EDITORIAL COMMENTS: Investigating the Sago mine tragedy
So by the latest count, the mine debacle will be investigated on three fronts. One day before Sen. Enziâ€™s announcement, West Virginia Governor Joe Manchin outlined a federal-state investigation involving the West Virginia Office of Minersâ€™ Health, Safety and Training, the U.S. Department of Labor, and the National Institute of Occupational Safety and Health.
The day after hope turned to horror in West Virginia, the U.S. Mine Safety and Health Administration named an eight-member team to probe the cause of the explosion and the botched handling of communication regarding the condition of the trapped miners.
All three investigations hold to the same goal: â€œTo find out what went wrong and fix it,â€ said Governor Manchin.
â€œTo prevent such tragedies in the future,â€ said MSHA acting administrator David Dye.
â€œTo ensure that this never happens again,â€ said U.S. Secretary of Labor Elaine Chao.
Building defensesLetâ€™s see how successful they are in breaking down defenses quickly erected after the full scope of the tragedy came to light:
- MSHA threw statistic after statistic up on its Web site to explain itself. Inspectors spent 744 hours on-site at the mine in 2005, an 84 percent increase over 2004. Triple the number of citations, orders and safeguards were issued against the mine in 2005. But of the 208 citations issued against the mine last year, none involved an immediate risk of injury. To counter claims it had gone soft on the job, MSHA took five yearsâ€™ worth of data (fiscal years 2000 to 2005) and pointed out total â€œsignificant and substantialâ€ citations and orders issued at coal mines increased from 23,774 to 26,779.
- International Coal Group, the mineâ€™s owner, quickly unearthed its own safety stats and accounting ledger. A senior vice president told reporters there was an 80 percent improvement in safety violations between the second and fourth quarter of 2005. Fending off claims that cost-cutting might have contributed to the explosion, Wilbur L. Ross, whose investment firm owns ICG, told The New York Times his company spent $139 million to modernize its mine in 2005, and has committed $165 million to capital investments this year.
- At a White House press briefing, spokesman Scott McClellan said improved mine safety has been a priority for the Bush administration, despite MSHA losing 170 staff positions since 2001, $4.9 million in funding in inflation-adjusted terms for fiscal 2006, and operating under an acting administrator since November 2004. â€œIn fact, this administration proposed a fourfold increase in fines and penalties for violations of the Mine Safety and Health Administration rules,â€ McClellan said.
- Attempting to put the mining industryâ€™s safety record in perspective, the president of an online publication for mine managers told The Pittsburgh Post-Gazette more than 20 times more workers died in 2004 from fishing, hunting, farming and related occupations than died from coal mining. â€œWhen an airline goes down, you donâ€™t damn the entire aviation industry,â€ he told the paper.
- Slightly more than half of 250 U.S. newspapers published front-page stories reporting the miners were found alive, according to a study by a Washington-based news group. How could so many be so wrong? â€œI donâ€™t regard it as our error, but as an error by the people in charge of the rescue,â€ said the executive editor of The Washington Post. â€œThe best information would have come from mine company officials, but they chose not to talk,â€ explained the Associated Pressâ€™s managing editor.
Practical politicsThese â€œstakeholdersâ€ in the Sago tragedy understand the realpolitik of accident investigations: blame follows the path of least resistance, and he with the least protection â€” the fewest documents, statistics, flak-catchers and attorneys to defend himself â€” loses.
Of course everyone from Secretary Chao to the governor and the senator will tell you accident investigations are never a win/lose exercise. Itâ€™s about unearthing facts, not finding fault, and then fixing problems. Sure. So there really was no reason for everyone to be armed with â€œfactsâ€ the morning after to defend themselves.
In reality, two outcomes are customary after accident investigations: individuals need to be disciplined and/or retrained, or systems and cultures need to be fixed. Anything in between is usually too gray for a quick-fix and a quick sound bite from an executive or a politician.
The onus of error traditionally has been put on individuals. This dates back to H. W. Heinrichâ€™s studies at the Travelers Insurance Company in the 1930s and 1940s. Heinrich reviewed thousands of insurance and injury/illness reports written by corporate supervisors. The reports blamed workers, so-called â€œman failureâ€ in the parlance of the time, for 73 percent of the accidents. Heinrich revised this figure to conclude that 88 percent of industrial accidents result from â€œundesirable traits of characterâ€¦ passed along through inheritanceâ€ and the fault of workers who commit unsafe acts.
Political correctnessToday itâ€™s politically incorrect to discuss accidents in the same breath as â€œinherited undesirable traits.â€ But the tradition of blame finding the most exposed, least protected individual does persist. Just last month The Houston Chronicle chided BP for its internal report that the paper said tried to blame relatively low-level employees as the root cause for the explosion that killed 15 people and injured 170 more at a BP refinery in Texas last March.
What is increasingly politically correct, it now seems, is to wrap up an investigation by claiming the culture needs to be fixed. This was one of the highly publicized findings after the space shuttle Columbia tragedy in 2003. Reported the Associated Press: â€œThe Columbia accident investigators are giving NASA months, if not years, to change the deeply rooted culture that led to the destruction of Columbia and the deaths of seven astronautsâ€¦â€
We see the same emphasis now in healthcare, where estimates of 44,000-98,000 patient deaths each year due to medical errors led the authors of the book, Internal Bleeding, to conclude that â€œsustaining a robust safety systemâ€¦ depends on creating a culture that prizes safety and frets about it incessantly.â€
Some patient safety advocates complain, though, that this talk of system failures and broken cultures is a cover-up for negligent misconduct of caregivers. Whereâ€™s the accountability, they declare, the personal responsibility?
Often it lands at the feet of those least able to defend themselves. It will be interesting in the coming months to see if the Sago mine investigations can arrive at a different outcome.