10 Pathways to Death and Disaster

admin • March 18, 2025

Michael Quinlan’s book ‘Ten Pathways to Death and Disaster’ includes a review of fatal mine incidents. What he found was that the each disaster was preceded by common causes. There are 10 recurring reasons why disasters happen in the workplace.

He describes 10 pathways:

Pathway 1:      engineering, design and maintenance flaws

Pathway 2:      failure to heed warning signs

Pathway 3:      flaws in risk assessment

Pathway 4:      flaws in management systems

Pathway 5:      flaws in system auditing

Pathway 6:      economic or reward pressures compromising safety

Pathway 7:      failures in regulatory oversight

Pathway 8:      worker or supervisor concerns that were ignored

Pathway 9:      poor worker or management communication and trust

Pathway 10:    flaws in emergency and rescue procedures


In most cases, at least 3 of these pathways will be present. However, some cases will have features of all 10.


The 10 pathways don’t just apply to mine incidents – they have been applied across other high hazard workplaces and have found to be equally relevant across industries.


Ultimately, this shows that death and disaster in the workplace is predictable and preventable – so why do major industries continue to kill in the same old ways?


If the 10 Pathways approach defines the issues which lead to major incidents, then why aren’t these being used to prevent such events?


In other jurisdictions, the 10 Pathways Theory has been used to inform prevention. Perhaps it is something which regulators, employers, and also HSR’s could consider when thinking about how to prevent death and injury in Victorian Workplaces.



Ten Pathways to Death and Disaster eBook - The Federation Press

HSRs rights to training

By admin • January 19, 2026
Under the Victorian Occupational Health and Safety Act 2004 , Health and Safety Representatives (HSRs) are not required to be trained in order to exercise their powers. However, in order to fully understand their role and powers, training is highly beneficial and recommended by WorkSafe. Most HSRs will not understand how to make the most of their role as an HSR without participating in training – and therefore it is not until training has been completed that an HSR can maximise their positive impact upon the safety of their workplace. HSRs rights in relation to training are outlined under Section 67 of the OHS Act. They include: The right to attend initial training after being elected The right to attend a refresher course at least once a year The right to choose their course. This includes their course provider and course* The right for their course to be paid for by their employer, as well as associated costs with attending the course The right to be paid while attending the course *The course must be approved by WorkSafe and delivered by a WorkSafe approved provider, such as BeSafe. The HSR must consult with their employer and give 14 days notice. Section 69 of the OHS Act also discusses further the rights of HSR to training. This covers the right to attend additional training, when WorkSafe has approved them under Section 69 . HSRs have a right to attend these courses on top of the s67 courses. HSRs can be a very useful resource for employers in helping to create safe and healthy workplaces. It is in their best interest to encourage their HSRs to be trained. However, in the case where an employer does not allow the HSR to be trained as per the requirements under The Act, there are penalties which apply to this conduct, as it is a breach of the Legislation. For more information take a look at: Health and safety representative training | WorkSafe Victoria HSRs' Right to Training - OHS Reps Or get in contact with us for assistance: 0467002060 HSR Training and support | BeSafe | Regional Victoria You can book WorkSafe approved courses with us at HSR Training Courses | BeSafe | Regional Victoria

The Granville Train Disaster

By admin • January 12, 2026
The Granville rail disaster occurred on 18 January 1977 and remains the deadliest rail incident in Australian history. It resulted in the death of 84 people and injured a further 213. The train left the Blue Mountains at 6:09 on 18 th January 1977 and by the time it reached Sydney there were at least 469 passengers on board. At 8:10 the train derailed on a curve in a deep cutting at Granville and it hit the supports of the Bold St Bridge. This resulted in the bridge collapsing onto the train carriages and the passengers inside. The result was catastrophic loss of life and vast numbers of injuries, with many passengers and rescuers suffering from ongoing trauma. The train crash would expose inadequacies in the NSW railway maintenance processes, oversight and emergency response preparedness. The inquest and reviews into the incident became controversial in that there were allegations that the process was unduly influenced. Despite this it was clear that there were many opportunities for prevention of future railway disasters. There has been extensive criticism of the management and oversight both before and after the disaster.  There is much that is concerning about this case, including the support of those injured and bereaved in the incident. The failure to act following previous incidents on the track is particularly disturbing. There had been two previous derailments on the same section of track, resulting in trains hitting the Bold St Bridge. One in 1967 and another in 1975. Had the issue been addressed on either of these occasions, perhaps the disaster in 1877 would have been avoided. This highlights the importance of investigating incidents and ‘near misses’ and acting to resolve safety issues at the earliest opportunity. 40 years after the disaster, in 2017, the Premier of NSW delivered a belated official apology on behalf of the Government: Granville: Mixed response as NSW Government apologises for Australia's worst train disaster - ABC News An award winning docu-drama named “The Day Of The Roses” was produced as a dramatic depiction of the events surrounding the Granville train crash. It can be found here: https://youtu.be/ZkFBfQA9oxg?si=g_ePZ0kn0KpFrLLE . Those interested in incident investigation, prevention and related matters may well find it thought-provoking.