Book review: Michael Quinlan, Ten Pathways to Death and Disaster: Learning from Fatal Incidents in Mines and Other High Hazard Workplaces

Michael Quinlan is well placed to write this book. He is a professor in the School of Management at the University of NSW, where he teaches courses in risk management and occupational health and safety. During his long career, he has chaired or otherwise been involved in several major inquiries into work health and safety issues. Perhaps the highest profile inquiry in which he participated was the investigation into the 2010 Pike River mining disaster in New Zealand, in which 29 men died. Ten Pathways grows out of that investigation but goes far beyond it and has roots much further back in time. Major accidents in hazardous industries frequently give rise to public inquiries, especially where large numbers of people are killed. These inquiries uncover a wealth of information about how the organisations in question were operating – their cultures, incentive arrangements and organisational weaknesses, and in addition, the way in which regulators failed to deal with any of this. The material generated in these inquires is so rich that writers such as myself can use it to produce what are almost ethnographic accounts of what happened. We are able to identify a series of human and organisational causes that gave rise to the incident, such that for each cause it is possible to say – had it been otherwise, this incident would not have occurred. But does it follow that correcting the problems identified in a particular incident will prevent any or all such incidents in the future? Unfortunately, case studies do not allow us to generalise with any certainty. It is only if these studies are synthesised that causal patterns can be identified and preventive recommendations made with reasonable confidence. This is where Quinlan’s book comes in. He has studied a large number of major incidents, each involving numerous fatalities, primarily in the mining industry, but also in other major hazard industries such as petrochemicals and aviation. This has enabled him to identify what he calls ‘pattern causes’ that repeatedly occur in these accidents. It will be helpful to list them here: