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

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Reasonably Practicable?

By admin • March 25, 2025

The Victorian Occupational Health and Safety Act 2004 requires that the employer has a duty to ensure a healthy and safe workplace. This duty must be met as far as reasonably practicable. But what does this actually mean? The following must be considered when determining what is reasonably practicable: (according to section 20(2) of The Act): (a) The likelihood the hazard or risk concerned eventuating; (b) The degree of harm that would result if the hazard eventuated; (c) What the person concerned knows, or ought to reasonably know, about the hazard or risk; (d) The availability and suitability of ways to eliminate or reduce the hazard or risk; (e) The cost of eliminating or reducing the hazard or risk. This is often an area of confusion – primarily because the test for what is ‘reasonably practicable’ is in fact objective. When we consider this, it is best to look to WorkSafe for guidance. WorkSafe Victoria provides some clarification in their Position Statement on the matter: ‘a person is to be judged by the standard of behaviour expected of a reasonable person in the duty-holder’s position who is required to comply with the same duty and is: • Committed to providing the highest level of protection for people against risks to their health and safety. • Proactive in taking measures to protect the health and safety of people.’ - WorkSafe position statement - reasonably practicable There must be a weighing up of each of the 5 points listed under section 20(2) of The Act (above), but with a clear presumption in favour of safety. This means that the likelihood of harm occurring, and the seriousness of the potential outcome, must be the most important factor. The cost must be considered to be the least important factor when deciding what is reasonably practicable. ‘If the degree of harm is significant, e.g. death or serious injury is highly likely, then it is extremely unlikely that the cost of eliminating or reducing the risk would ever be so disproportionate to the risk to justify a decision not to implement an available and suitable control measure.’ - WorkSafe position statement - reasonably practicable When considering what the person concerned should reasonably know about eliminating the hazard, the state of knowledge regarding hazards and controls must be considered and this must be applied in line with the ranking under the hierarchy of control. The definition of what is ‘reasonably practicable’ is often one which causes some contention. It is important to go back to the WorkSafe position statement to make sure that you are making decisions in line with the intentions of The Act . Of course, it is always required that the highest level of protection from a hazard is provided in order to ensure a safe workplace. To read more about this: How WorkSafe applies the law in relation to Reasonably Practicable | WorkSafe Victoria

The Sentencing of OHS Offences in Victoria

By admin • March 11, 2025

The Sentencing Advisory Council (SAC) has recently reviewed the sentencing of breaches of the Victorian Occupational Health and Safety Act 2004. Through their review, they discovered that there is a need to change sentencing practices in Victoria. They found that punishments were often not appropriate and not in line with community expectations, and that sentencing orders such as adverse publicity orders and health and safety orders are being underutilised. In addition, many fines are going unpaid. Following a period of review and consultation, the SAC has recently published its’ report into the sentencing of OHS offences in Victoria. The SAC have made 12 recommendations, divided into 3 categories: 1. Victim related recommendations – relating to victim impact statements and restorative justice. 2. Sentencing Practices – relating to enforceable undertakings/ health and safety orders, adverse publicity orders, increasing penalties for OHS breaches and the inclusion of Sentencing Guidelines in the OHS Act. 3. Fine Payment – relating to fines being paid to WorkSafe, reviews of fines outstanding, declared director notices and successor liability. The recommendation to introduce Sentencing Guidelines would follow the example of the UK, where they already exist. However, Victoria will represent a world first if these guidelines are introduced as recommended – in legislation. If implemented, this suite of changes could lead to much improved Occupational Health and Safety outcomes for Victorian workplaces. Interested in finding out more? Take a look at: Sentencing Advisory Council Recommends Major Changes to Sentencing of Workplace Safety Offences | Sentencing Council