AMSJ » Confidential cabinet documents reveal mine safety slow to improve

Confidential cabinet documents reveal mine safety slow to improve

Moura No 4 Mine Disaster showing conveyor damage following explosion
33 years ago today an explosion ripped through the Moura No 4 mine.

A swag of 1990 Confidential Cabinet Minutes released this week on the 1986 Moura No 4 Mine explosion has revealed the pace of safety improvements in the mining sector has moved incredibly slowly with several recommendations not being adequately implemented almost 30 years later. The minutes also raise more questions on the cause of the ill-fated Moura No.4 mine disaster.

On 16th July 1990, a report into a coal mine explosion research project issued by now deceased Labor Mines Minister Ken Vaughan was tabled before the Queensland Cabinet. Some evidence provided for the report reportedly challenged the findings of the Warden’s Inquiry that indicated that a flame safety lamp was responsible for the Moura No 4 blast.

According to the minutes released early this month, The Queensland Goss Government established a “Project Team” headed by the Director of Safety in Mines Testing and Research Station ( SIMTARS), and including expert consultants in the fields of forensic pathology, blast analysis and computer modelling.

The project team reported to Government that there was “no evidence” to challenge the findings of the Warden’s Inquiry despite being provided with a range of world-leading expert forensic evidence. The project team had gathered its own evidence and submitted this to Government on the cause of the inquiry. Ultimately though, the Goss Government denied the additional evidence and accepted a range of recommendations from the project team on the use of forensic pathology and computer modelling to assist in determining the path of mine explosions.

AMSJ has learned that there was a plethora of expert forensic evidence on blast paths provided to the committee which disputed the final findings of the project team headed by the Safety In Mines Testing & Research Station (Simtars). There was a range of questions raised by world-leading forensic pathologists that were seemingly ignored or dismissed by the project team.

AMSJ has reviewed a report made available in September 1988 to the project team which examined blast and heat patterns with the Moura No 4 mine. The review examined equipment in the mine together with post mortem examinations of miners, photographs of bodies, and forensic odontology. The authors concluded, “It is considered by the authors that an incorrect judgement on the roles of the flame safety lamp could mean that false assumptions are being made by the industry on the cause of the Moura mine explosion.”

The evidence provided by experts to the project team was reportedly significant with forensic experts recommending that the then Chief Inspector of Coal Mines review the information such that it be incorporated in the inquiry.

Cabinet dismisses expert evidence

Vaughan told Cabinet “Part of one chapter of the report contains details of the physical and medical condition of the victims which could cause distress to their relatives and other persons in the industry. For the purposes of publishing the report, the sensitive details have been deleted and a note inserted to explain the reason.”

Vaughan quickly moved to quell growing community anger over the Moura No 4 disaster through publically highlighting that the Queensland Labour Government was implementing recommendation to mitigate gas explosions.

Following approval from Cabinet, Vaughan released a minute stating “The safety of Queensland’s miners is something that cannot be compromised. If reasonable measures can be taken to prevent another tragedy like Moura, those measures will be taken.”

Vaughan subsequently established a task force headed by the Chief Inspector of Coal mines, examine methods of lessening the explosion risk from gases which collect in mines. the government’s safety in mines testing and research station is already examining existing research, and considering further work, on making underground coal mining equipment safer.

In his release to the Queensland public, Vaughan said “The task force will involve the police, health officials and Scientists at the state government’s safety in mines testing and research station (Simtars) to ensure prompt, co-ordinated action after underground mine explosions. The task force will also look at training specialist investigators and using safe photographic equipment to record evidence as soon as possible after explosions. Another recommendation under consideration is improving facilities for forensic tests in regional areas.

Like other Governments, before and after him Mr Vaughan told Queenslanders that “the Goss government believed workers had a right to a safe workplace”

While many changes in the industry have evolved, there are several examples where recommendation have not been incorporated into current practices (See table below). These include lack of forensic capability/competence within the mines inspectorate and failure to incorporate frictional ignition competencies into industry training packages.

Recommendations on Coal Mine Explosion Research Project following Moura No 4.

RecommendationsRecommendation SummaryWhat Minister Vaughan said Happened?What happened
InertisationResearch including study of existing overseas practicefor rendering inert the atmosphere in the goaf.A committee has been constituted under thechairmanship of the Chief Inspector of Coal Mines(CICM) with the first meeting scheduled for 17th July,1990.The QMRS was eventually equipped with a GAG jet inertisation from Poland. 
TrainingUnderground coal mine personnel to be made aware of risk of frictional ignition by machines impacting on rock where flammable gas is presentRevised training/re-training programs for coal mineemployees are currently in the hands of CICM forapproval under the Coal Mining Act.Currently not included in RIIMCU306A – Conduct shearer operations 
Flame SuppressionResearch/investigations be undertaken to determine how underground coal getting equipment can be fitted with means of preventing ignition of flammable gas by machines.SIMTARS’ Principal Research Engineer will prepare a research proposal after discussion with other research organisations (to avoid possible duplication).A range of underground mining equipment is now fitted with gas sensors that isolate the equipment in high gas concentrations.
ContrabandEnforcement of regulations to eliminate use ofmaterials underground in coal mines which are able tocause an ignition of flammable gas. Examples are prohibition of certain alloys and the use of hoses other than the fire-resistant, anti-static CFRAS) type.Adequate legislative power already in the Coal MiningAct. Stricter enforcement depends upon adequatestaff (there are currently three vacancies in the coalmines inspectorate). Commonly accepted practice in Queensland mines
Structuring of Scientific Investigation of Mine Explosions.The Chief Inspector of Coal Mines to be charged with the responsibility of conducting such investigation into any future incident in the manner described in Section8.4 of this report. The investigation report should be made available to the Mining Warden for purposes of Inquiry into the cause.The CICM has been given the responsibility and has already .held discussions with relevant experts who might be involved in new investigation procedures. Preliminary enquiries have been made regarding appropriate training for specialist investigators(inspectors).Currently, informal processes exist in Resources Safety & Health. There is a range of investigators used on an ad-hoc basis.
Liaison with Other Government Departments…. the Chief Inspector of Coal Mines should arrange a close liaison with the Queensland Police Force and the Queensland Health Department as well as SIMTARS to ensure prompt action: in the event of an underground mine explosion … “The CICM has taken initial steps to establish a specialtask force (see Recommendation No. 5Unknown 
Forensic PathologyAdequate facilities need to be made available in regional centres to obtain the maximum amount of information needed to investigate the cause of an explosion. Alternatively, arrangements can be made for speedy transportation to Brisbane and the forensic work carried out there.To be considered by the special task forceNot established 
Recording of Information in the MineIt is recommended that a photographic record be made of explosion-affected mine workings at the earliest opportunity …….. The use of a video camera complete with voice recording would provide the most effective means of gathering information. .. …..Task Force to consider and investigate the availability of suitable equipment (flameproof and intrinsically safe).A number of intrinsically safe cameras are available commercially 
Further ResearchThe statement is totally supported by this Department, the mines inspectorate and SIMTARS. Research projects aimed at ‘prevention’ will continue to feature significantly in SIMTARS’ plans. Whether or not those plans eventuate will depend in large measure, on the future role of SIMTARS which seems to be under a certain cloud at the moment.A significant level of responsibility for ensuring that research is carried out in the future must rest with the industry itself. To the extent that it can influence the future direction, SIMTARS will certainly accept its share of the responsibility.Industry research is funded by ACARP 

Secret report may reveal ‘significant blunders’ in Moura inquiry

AMSJ has learned of an additional ‘secret report’ provided by experts to the Queensland Government Simtars project team and the then Chief Inspector of Coal mines that provided significant evidence by a Forensic Ondotologist and another world-leading expert in forensics that was refuted by investigators.

The report reportedly provides significant evidence to suggest that the blast patterns at the Moura No 4 mine indicate that the source of ignition was not the flame safety lamp.

Of course, as we have seen with the recent Grosvenor inquiry, expert evidence can be somewhat tainted by the ultimate objectives of an inquiry… one that may not want the truth to be learned for fear of reprisal on the Government itself.

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