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

Failure to report a notifiable incident is an offence

By admin • May 20, 2025
Section 38 of the Occupational Health and Safety Act 2004 imposes a legal duty on employers to notify of incidents: "An employer or self-employed person must not, without reasonable excuse, fail to notify the Authority immediately after becoming aware that an incident has occurred at a workplace under the management and control of the employer or self-employed person. s38(1) The employer must notify immediately by calling WorkSafe by calling 13 23 60, at which time they will be given a reference number. Thie reference number serves as proof that the employer did immediately notify the regulator." s38 The employer must fill out an incident notification form (found at Incident notification form | WorkSafe Victoria ) and this form must be submitted within 48 hours of the incident occurring. Failure to notify is a breach of legal duty and the offence can result in prosecution. It is also a legal duty for the employer to preserve the site of the incident. Failure to preserve the scene is an indictable offence under section 39 of the OHS Act. So, what classifies as a notifiable incident? Any of the following: 1. Death 2. Exposure to a substance resulting in a need for medical treatment within 48 hours 3. Any incident resulting in the need for immediate in-patient hospital treatment 4. Any incident result in the need for immediate medical treatment for any of the injuries listed: a. Amputation b. Serious head injury c. Serious eye injury d. Removal of skin (eg: scalping, degloving) e. Electric shock f. Spinal injury g. Loss of bodily function h. Serious lacerations (ie: requiring stitching or other medical treatment) 5. Any incident through which a person is at serious risk as a result of exposure to an: a. Uncontrolled escape, spillage, or leakage of a substance b. Implosion, explosion or fire c. Electric shock d. Fall or release from height of any plant, substance or thing e. Incident involving plant (collapse, overturning, failure or malfunction) as per OHS Regulations f. Collapse or failure of an excavation or mine (or of any shoring support) g. In-rush of water, mud or gas into an excavation, tunnel or mine h. Interruption of ventilation in a mine, excavation or tunnel i. Any incident involving dangerous goods or explosives WorkSafe has a straightforward guide on the process here: Report an incident | WorkSafe Victoria Don’t forget that as Health and Safety representative, you have the right to access information in relation to incidents which affect your DWG. For more information on this topic, take a look at previous articles relating to relating to HSR’s entitlements to access information: HSR Training & Workplace Safety | BeSafe | Reg. Vic. For more detail on this, visit Obligations of an employer to health and safety representatives | WorkSafe Victoria As always, you are welcome to get in touch with us for a chat HSR Training and support | BeSafe | Regional Victoria

Young workers are vulnerable

By admin • May 13, 2025
Young workers are at among the most vulnerable in the workplace. They are at an increased risk of injury or death at work. There are a number of factors which contribute to this, including: Being new to their job or industry Not knowing what their OHS rights are Not having OHS training Not being supervised sufficiently Have less experience in their role Feeling afraid to speak up about safety issues Not knowing how to report safety issues Being under pressure by other workers or their employer Insecure work Employers have a duty to provide a safe workplace to their employees, and particular care should be taken to ensure the safety of the young and vulnerable workers. Read more about this at Young workers: Safety basics | WorkSafe Victoria . When a young worker is killed at work, the ramifications are devastating. In these videos, two brave fathers describe what happened when their sons went to work and never came home: Workplace Incidents Consultative Committee: David Brownlee's story | dtf.vic.gov.au Workplace Incidents Consultative Committee: Brett Struhs' story | dtf.vic.gov.au Both companies were charged following the deaths of these young men, but nothing will bring them back to their families.  Both stories highlight the importance of protecting young workers from hazards in the workplace, as is the duty of the employer.