Coal Inspectorate | Bulletin | No.197 V 1 | 07 October 2021

High Potential Incident under reporting

What happened?

There has been a significant decrease in the number of High Potential Incidents (HPIs) reported by Queensland coal mines during the 2020/21 fiscal year. The number of HPIs reported in 2020/21 was 25.7 per cent less than the previous year, and in parallel to this, the reporting frequency rate (HPIs per million workhours) also dropped by 22 per cent. The graph below (figure 1) depicts the HPIs reported over the past five fiscal years and the reporting frequency rates.

How did it happen?

The Coal Mines Inspectorate is undertaking a project to audit mine incident reports against the HPI reporting requirements to ensure all HPIs are being reported to the Inspectorate, enabling learnings to be communicated to industry. This continuous learning from incidents is a key part of any High Reliability Organisation or industry. It is also a key finding in the 2019 Brady Review into fatal accidents in Queensland, and that of the 2021 Coal Mining Board of Inquiry. 

During the past six months the Coal Mines Inspectorate has requested and received from 20 per cent of mines, both underground and open cut coal mines, copies of their internal incident reporting data. The remaining 80 per cent of mines will be audited in a similar manner. An analysis of this data shows there have been incidents occurring that were not reported as HPIs, when evidence suggests they were HPIs as defined by section 17 of the Coal Mining Safety & Health Act 1999.

Meaning of HPI

A high potential incident at a coal mine is an event, or a series of events, that causes or has the potential to cause a significant adverse effect on the safety or health of a person.

Some event types not reported as HPIs include, but are not limited to the following:

• steering mechanism failures on operating mobile equipment in surface mines (tie rods separating etc.)
• wheels separating from light vehicles whilst travelling in surface coal mines
• falls of ground in underground mines
• braking mechanism failures on mobile equipment occurring whilst being operated in surface mines
• significant structural failures occurring on mobile equipment whilst being operated in surface mines
• flameproof enclosures compromised in underground mines
• isolation breaches that have resulted in an energy source not being positively contained
• significant strata failures in surface mines
• collision near misses in surface mines
• uncontrolled movement of mobile equipment in surface mines
• fatigue events such as microsleeps occurring when operating mobile plant in surface mines.

Key issues

• Learning opportunities for hazards are lost to the industry.
• Under reporting does not promote a positive safety and health culture.
• The potential consequences associated with incidents is not always realised.
• Evidence shows some incidents not reported as HPIs have been classified within their mine’s internal incident reporting system as being 'a potential single fatality', yet still not reported to the Inspectorate.

The following is an extract from Dr Sean Brady’s review of all fatal accidents in Queensland mines and quarries from 2000-19.

“In High Reliability Organisations there is no such thing as a safety culture, rather there is a reporting culture. Currently, the data suggests under-reporting of incidents is occurring, and steps to address this issue are required.”

Recommendations

• Coal Mine Operators to review their processes for reporting HPIs.
• Coal Mine Operators should implement the reporting standards adopted by High Reliability Organisations.
• Coal Mine Workers are encouraged to make confidential complaints concerning HPIs not reported, enabling the Inspectorate to investigate such under reporting and take appropriate action.

References and further information

Section 17 of the Coal Mining Safety & Health Act 1999 “Meaning of a high potential incident”

Brady Heywood “Review of all fatal accidents in Queensland mines and quarries from 2000 to 2019”