The following is a brief synopsis of the more significant facts that came to light during the course of this Inquiry. This summary is provided as an introduction to the consolidated findings and recommendations, which have been abstracted from the Report and included here. I urge the reader to refer to the full report for a more comprehensive discussion of the testimony and other evidence from which the numerous findings and recommendations are derived. This summary, which is organized according to the structure of the Report, includes key points from the first four parts: Prelude to the Tragedy, The Explosion, The Regulators, and The Aftermath. The reader should also consult the photographs, maps, and other material found in the Reference volume.
The first of the Terms of Reference of this Inquiry deals with the direct cause of death of the 26 miners in an underground explosion in the Westray mine at 5:20 in the morning of 9 May 1992. Accordingly, this Inquiry must address two main questions: How did those 26 miners die? And why did those 26 miners die? The "how" is relatively straightforward. The "why" is decidedly more difficult and involves multifaceted considerations of planning, development, supervision, management, working practices, and regulations. The Inquiry heard testimony from miners and mine experts, and examined all the expert opinions and anecdotal evidence. As the findings specify in detail, I find that the source of ignition was sparks struck by the cutting bits of the continuous miner working in the Southwest 2 section of the mine. But it became apparent as the Inquiry proceeded that conditions at Westray were of greater significance to what happened than was the source of ignition. Had there been adequate ventilation, had there been adequate treatment of coal dust, and had there been adequate training and an appreciation by management for a safety ethic, those sparks would have faded harmlessly.
The Westray mine is located at Plymouth, near Stellarton, in Pictou County, Nova Scotia. Westray was the only operating underground coal mine in Pictou County at the time of the explosion. The Pictou coalfield had been mined for some 200 years, and elements of the disaster rest in the nature of that coalfield with its thick and gassy seams. The Foord seam, which Westray was mining, has hosted at least eight mines. The Allan mine, the most productive and the one that lay just northwest of Westray's workings, finally closed in the 1950s, but during its 40-year lifetime, it experienced eight methane explosions.
The Westray project was controversial from the outset. Although various companies including Brinco Mining Limited, Suncor Inc., and Placer Development Limited had been interested in the area with its low- sulphur coal, it was Curragh Resources Inc. that eventually put the pieces together, incorporated Westray Coal in November 1987, and some 16 months later began underground development. In seeking government funding (and later in preparing its development and operating plans), Curragh relied on feasibility and planning studies, some of them quite preliminary works, prepared for Suncor and Placer. On 9 September 1988, Westray finalized a deal for Suncor's coal interests in Pictou County and signed an agreement with Nova Scotia Power Corporation, which agreed to purchase Westray coal for its new coal-burning generating stations at nearby Trenton, Nova Scotia. A letter dated that same day was sent to Westray by Donald Cameron, provincial minister of industry, trade, and technology, which committed the province to a mining lease, a loan of $12 million, and a take-or-pay agreement for 275,000 tonnes of coal per year for 15 years. The cabinet did not approve the take-or-pay agreement until two years later.
The proposed mine developed amid opposition from the bureaucracy and unwavering support from the provincial government. As development proceeded, the mine was the subject of debate and criticism in the legislature and in the media. It also proceeded with an uncompromising and abusive Curragh negotiator, chief executive officer Clifford Frame, at the helm. For these reasons, it is not surprising that the negotiations for financial assistance between Curragh and government proved to be arduous and taxing. In the end, the strong and single-minded political backing for the project, by Donald Cameron in particular, prevailed. Westray received tremendous financial support from the public sector, which resulted in minimal equity investment by the company. In addition to the $12 million provincial loan and a most unusual take-or-pay agreement with the province, Curragh managed to secure a federal loan guarantee of approximately $85 million, a direct contribution against interest, and an $8 million interim loan.
Before all the financing was in place, the underground work began. Early in 1989, Curragh's subcontractor, Canadian Mining Development (CMD), began driving the main access slopes. The Department of Natural Resources had approved Curragh's application for the mining lease in 1988, and, in January 1989, the department discovered that the tunnel alignment had been changed from the approved layout. CMD was to drive the two main slopes to the limits of the planned workings, and Westray would then take on the development of coal-producing sections off the mains. Meanwhile, several provincial government departments were engaged in continuing negotiations with Curragh. The Department of the Environment had a number of concerns about the effect of the development on the area. The Department of Labour expressed concern about training and certification, equipment approvals, plans for emergencies, and delays in setting up a workplace safety committee. The Department of Natural Resources was concerned that the new tunnel alignment would intersect major geological faults at oblique angles, resulting in extensive tunnel development through bad ground. Poor roof conditions in the earliest days of tunnel development gave credence to that concern.
In late July 1989, with the funding for the project still not finalized, development was suspended. Construction did not resume fully until fall 1990, when the federal government guaranteed financing for the project, less than a year before the mine was supposed to begin shipping coal to the new Trenton power plant.
Roof conditions emerged as a major problem in 1991. Westray took over development from CMD in early April 1991, at a much earlier stage of development than originally planned, and began using continuous mining machines to drive the mains. The company decided to scrap the original mine layout and to change direction so it could tap into the coal seam sooner. That change took development into the Southwest section of the mine. During the summer, development also continued down into the North mains, splitting the mine into two distinct sections, each with its own crews and supervisors. In the rush to reach saleable coal, workers without adequate coal mining experience were promoted to newly created supervisory positions. Workers were not trained by Westray in safe work methods or in recognizing dangerous roof conditions despite a major roof collapse in August. Basic safety measures were ignored or performed inadequately. Stonedusting, for example, a critical and standard practice that renders coal dust non-explosive, was carried out sporadically by volunteers on overtime following their 12-hour shifts.
The official opening of the mine was on 11 September 1991. For that occasion, the mine was "spruced up" and stonedusted.
Four more roof falls were reported in September and October. The mine manager, Gerald Phillips, minimized the seriousness of roof problems, claiming that the falls were controlled and that they posed little threat to the miners or to production. To the contrary, realistic accounts of the miners' experiences revealed a series of near misses and increasing danger. There were approximately 160 employees at the site by October, a large majority of them working shifts underground. Management trivialized the concerns of workers, some of whom quit their jobs at the mine. Although the mine inspectors asked the company for roof support plans, as well as stonedusting plans, it repeatedly deferred supplying them. Westray is a stark example of an operation where production demands resulted in the violation of the basic and fundamental tenets of safe mining practice.
The first drive to unionize the workforce at Westray was officially begun on 2 October 1991 by local 26 of the United Mine Workers of America. The union was defeated by 20 votes in January 1992. In the spring of 1992, the United Steelworkers of America succeeded in its drive to unionize the workers, but certification was not granted until after the 9 May explosion.
The Southwest section was plagued with roof problems. The decision to drive into the Southwest section was proving a serious mistake. The levels of production and the quality of the coal were less than anticipated. Production remained behind schedule, and the company was not able to meet its commitments to supply coal. In late March 1992, the workforce was literally chased out of the Southwest 1 section by rapidly deteriorating ground conditions. In its determination to save equipment, the company put employees at extreme risk during the abandonment.
The Department of Natural Resources staff expressed concern about proximity to the old Allan mine workings, potential subsidence problems, and deviations from the approved mine plan. The department suggested that non-compliance could threaten the company's mining permit but inexplicably retreated from its position. Skeletal new plans submitted by the company were approved, and the department assisted the company in developing a surface mining operation to help meet its coal supply obligations. Federal and provincial money and expertise met most of the costs of technical studies for monitoring roof conditions and subsidence.
The regulatory framework in Nova Scotia requires that almost every person employed in underground coal mining hold a certificate of competency issued by an appointed provincial board of examiners. Section 11 of the Coal Mines Regulation Act (1989) sets out the education and work experience required for the various certificates. The administration of certification for mine rescue and for competency as a coal miner was delegated to the Department of Labour. In Nova Scotia, the company is responsible for training miners. The role of the Department of Labour is to ensure that the company complies with the Coal Mines Regulation Act and the Occupational Health and Safety Act.
It is clear that the company was derelict in carrying out its obligations for training. The testimony of the miners shows that training fell far short of need. Don Mitchell, mining consultant for the Department of Labour, concluded from his post-explosion investigation that the mine "had no program that was appropriate to the needs of that mine." And expert witness Dr Malcolm McPherson referred to the inadequate training of mine workers as making an equally potent contribution to the propagation of a mine explosion as did the ventilation engineering deficiencies.
Quite simply, management did not instil a safety mentality in its workforce. Although it stressed safety in its employee handbook, the policy it laid out there was never promoted or enforced. Indeed, management ignored or encouraged a series of hazardous or illegal practices, including having the miners work 12-hour shifts, improperly storing fuel and refuelling vehicles underground, and using non-flameproof equipment underground in ways that violated conditions set by the Department of Labour to mention only a few. Equipment fundamental to a safe mine operation from the cap lamp to the environmental monitoring system did not function properly.
It was equally clear that the Department of Labour was derelict in its duty to enforce the requirements of the two acts.
Early in this Inquiry, I reached the conclusion that ventilation is the most crucial aspect of mine safety in an underground coal mine. Methane fires and explosions cannot happen if the gas is kept from accumulating in flammable and explosive concentrations. A coal mine can be quite "forgiving" with respect to other aspects of safety, as long as the ventilation system is properly planned, efficient, and conscientiously maintained. The other major requirement of coal mine safety is control of coal dust, through strict clean-up procedures and regular stonedusting.
The ventilation system of any underground mine is a network of interconnected passages, many of which are also used as transportation routes for personnel, vehicles, and the products of mining. Fresh air is drawn from the surface atmosphere. As the air passes through the underground passages, its quality deteriorates as a result of pollutants produced from the strata and from the effects of machines and mining procedures. The contaminated air is returned to the surface. A mine ventilation system has to deal with both gaseous and particulate pollutants. Methane is a dangerous pollutant present in coal. Although non-toxic, it is hazardous because of its flammability. It will explode in concentrations of between 5 and about 15 per cent by volume in air, and it reaches maximum explosiveness at about 9.6 per cent.
Methane is a natural component of coal, a by-product of the decomposition of the plant matter from which coal is formed. Methane is released as the coal-cutting machines break coal away from the face. As methane continues to emerge from the coal, it moves through fissures in the coal that remains after mining, and it can escape into the active roadways from abandoned or mined-out sections, depending on the effectiveness of the stoppings constructed at the entrances to abandoned sections. One of the principal functions of a ventilation system is to clear the methane at the working face of the mine and to exhaust it from the mine in non-explosive concentrations. It is clear that the Westray ventilation system was grossly inadequate for this task. It is also clear that the conditions in the mine were conducive to a coal-dust explosion.
The miners, faced with management pressure for production, undoubtedly indulged in many dangerous and foolhardy practices in the days immediately preceding 9 May 1992. In his various comments reported in the media following the explosion, Gerald Phillips blatantly blamed the miners for the explosion. In light of all the evidence of mismanagement, neglect, and incompetence at Westray, this simplistic explanation can only be regarded as a defensive ploy to deflect attention away from the real causative factors. Unfortunately, this explanation was picked up by former premier Donald Cameron. From all the evidence and the extensive analysis and studies by mining experts, however, it becomes abundantly clear that ventilation in the Westray mine was woefully deficient in almost every respect. The airflow was inadequate for the purpose of clearing methane from the working face during mining and preventing the layering of methane on the roof.
Therefore, I should like to put to rest the question raised by Cameron's testimony, as well as the statements of Phillips and Frame to the media: Had it not been for these unsafe practices attributed to the miners, would the explosion of 9 May have occurred? The answer must be yes, it would have. The consensus of the experts suggests strongly that Westray was an accident waiting to happen.
The Department of Natural Resources (the Department of Mines and Energy before September 1991) was charged with regulatory authority over the mine-planning approval process. As the testimony at the Inquiry unfolded, it became clear that the Department of Natural Resources had failed to carry out its statutory duties and responsibilities as they related to the Westray project. Natural Resources witnesses had mixed views on fundamental regulatory issues, such as whether the department was within its mandate to regulate for "safety," or whether its duty included monitoring Westray to ensure that it was operating in conformity with the approved mine plan.
The mandate of the department vis-à-vis the Department of Labour and the mine inspectorate was not formally defined in any way, and the changes affecting the departments over their history contributed to this lack of definition. Before 1986, both the mine engineering unit and the mine inspection unit were part of the Department of Mines and Energy, and their duties overlapped somewhat. When the inspectorate transferred to the occupational health and safety division of the Department of Labour in 1986, it lost its link to the engineering section. When the chief inspector left a short time later, the liaison between the two functions effectively ended. It is clear that the Department of Natural Resources, in spite of these changes, retained legislative responsibility to ensure, before permits are granted, that mining plans are not only efficient but safe.
In the view of the Department of Natural Resources, its responsibility for monitoring the Westray operation for compliance with the approved mine plan was limited to an annual review of plans submitted by the operator. Section 93 of the Mineral Resources Act (1990) is explicit: the permit holder "shall conduct mining operations in conformity with the approved mining plan." The Department of Natural Resources was ill-advised in approving the Westray mine proposal in the form submitted. The department did not insist that the company submit sufficient information to support its application. Furthermore, it did not insist that the company submit any changes to approved plans. Consequently, for a critical period, the department was not aware that Westray was working an unapproved section of the mine. The department's explanation was that such day-to-day monitoring was the responsibility of the Department of Labour. What it did not explain was why the department failed to shut down a company that was undeniably in violation of the Mineral Resources Act an action that fell squarely within its own mandate. The evidence of the public servants of the Department of Natural Resources is replete with examples of neglect of duties, submissiveness to Westray management, and just plain apathy.
The Department of Labour shares with the Department of Natural Resources the responsibility for failure to coordinate the several aspects of mine regulation. The Department of Labour was responsible for regulating occupational health and safety at the mine, and as such was the body most responsible for the exercise of regulatory authority respecting safe mining at Westray. What is clear from the testimony of Labour witnesses at the Inquiry is that the department did not discharge its duties with competence or diligence, and thereby failed to carry out its mandated responsibilities to the workers at Westray and to the people of Nova Scotia.
The Report enumerates in detail the many ways in which Westray Coal violated the regulations governing mine operations. The Department of Labour's mine inspectorate should have detected these violations and ensured compliance. To give just one example, despite the company's repeated violations of the Coal Mines Regulation Act in the matters of clearing coal dust from the working sections of the mine and applying stonedust to render the coal dust inert, the mine inspectorate did not use the means at its disposal to ensure compliance. It was not until 29 April 1992 that inspector Albert McLean gave oral orders, followed up by written orders, to Westray underground manager Roger Parry and mine manager Gerald Phillips to clean up and treat the coal dust immediately and to produce the stonedusting and dust sampling plans that had been promised in September 1991. McLean failed to follow up on his orders during his visit to the mine on 6 May 1992.
The Report also examines the involvement of politicians in the development of the Westray project and their very active support of a project that would mean jobs in Pictou County. The three provincial politicians most involved with the Westray project were John Buchanan, Donald Cameron, and Leroy Legere. Cameron had the most prominent and enduring role in the project, serving as minister of industry, trade, and technology from April 1988 until he succeeded Buchanan as premier in February 1991, a position he held until late spring 1993. Legere was appointed minister of labour in February 1991. It became clear in the course of the Inquiry that Buchanan, Cameron, and Legere had disparate understandings of their roles as ministers of the crown. The fact that they had such an imperfect understanding of the nature of their responsibilities suggests that a formal clarification of constitutional responsibilities is required. In the Report, I recommend establishing a program offering guidelines to ministers on their responsibilities, perhaps modelled on the one used in the United Kingdom. At the same time, there appears to be some misunderstanding respecting the concept of ministerial responsibility, and for that reason I have devoted some attention to what it means in modern government.
As part of the preparation before the public hearings began, I undertook a general review of legislation pertaining to mining and safety in Nova Scotia and in other jurisdictions. Clearly, the aim of mining legislation should be the protection of the miner in the mining environment. Coal mining is inherently hazardous, and safety regulations must protect the miner in a way that is consistent with the economic viability of the undertaking. This goal has been expressed in terms of safe mine production. "Attitude," which may be the most significant single factor in attaining safe mine production, cannot of course be legislated. It must, however, be cultivated within an organization, whether it be a mining company, a union, or a government agency charged with enforcement of safety legislation.
I would be remiss if I did not comment on the selfless bravery shown by the rescue teams in the days following the explosion. The conditions in the mine were terrifying. The force of the explosion resulted in severe instability within the roof and walls of the mine. Rock falls, of varying degrees of intensity, were almost continuous. Signs of the devastation were rampant, as were signs of impending danger. The poisonous, unbreathable atmosphere and the actively "working" ground surrounding the mine openings, with the attendant grinding and cracking, were extremely stressful. Yet these men, miners trained in mine rescue, each wearing his personal life-support system, went unquestioningly into that perilous environment with the hope of finding some of their comrades alive. The rescuers came from mainland Nova Scotia, Cape Breton, and New Brunswick. We can only be thankful for this valiant display of concern for fellow workers. I also wish to recognize the entire community for its selfless work in those difficult days.
I must point out that Westray Coal was ill prepared for a disaster. I have made a number of recommendations pertaining to what a company can do in preparation, as well as what the regulator's role should be.
Finally, I describe my preparations for the public hearings of this Inquiry, which was established six days after the explosion amid grief, calls for recrimination, and confusion. I then record the factors that caused the delay in concluding the Inquiry.
Published on the authority of the Lieutenant Governor in Council by the Westray Mine Public Inquiry.