and size of pillar (if required);
(iii) thickness of seam;
(iv) method of support to be used;
(v) type, sequence, and spacing of support materials;
(vi) requirements for temporary roof support systems; and
(vii) type and thickness of strata in the roof and in the floor for a depth of 3 m below the coal bed.
(e) The regulator may require further and better information on the plan and may require that the plan be reviewed by a qualified specialist in rock mechanics.
(f) The regulator may require revisions to the plan at any time if satisfied that conditions or accident experience indicate that such revisions are necessary or conducive to safety.
(g) The ground control plan should be reviewed at least once every six months by the regulator.
(h) The mine operator should record on the plan and report to the regulator any unplanned fall of roof or rib or any significant rock burst (more than 0.3 m in thickness) that occurs above the bolt anchorage area, impairs ventilation, impedes the passage of persons, causes injury to miners, causes miners' withdrawal from the area, or disrupts activities for more than one hour.
(i) All roof control materials should conform with standards as established by various testing agencies such as the Canadian Standards Association (CSA) or the American Society for Testing and Materials Specifications (ASTMS). In the absence of standards, such materials could be approved by the regulator.
(j) The regulator should from time to time issue directions, such as found in 30 CFR, respecting the use of roof bolts, torquing requirements for roof bolts, and testing requirements for roof bolts and for other types of roof support systems.
(k) All entries and drives where roof bolting is the main means of roof support should have imbedded warning devices that monitor any downward movement in the roof strata. Such warning devices should be of a type approved by the regulator and should be placed at intervals specified on the plan. Installation of such devices should not relieve the operator from making regular inspections as prescribed. (The type of device referred to here is that generic category in which the "tell-tale" extensometer — the simple mechanical gauge produced at the CANMET Coal Research Laboratory in Cape Breton — would be included.) [See page 384.]

Internal Expertise
45 The legislation governing coal mines should be revised to ensure that every underground coal mine operator be required to engage, when required, the services of a qualified mining engineer with specialized post-graduate training in rock mechanics relating to coal mines. [See page 385.]

46 The legislation and regulations governing coal mines should be reviewed to ensure that all personnel working underground receive training in ground control as appropriate to their activities and responsibilities. In particular:

(a) Coal miners should receive a course on ground control as part of their basic mine training, plus annual refresher courses on ground control.
(b) Mining supervisory staff, including mine managers, underground managers, and overmen, should receive extensive training in ground control.
(c) Non-mining personnel employed underground should receive sufficient training in ground control to enable them to recognize potential hazards.
(d) Training programs for these three categories of employee should be developed by mine management in cooperation with the joint occupational health and safety committee and the regulator. The regulator should review these training programs to ensure that they reflect changing technology and mining practices. [See page 385.]


The Regulators: Departmental and Ministerial Responsibility

Chapter 11 Department of Natural Resources

47 The mandate of the Department of Natural Resources should be formally reviewed and clarified vis-à-vis the mandate of the Department of Labour to ensure that there are no gaps in the regulatory process. [See page 404.]

48 A formal procedure should be put in place to provide for adequate communication and cooperation between the Department of Natural Resources and the Department of Labour to ensure that there is adequate provision for all aspects of the regulatory process. [See page 404.]

49 The Mineral Resources Act should be amended to identify clearly the role of the Department of Natural Resources in monitoring mine planning in the province. Such a role should encompass the duty to make site inspections to ensure that an operator is mining in conformity with plans approved by the department. [See page 405.]

50 The Mineral Resources Act should be amended to identify clearly the role of the Department of Natural Resources in ensuring the "safe" operation of mines in the province. [See page 405.]

Responsibility of a deputy minister
From testimony during the Inquiry, I formed the opinion that the role of a deputy minister in Nova Scotia was largely determined by the attitude and approach of the incumbent. There appear to be few guidelines for deputy ministers, as chief executive officers of their respective departments, to help define an approach to the proper conduct of the office of deputy minister. The recent tendency to place generalist "managers" in these important positions seems to result in some deputy ministers' having an incomplete and inconsistent understanding of the job. The proper role of deputy minister was canvassed during testimony and deserves careful attention.
By mid-1991, when Westray most needed firm scrutiny and guidance from the department, the new deputy minister of natural resources did not consider it important to be familiar with the relevant legislation; he did not know at the time that the company was out of compliance with the legislation; and he had not made much effort to follow up on warnings from his staff that all was not well at the Westray mine. That, in my view, is an unacceptable position for a deputy minister.

51 The province should act to ensure that deputy ministers' positions are adequately described in detailed job descriptions. Such job descriptions should include but not be limited to the following requirements:

(a) Upon appointment, the deputy shall forthwith familiarize himself or herself with all the operations of the department as set out in a current organizational chart.
(b) The deputy shall have a working knowledge of all the legislation and regulations the department is administering.
(c) Where there is more than one department with responsibilities for common projects or interests, the deputy shall ensure that proper procedures are instituted and maintained to provide adequate liaison with the other department or departments, with the result that no gaps exist in the administration of the legislation. [See page 431.]

Function of the department
52 The Department of Natural Resources should no longer act as both promoter and regulator of the development of mineral and energy resources in the province, since this dual mandate constitutes a conflict-of-interest situation. The department should assume the role of helping the developer to formulate a plan that ensures both the safe and the efficient exploitation of the resource. The department must, first and foremost, work to ensure compliance with the general structure of the legislation in keeping with the purposes for which such legislation was enacted. [See page 437.]

Review of the department
53 The structure and staff of the Department of Natural Resources should undergo a complete and intensive review, preferably by an outside agency, with the objective of establishing an efficient and responsible mechanism for the supervision and husbanding of our natural resources. [See page 449.]

Chapter 12 Department of Labour

Notice of inspection
54 Visits by the inspectorate to the industrial site should not always be subject to prior notice. The inspectorate should schedule visits irregularly, and the operator should expect inspections at any time. Frequency of visits should be dictated by the safety performance of the operator. [See page 488.]

Mine-safety inspectors
55 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 the people of Nova Scotia might have had in the department's safety inspectorate. Accordingly, both White and McLean should be removed from any function relating to safety inspection or regulation. [See page 506.]

Independent review of inspectorate
56 The lassitude that paralysed the inspectorate and rendered it ineffectual in dealing with Westray seems deep-seated and pervasive. Therefore, an independent and professional safety consultant should evaluate the inspectorate and its personnel. The consultant should make recommendations for the restructuring of the safety inspectorate and its staff to ensure that the workers and the people of Nova Scotia benefit from a competent, well-trained, and properly motivated safety inspectorate. [See page 506.]

Occupational Health and Safety Act
57 The Occupational Health and Safety Act, 1996, should be revised to incorporate the following changes:

(a) Except in the case of a demonstrated emergency, any communication respecting health and safety concerns should go initially to the first-line supervisor. If the first-line supervisor is unable or unwilling to resolve the matter, then the complaint should be taken directly to a member of the joint occupational health and safety committee, for resolution by the committee as expeditiously as possible.
(b) Provisions should be adopted to clarify how interests of non-union employees in a union shop will be met on the joint occupational health and safety committee.
(c) No member of management whose principal duty or concern relates to production quotas should be eligible for membership on the joint occupational health and safety committee.
(d) No member of the executive of any employee organization or union, or any person who has served in such capacity within the preceding year, should be eligible for membership on the joint occupational health and safety committee.
(e) Provisions should be adopted to define clearly the health and safety obligations of employees to workers on site who are employed by contractors other than the principal employer. Those contractor employees should have obligations similar to those of the employees of the principal employer.
(f) For greater certainty, the terms "serious injury" and "bodily injury" should be replaced with the one term "serious injury," defined as any injury that requires immediate medical aid or hospitalization or renders the employee unable to perform his or her regular duties for a period in excess of 24 hours. [See page 510.]

Chapter 13 The Politicians and Ministerial Responsibility

Guidelines for ministers
58 The province of Nova Scotia should immediately study the British approach to ministerial responsibility, as illustrated by the publication Questions of Procedure for Ministers (1992), and move to adopt this type of program. Other jurisdictions should be canvassed for information on similar programs. The program adopted should include a codified and published statement of guidelines for ministers outlining ministerial responsibilities.

(a) The guidelines for ministers program should be provided to all new ministers. It should include definitions of the nature and extent of the responsibility and accountability for the actions of the department over which a minister presides.
(b) A minister should have clear guidelines to the frequency and detail of division briefings and the circumstances under which the immediate division head should participate in the briefing along with the deputy minister.
(c) A minister should have access to independent advice about the nature and the extent of ministerial responsibility in specific situations. Such advice could be provided, ad hoc, by a person with recognized expertise in the field. [See page 533.]

Chapter 14 Legislation

What should the aim of mining legislation and regulations be? Clearly, the aim should be the protection of the miner in the mining environment in a manner consistent with safe production. It is obvious that legislative change will not, of itself, ensure that future coal mining in this province will be carried out with safety as the paramount consideration. Attitudes must be directed towards safe mine production, and mine operators, unions, and government must dedicate themselves to this concept. To further relieve the pressure on mine operators and miners, there must be a safety factor built into production schedules.

Underground coal mining permits
59 Any applicant for an underground coal mining permit should make a clear and unequivocal commitment to the concept of mine safety in the context expressed in the phrase — safe mine production. This clear commitment must be manifest in mine development proposals and plans. Therefore, before a mining permit is granted, the applicant should have to show that it has sufficient financial and other resources to ensure a reasonable margin of safety. The existence of this margin of safety will minimize the possibility that safety measures may be overlooked or avoided to maintain production schedules. [See page 537.]

Underground coal mining regulations
After a disaster, there is a temptation to overreact. With respect to the formulation and implementation of mining regulations, two general observations need to be remembered. First, the requirements of the regulations should not be unreasonably onerous. If this golden rule is overlooked, mine management will go through the motions of observance but without the attention to the substance of the regulations. Second, excessive volumes of regulations and restrictions are often counterproductive. It is critical to their success that mining regulations are reviewed in substance originally and revised thoughtfully when circumstances change.

60 All rules and regulations relating to the operation of coal mines should be contained in Regulations made pursuant to the Occupational Health and Safety Act. The Coal Mines Regulation Act and the portions of the Mineral Resources Act dealing with operations should be repealed. [See page 540.]

Legislative review committee
61 A legislative review committee should be established to review periodically the underground coal mine regulations to ensure that the regulations reflect current technology and that the use of such technology is consistent with mine safety. The committee should have the power to engage mining consultants with specific expertise consonant with the technical matters being considered. This committee could be modelled after the Mining Legislative Review Committee of the province of Ontario and should contain representation from the provincial departments involved in the planning and regulation of underground coal mines. [See page 540.]

Variances to the regulations
Some flexibility is needed so that new techniques or technology can readily be introduced into a mine without compromising safety. Exemptions or variances to the regulations should be subject to approval by the legislative review committee within a fixed time after their implementation, thus providing another level of review.

62 The regulator should be given authority to grant exemptions to or variances in the regulations if satisfied that such exemptions or variances will in no way detract from the safety of the miners and other underground workers. The burden is on the mine operator to demonstrate to the satisfaction of the regulator that safety considerations have not been prejudiced. [See page 540.]

Approval of mine plans
63 A mine developer or mine operator should submit all mine plans, including plans for the development, construction, or alteration of an underground coal mine, to the regulator for approval. No such plans should be acted upon or otherwise implemented until they have been approved in writing by the regulator. The regulator may require further detailed plans of the mine or the surrounding geological configurations. The regulator may require that the developer or operator have the plans, or portions of them, reviewed at the expense of the developer by mining consultants having expertise in any or all of the following disciplines: rock mechanics, mine ventilation, roof control, underground equipment, and electrical applications. [See page 541.]

New regulatory regime
A regulatory regime should be formulated so that any prospective operator of an underground coal mine will have a clearer idea of the regulatory environment. At the present time, Nova Scotia coal mines are regulated by two separate regimes, federally by the coal mining regulations made pursuant to the Canada Labour Code, and provincially by the Coal Mines Regulation Act. Labour Canada's inspectorate in Sydney administers the Canada Labour Code regulations at the Devco mines. In my view, it is unrealistic to have two such regimes in place in a province the size of Nova Scotia.

64 The province should take immediate action to reach agreement with the federal Department of Labour for the inspectorate of that department to assume the underground coal mine regulation and inspection functions currently under the aegis of the provincial Department of Labour. [See page 542.]

65 The province should collaborate with the federal Department of Labour to draft updated underground coal mining regulations applicable to all coal mines in Nova Scotia. These common regulations would then be administered throughout the province by the inspectorate at present functioning under the provisions of the Canada Labour Code regulations. Such regulations should be drafted with the advice and assistance of competent coal mining professionals with demonstrated expertise in the various fields of ventilation, ground control, electrical applications, training, and mine rescue. [See page 542.]

Method of regulation
It is essential that the administration of underground mining regulations be competent and aggressive. Regulations are only as good as the enforcement and administration of them. It has been stressed on several occasions that mine inspectors must be certified mining engineers. This follows the approach to mine inspection adopted in the United Kingdom and in most Canadian jurisdictions. The U.S. approach is to engage technicians who enforce very comprehensive regulations and who have engineering back-up when needed. Virtually all mine managers and most underground mine managers are professionally trained mining engineers. The inspectorate must be able to face them on an equal professional basis.

66 If it is decided to pattern the Nova Scotia coal mine regulation regime after that of the United Kingdom, all mine inspectors should have at least a degree in mining engineering, with some specialist training in both rock mechanics and ventilation relating to underground coal mining. If the U.S. Mine Safety and Heath Administration approach is adopted, all mine inspectors should receive adequate initial training. In either case, all mine inspectors should be required to take periodic training, of at least one week per year, at an institute specializing in mine inspection and safety. [See page 543.]

One of the most disturbing aspects of mine safety, and one that the individual miner can control, is the practice of tobacco smoking underground with its attendant risk of explosion. In the face of good common sense and judgment, smoking remains a problem in underground mines. According to numerous mining officials, the clandestine transport of smoking materials by workers into underground coal mines remains a nagging and frightening reality. This problem concerns the wilful and wanton disregard for not only one's own safety, but also the lives of fellow workers.

67 Labour and management should work together to educate and regulate the underground miner with a view to eradicating the practice of smoking in the coal mining environment. The following requirements should apply:

(a) Tobacco smoking and the possession of smoking materials and lighters by any person underground should be grounds for immediate dismissal from employment, the reason for dismissal to be recorded in the employee's record.
(b) Proof of tobacco smoking underground or possession of smoking materials underground should provide sufficient grounds for dismissing any grievance taken by an employee for unjust dismissal, and any arbitrator should be prohibited from substituting any other penalty in lieu of dismissal.
(c) Labour and management, with the cooperation of the Department of Labour, should investigate the feasibility of acquiring tobacco detection devices that would monitor miners entering the mine. [See page 545.]


The Aftermath: Rescue Efforts and the Inquiry

Chapter 15 Rescue Efforts

Owing to the devastating nature of this explosion, the mine rescue efforts proved ultimately futile. No one in the Westray mine in the early morning hours of 9 May 1992 survived for more than one minute following ignition of the methane. The ensuing rescue operation demonstrated the bravery and dedication of the mine rescuers and the other volunteers who rallied so quickly in support of their lost friends, fellow miners, and neighbours. Much can be learned from this rescue operation to assist others in the future. It is so unfortunate that we must await a tragedy such as Westray to initiate improvements designed to avoid such similar situations. We must strive to perfect a system of review, both in the context of underground mining and in the industrial community generally, wherein the advancement of safety is not disaster driven but, rather, results from continued review, earnest safety-oriented consultation, and aggressive enforcement of the regulatory regime. Anything less may only result in sustaining the disaster-driven safety mentality.

Emergency procedures
68 Every mine operator, indeed, every industrial plant or facility, should have a well-defined and comprehensive emergency procedures manual containing a complete and up-to-date list of all persons involved in any emergency operation. This list should contain an organization chart listing the individuals and their respective tasks, and a current telephone listing for each person. The manual should be prepared by the company in consultation with both the joint occupational health and safety committee and the safety coordinators with the appropriate government departments. The manual should set out, in detail, the quantity and location of all emergency supplies and equipment and the details of the deployment of these materials. A current copy of any such approved emergency procedures manual should be filed with the director of occupational health and safety, and copies should be provided to each person assigned any duty under the manual. [See page 560.]

Involvement of the regulator
69 The Department of Labour, in consultation with the operator, should establish such rules and regulations that would ensure the department a full and active role in every mine-related emergency procedure or rescue operation in the province. The rules and regulations should set out the duties and responsibilities of each department inspector or safety examiner in any mine-related emergency or rescue operation. [See page 561.]

Emergency preparedness
70 Rescue and emergency equipment should be standardized so that those persons trained in rescue procedures will be completely familiar with the equipment available. Similarly, the various testing devices should be standardized so that the rescuers are able to use these devices without losing valuable time and without the danger of mistaken or inaccurate readings. [See page 561.]

71 Every community at or near which underground mining operations are carried out should have a plan to provide emergency medical, fire, and other support services. The plan should include providing emergency training to the appropriate people in those communities. Some familiarity with the underground environment could be helpful in the event of a disaster. [See page 561.]

Mine-rescue competitions
72 Mine-rescue competitions, long a fixture in the underground mining industry, provide a valuable training incentive for miners. These competitions should be continued. [See page 561.]

Chapter 16 The Inquiry

Corporate accountability
73 The Government of Canada, through the Department of Justice, should institute a study of the accountability of corporate executives and directors for the wrongful or negligent acts of the corporation and should introduce in the Parliament of Canada such amendments to legislation as are necessary to ensure that corporate executives and directors are held properly accountable for workplace safety. [See page 601.]

74 The province of Nova Scotia should review its occupational health and safety legislation and take whatever steps necessary to ensure that officers and directors of corporations doing business in this province are held properly accountable for the failure of the corporation to secure and maintain a safe workplace. [See page 601.]

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

Table of Contents

© 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