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

OHS Prosecution on Pure Risk

By admin • June 17, 2025
The Victorian Occupational Health and Safety Act 2004 is primarily a risk-based law. That is, it requires the prevention of harm. The objects of the Act require that health and safety be secured and that risks to health and safety be eliminated at the source, with the highest level of protection against risks being provided. The employer is legally required to eliminate (as far as reasonably practicable) any risk to health and safety. It follows that the majority of offences under the Act are indeed risk-based offences. This means that a prosecution can occur whether or not the risk has resulted in death or injury. It is enough to have simply exposed a person to the risk of harm. The argument for this is that the OHS Act aims to prevent injury, disease and death at work. So why do we see many prosecutions occurring after the harm has in fact materialised into an injury or death? Perhaps it is due to a public expectation that these horrific incidents should result in some punishment of those responsible? Perhaps it is that the ultimate evidence of the safety failure is now present – providing a compelling argument as to the egregious nature of the risk that was posed by the breach? Perhaps there is motivation to provide general deterrence as a result of these tragic events? It is important to note that the death or injury does not form part of the offence in these prosecutions, rather it forms part of the evidence. But, we do see pure risk prosecutions. The regulator can and does charge on the basis of risk only, before the safety failure has resulted in harm to anyone. This is the ultimate outcome – to prevent . Prosecuting on the basis of risk may be for the purpose of primary prevention, or as the ultimate escalation in a hierarchy of sanctions. It may serve as specific deterrence, to effect change in an individual’s or company’s behaviour. General deterrence is often seen as very important – reinforcing to all duty holders that they are required by law to take a pro-active approach to safety. Here are a few examples of cases of pure-risk prosecutions: $7.5K FINE IN PURE RISK FALLS CASE - OHS Reps $25K FINE IN AHWAZ ROOFING PURE RISK CASE - OHS Reps CONSTRUCTION COMPANY FINED $12K IN ‘PURE RISK’ PROSECUTION - OHS Reps The following Melbourne Law School presentation also makes for some interesting reading on this topic: CELRL-Seminar-21-May.pdf Proceeding to prosecution on the basis of risk represents an alignment between prosecution strategies and the principles of the OHS Act . Certainly, it serves as a reminder that duty holders have a legal requirement to provide the highest level of protection and to prevent harm in the workplace.

Working Alone on Farms

By admin • June 10, 2025
Farm workers are often working alone and in an isolated location where there is no assistance from others and often limited or no communication. Remote or isolated work often includes working alone and outdoors and it may be difficult to get help in an emergency. Access can be long and difficult and there may be limited access to resources. On top of this, there is less access to support networks and communication and technology may be unreliable or absent. All these factors can add to the risk of the work. These unique challenges should all form part of the thinking when working to create a safer workplace for those working on farms. The duty to provide a safe workplace sits with the employer, who has a legal requirement to provide a safe workplace for the workers on the farm. Often the employer may also work on the farm themselves, and the same hazards will pose a risk to them too. Implementing some controls to help reduce the risk of working alone on farms can help ensure that everyone gets home alive and well, including the employer/ farm owner. The control measures will depend on the exact type of work being conducted on the farm, but things to think about may include: Monitoring weather conditions and emergency warnings Ensuring some form of communication is available Providing personal distress beacons Ensuring all personnel have a first aid kit and are trained in how to use it Implementing a buddy system to reduce the time spent working alone Additional training provided to reduce the impact of isolated work Mental health support Farming will usually involve work which is dangerous, including machinery, powerlines, heights, animals, chemicals, and the list goes on. All these risks need to be controlled to a level which is reasonably practicable, but they become more dangerous when the worker is working alone or in an isolated location. Often even the most basic issue is not adequately dealt with – how to call for help? One of the most important issues is to consider is: Is there are reliable means of emergency communication? You must consider how you will know if something has gone wrong and how to locate the person in the case of an emergency. You may like to think about: Is there a check in procedure? Do you have a location system? Do you have a satellite communication or radio if there is no phone signal? Do you have an Emergency Locator Beacon with GPS for use in case of an emergency? If you have mobile coverage, have you considered using Emergency Phone Apps?  For more information on this topic, including on how to develop emergency procedures, take a look at: Working alone on farms | WorkSafe Victoria and Working alone or in remote areas | Safe Work Australia It really is important to take the time to consider the risk of working on farms, especially when alone and in isolation. Not only do we need to do this to fulfil the legal duties under the OHS Act - but most of all, to make sure we all make it home at the end of the day.