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

Engineered Stone - Anniversary of The Ban

By admin • June 29, 2026
Today is the anniversary of the banning of Engineered Stone. On the 1 st July 2024, Engineered Stone was banned due to the high levels of silica it contained, which presented a health and safety risk to those working with it. The banning of engineered stone is a huge win for the safety and health of workers, but it does not mean that workers are safe from silica related disease. Workers can still be exposed to silica from other sources, including: Stone Asphalt Cement, mortar and grout Concrete, concrete blocks and cement products Bricks and pavers Tiles Sand These and related products still present a risk and this comes in the form of respirable crystalline silica. Small particles of silica can be produced when dust is produces through cutting, sanding or processing the materials. This can occur during manufacturing and construction, when mining or digging, and when handling waste. The silica dust can be breathed deep into the lungs and can cause serious disease., including silicosis, fibrosis, COPD, bronchitis and lung cancer. In addition, it can cause other systemic diseases including serious effects on the kidneys, immune system, eyes, etc. Employers must control the risk of exposure and workers should be aware of the risks so that they can make sure that they are safe. BeSafe is still horrified to occasionally see dry cutting by workers who may not be aware of the serious risks of this practice. Just remember, that just because engineered stone has been banned, it doesn’t mean you are safe from silica related disease. Make sure you know how to protect yourself and stay safe from this serious and deadly hazard. More information: For the general information page with resources relating to crystalline silica, take a look at: Crystalline silica | WorkSafe Victoria For information relating to how employers must identify hazards, assess risk, control the risk and review and revise controls regularly, take a look at: Preparing a crystalline silica hazard control statement for high-risk crystalline silica work | WorkSafe Victoria For a practical guide on how to safely work with engineered stone, including exemptions, take a look at Compliance code: Engineered stone | WorkSafe Victoria

Welding Fumes

By admin • June 15, 2026
Welding fumes are hazardous, and employers must control the risk of harm. Various types of welding are used in the workplace, with varying levels of welding fume production. The amount and type of fumes produced during welding will vary based on various factors including: the metals being welded, the welding process used, the composition of the welding rod/wire, the shielding gases used and any contaminants or coating on the metal, etc. There are a number of health effects which may occur due to exposure to welding fumes. These include both short-term and long-term affects Short term: eye irritation, respiratory irritation, metal fume fever (zinc oxide). Long term: siderosis (iron accumulation in the body), lung and kidney cancer, nervous system disorders, asthma, pneumonia. The likelihood of developing damaging health effects from welding will depend on the type of welding being used (and therefore the type of fumes produced), the duration and frequency of exposure, the worker’s proximity to the fumes, the ventilation of the welding area, and any controls which were utilised during the exposure. Welding fumes are a hazardous substance and must be controlled according to the hierarchy of controls. Controls may include: Eliminating the need for welding if possible, for example by using different fastening methods or prefabricated components. Substituting the welding method, for example by using a method which generates less fumes, or using automation methods. Engineering controls including mechanical ventilation such as on-torch extraction or local exhaust ventilation. PPE should be provided by the workplace and includes the use of air fed ventilators. The use of respirators such as Powered Air Purifying Respirators can be used but only in addition to a higher-order control, or if higher-order controls are not possible. Other types of respirators are available but less effective. Several different controls may need to be used and as with any controls, training must be provided on their implementation. Atmospheric monitoring may also be required to monitor exposure levels in the workplace and health monitoring must also be carried out in accordance with the OHS Regulations 2017 Part 4.1 - Hazardous Substances.  Consultation with the workforce, including any elected health and safety representatives, must take place in accordance with requirements under the Occupational Health and Safety Act 2004. For more information on welding fumes, take a look at the following links: https://youtu.be/0tvrOw18Vr0?si=oK_v3vkbGebCzuMf Controlling exposure to welding fumes | WorkSafe Victoria Compliance code: Hazardous substances | WorkSafe Victoria - Welding fumes | Safe Work Australia