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

WorkSafe HSR of The Year!

By admin • March 3, 2026
The Annual WorkSafe Awards Night was held last week at the Plaza Ballroom in Melbourne. BeSafe was there and, of course, the highlight of the night was the presentation of the Award for Health and Safety Representative of The Year! This category acknowledges Health and Safety Representatives (HSRs) who have represented their designated work group (DWG) in an outstanding manner. There were four finalists this year and all of them showed how effective representation by HSRs is vital to safe workplaces. Anna Musgrave – Ambulance Victoria Anna is an ALS paramedic from Maffra who worked on a really challenging workplace hazard: fatigue. She advocated for the health and safety of her DWG, ultimately creating a fatigue monitoring self-assessment tool and changing the culture around fatigue and fatigue management. See more about Anna here: https://youtu.be/7tXtrXnVfME?si=BdtOF4t-ZP61otfx Ben Lennon – Crown Melbourne Ben is a table games dealer at Crown Casino, a delegate and HSR. He has been able to ensure all workers’ DWGs are represented, help workers to understand their rights and to feel safe to report. By helping spa treatment workers with their safety issues, he was able to facilitate a resolution. He has focused on effective consultation through building trust and working together. See more about Ben here: https://youtu.be/iVCcWq1mjKw?si=7qz2VfKfv_RLiF9L Bess Taitoko and Owen Glassenbury – Northern Health Two amazing HSRs who worked together to address serious Occupational Violence and Aggression issues in the Broadmeadows Inpatient Psychiatric Unit. The working environment involved the balancing of patient safety and wellbeing and that of the staff. These HSRs worked within a complex environment to ensure the safety of the work group which they represent, including creating a flow chart to assess and address risks proactively. See more about Bess and Owen here: https://youtu.be/wySo4Q0Vuxw?si=r7HuyV11XQOuHa5u Manny Mason – City of Ballarat - The 2025 HSR of the year award winner! Manny works in the Arboriculture Unit at the City of Ballarat and has been an HSR for over 15 years. He has dealt with many issues over the years. He has provided support and advocacy in bullying and sexual harassment cases, through to addressing physical hazards in fountain maintenance. He highlighted the importance of communication, advocacy and supporting co-workers while holding the employer to account in ensuring the safety of the workplace.  See more about Manny here: https://youtu.be/EQwPxiu43FA?si=qtKYItVTAxt7rgnf Congratulations to these Safety Reps and a big shout out to all the HSR’s out there who are doing great work every single day as the safety superheroes in their workplace!

Coronial Findings on workplace deaths – an opportunity to learn

By admin • February 16, 2026
Coroners Court findings are an opportunity to learn – especially when it comes to a workplace death. The role of the Coroners Court is to: “investigate reportable deaths, reduce preventable deaths promote public health and safety and the administration of justice” About us | Coroners Court of Victoria The Coroners’ Court deals with certain reportable deaths and this includes “When someone dies from an accident or injury, even if there is a prolonged interval between the incident and death.” – including workplace deaths. These deaths must be reported to the coroner for investigation. All of these reportable deaths are allocated to a Coroner who then investigates the death and then will consider whether anything could be done differently to help prevent similar deaths in the future. Inquests are not held for every death, in fact less than 5% of deaths will be the subject of an inquest. The rest of the cases will have findings made ‘in chambers’. The Coroner may or may not make ‘recommendations’ to prevent future similar deaths. The Coroner may or may not then order for the findings to be published. Those cases which are published can be found at: Findings | Coroners Court of Victoria The findings into any death are always sobering reading. But in the case of work-related deaths there is almost always a preventative opportunity – even when no specific recommendations are made. For this reason, it is important that these findings are made publicly available for those who wish to review them and learn (– assuming that the worker’s family has approved the publication of the report). The Coroners Court says that they aim to ‘identify how similar deaths may be prevented’. If that is to truly be the case, then they need to be published and we must seek to read them and learn from these tragic deaths. Perhaps the greatest tragedy of all would be if we do not learn from these horrific deaths in the workplace? We pay our respects to those who have lost their lives at work and acknowledge the pain and suffering of those left behind. Everyone has the right to come home from work alive and well at the end of the day.