I was distressed, though not surprised to read the USA Massey Energy investigation report in May 2011. The conclusions are damning of enforcement tolerance and industrial culture.
Even before investigation conclusions were reached, senior executives of Massey Energy were charged by the USA Federal Bureau of Investigation (FBI) for lying and obstructing justice in the investigation of the West Virginia coal mine disaster.
The company had made thousands of safety violations. There were over five hundred on Upper Big Branch site. I can hear the ghosts of BP Texas City disaster. Why were they allowed to operate? The event inspired Woodie Guthrie to write an industrial folk song.
It reminds me of the landmark TV documentary titled ‘It’s a Dangerous Business’, where McWane group was shown operating the most dangerous pipe foundries in the world.
They had one site that had more safety violations than the rest of the industry combined, and they were allowed to operate! McWane as a case study is so significant and powerful that I developed a ‘Beyond Compliance’ safety seminar series around it.
Why were the allowed to operate? The USA Department of Labour, in the form of the Mine Safety and Health Administration, was found to be incompetent in fulfilling its oversight responsibilities.
The author of the independent investigation report was Davitt McAteer, former USA assistant secretary of labour in charge of the Mine Safety and Health Administration under president Clinton. This was a work and enforcement environment in which the author had a unique understanding.
Safety systems are entropic
Very similar findings were indicated in the McWane case, a decade ago. I have written about the entropic (tending to chaos) nature of safety systems. Without regulation and enforcement, safety systems degrade, as they demonstrably do.
Safety entropy could be avoided when a business has a powerful and resilient positive safety culture. Sadly, we do not see that too often. Another crucial feature is consistent and positive safety leadership. Both critical elements were visibly absent at Massey Energy operations.
Their production was unbelievably placed above all living things. When I first read what was going on, I did not believe it. I had to confirm the information for myself. At Massey Energy, senior executives were required to be advised of tonnage and metres gained every thirty minutes, up to CEO Don Blankenship.
In my view this degree of priority ‘messaging’ is criminal, and should be treated as such. Massey claimed safety as a high priority and they spent a small fortune on marketing and safety videos, but the clear message at all levels of the business was production, production, production.
This was known to regulators and they did nothing! Regulators were even on site on the day of the explosion. This company was an incubator for a workplace disaster.
Fake Safety reports
On June 29 2011 at a private briefing of Upper Big Branch relatives, the USA Mine Safety Authority, trying to justify its pathetic performance, showed ‘fake’ safety reports. Employees confirmed that it was common practice to prepare two reports. Massey is not the first company to ‘doctor’ legal documents to deflect oversight.
Some CEOs have told me ‘it’s only a little fib, no one got hurt’. What is the message it sends though? Dishonesty and deception are corporate values and industrial culture.
International mining body promotes leading indicators
In March 2011 I co-facilitated a workshop for the International Council of Mining and Metals (ICMM), exploring the area of optimal leading indicators to use in mining. During a session on safety metrics I made an observation specific to the Massey Energy disaster, before the official report was released.
On the basis of a number of lagging safety indicators, Massey Energy had won multiple national safety awards, despite having recently killed 29 employees. The Bradbury Award is given for ‘excellent performance in safety’.
A company with a long history of safety violations, a proven track record of lying to regulators, a psychotic focus on production metrics, can achieve ‘perfect LTIFR results’. Are lost time injury frequency rates (LTIFR) type numbers a barometer of underlying safe systems of work?
The independent investigation report hangs out dirty laundry. Employees are lining up to tell their story in this established multi-generational coal mining community.
Fines are no deterrent
This organisation created and powerfully promoted a toxic safety culture. Society has no choice but to send some people to prison! Fines and public humiliation do not work. Some companies see fines as part of the cost of doing business.
There have even been cases where the annual budget has had a cost line item for “regulatory compliance” as a code for “infringement fines”.
BP had learnt very little from their experience as custodian of Texas City fatalities. BP received some of the largest fines in USA corporate OH&S history, not even due to Texas City. Filling state and government coffers by fat fines is a failed system, and no help to health and safety at all.
What message does it send when Tony Howard, former BP CEO, is fired with millions of pounds in his back pocket while entire communities have literally been destroyed by environmental devastation.
I appreciate the legal ‘beyond reasonable doubt’ hurdle as significant, but sheq practitioners and society have to fix legal and cultural problems, or allow more people to become ill or die prematurely.
The state imprisons many people for crimes that could result from one transgression, or one mistake without intent to cause harm, and courts often decide on the basis of harm suffered by victims. It is time to hold employers to the same level of expectation as we do domestic and road traffic ‘criminals’. Some employers expect to transgress, and cause harm, injuries and fatalities.
Industry is producing dead bodies as a by product. Some corporate executives promote toxic at risk cultures. Cooking books and reports is a serious offence. Telling lies to state investigators is a serious offence. The managers perpetrating these offences are not inherently criminals, but their behaviour is sanctioned and has its etiology in corporate and industrial culture.
The people who benefit most, and foster that culture, are not knee deep in the coal dust of West Virginia. There has to be consequences.
Do you truly know what the safety culture in your organisation is? If you do know, what have you done about it? Answers to these questions could determine whether some of your colleagues live or die.