Vaal Reefs Disaster

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were insufficient and recommendations were made to sure up the defence (vula vala system-works in a similar way to an air lock door system). The Mine Manager at the time did not act on the recommendations made by the shaft safety expert and instead is recorded blatantly contradicting his opinion and stating that arresting mechanisms are sufficient. Shortly after the audit the Mine Manager delegated the important decision of shaft safety to the relevant shaft engineer. The most probable reason for the Mine Manager’s disregard of the experts recommendations is that existing arresting devices were believed to meet ‘Mine Standards’, standards that in actual fact did not exist and the only existing gauge of arresting ‘standards’ were comparisons made to the rest of the industry. This latent failure stems from a governmental level and the fact that they had yet to define the correct arresting configuration. However there is an additional latent condition within the mine’s management to be complacent about the incumbent arresting mechanism and that it is sufficient as it meets the unofficial ‘industry standards’. The fact that the arresting system was insufficient is arguably the root cause of this disaster. Regardless of the condition of the locomotive and actions of the driver, if here was an effective mechanism in place to arrest a runaway locomotive headed toward the shaft, that accident would have not happened. The attitude of management in this case is reactive; an attitude that sews the seed for accidents to occur. Attempts were made to cover up the causes of the accident. An aeroplane sprag was placed in position after the accident and after the midnight meeting, the Foreman Electrician countersigned job request sheets and maintenance log books for the locomotives that had not been filled in at the time.

Poor health and safety systems- There are many examples of management and personnel at this mine presided over reactive safety systems. One example of a latent condition within the mine was with the inadequate in the testing of the redesigned arresting devices installed post the 1992 accident enquiry. Tumbler stop blocks were implemented after the accident, following ‘successful’ testing that consisted of hand pushing material carts into them. This clearly is not a suitable test for the integrity of the safety device and does not replicate a realistic situation where the locomotive is travelling under its own power. Several months after installation of tumbler stop blocks, it was being noted by the section engineer that the tumbler stop blocks were not user friendly and were being left permanently open by operators by placing a heavy object on the handle. Additionally, it was noted that they were requiring frequent maintenance. The section engineer scheduled for them to be replaced by by more user friendly RSJ stop blocks that required less maintenance. On the day of the accident, holes for the new RSJ stop blocks had been installed however the RSJ members were still yet to be supplied. In short, management had permitted the use of locomotives on that level even though this safety mechanism was not in place. Responsible management would have either not allowed locomotives to operate while the RSJ members were not in place, or they would have found a suitable temporary device to allow operations to continue safely. There should have been a safety regime at the mine that that could stop this sort of safety contravention, unfortunately however there was nothing of the sort in place. This again showed the reactive nature of the employed safety system.

Poor Communication- There are two examples of were lapses in communication between employees at the mine increased the probability of accidents at the shaft occurring. The report into the accident in 1995 noted that ‘shaft accidents’ throughout the mine were not communicated and circulated to other those working in other shafts so that necessary action could be taken to prevent repeat occurrences. Also, the locomotive driver of the morning shift failed to communicate the issues with the working condition to the incoming shift. This latent condition of poor communication meant that the health and safety mechanisms were not going under a process of continual improvement.

Accident Prevention

To summarise, Vaal Reefs is an underground mine transport disaster that resulted from all the safety devices being defeated. There were a vast number of human errors that played a part in the build up the of the accident and it would be difficult to attribute a single direct cause. Sadly, in the case of this disaster many of the active errors were intentional, cultural failures indicating it was the norm not to follow the rules. These sorts of human errors must be seen in context of the whole operation the procedures in place designed to overt these failures. Given this fact, the next thought one has is why is it the case that there was a culture not to follow the rules. The manifestation of latent conditions at various points within the mine’s operation facilitated the many of the active failures. A good analogy for this is given by the ‘Swiss Cheese Model’ (SCM), a model for developed by Professor James Reason at the University of Manchester. The SCM models the trajectory of a pathway to incident as moving from potential hazards to accidents. Between these two points are ‘layers’ of swiss cheese. The layers represent safety measures in place or training. The ‘holes’ in the layers can be represented by both active and latent conditions. The most important condition is the latent condition; until you solve the latent failures, active failures (and therefore accident triggers) will prevail. Good safety management is about eradicating as many of these ‘holes’ as possible. The best way to prevent accidents, like this one, is to have a good health and safety management system. A systems approach to safety has safety as the outcome as a result of good risk management. The system in place was much more numerical, which leads to a loss of control of safety management.

The Vaal Reefs disaster took place during the Leon Commission, an inquiry into the safety of mines in South Africa. The commission ranked 80% of mines in SA as 4-5 star in terms of safety (the highest) (Stanton, 1995); Vaal Reefs was given a 5 star rating. This show that a numerical safety system (like the one in place at Vaal Reefs) is ineffective at preventing mine disasters. A management system in the mining industry is a good set of mining engineering and management activities that provide the right equipment and materials to the right people, who are using the correct methods in a well supervised and working environment that is fit for purpose (Joy, 1999). A management system can be broken down into policy, organising, planning, measuring