This is why accidents happen on mines and people die: ten silly little things happen; each is trivial and insignificant in and of itself; but they all align in just the right way; and then there are one, two, three, and four people dead. The blame lies with every one of the ten people who let each of the ten silly little things happen, even though each of them is as innocent of ill intent as new snow. And not one of them is guilty of classic negligence.

This is a puerile statement of the profound thesis that incident control eliminates fatal accidents. In short if you want a safe work place you must manage trivial incidents in a no-fault environment. We can all manage and eliminate trivial incidents. None of us can control the conjuncture of ten incidents and the horrible death of many.

This perspective is glaringly absent from a news report (at that I have just read on the death of four people last April at the Sullivan Mine in Kimberly, BC. In the report you have a Capilano College professor assigning the deaths to the design of a sump that filled a shed with oxygen-poor air. You have the official report coming to the profound conclusion that the conjuncture of circumstance that killed the four has never happened before, so that everybody is beyond reproach. Then we have a UBC professor (whom I know and like) saying it is all the fault of putting clay over some waste rock dump downdrains. To all of this, one can only reply: FIDDLE-STICKS.

I am no expert on the accident, I have not seen the site, and I can barely read the scribbles that constitute the official accident report (available if you have patience to wait for it to download at .) So in due modesty I should have no opinion. But that is not my want or wit, so here goes. Stand by and if you do not like what I write and conclude, comment below and prove me wrong. Please, however, do not depose me as an expert, for I am not an expert.

Seems the ten things that went wrong include:

  • A questionable sump design
  • Absence of air quality inspection before entering a confined space
  • No buddy system in place or operative
  • Failure to observe access protocols by the mine
  • Failure to observe access protocol by the first consultant to die (did he or his company have a valid Health and Safety Plan for this activity?)
  • Untrained mine workers poking around the shed (dead as a result)
  • Untrained rescue workers (who themselves got killed—damn we were taught to avoid that error twenty years ago in Health and Safety classes.)
  • “Unexpected” consequence from common-old-garden covering of downdrains as part of dump covering
  • Management failure to enforce safety regulations
  • Unexpected buildup of foul air in a shed.

Of course there are probably additional trivial incidents that contributed to this tragedy. But the list above makes my point. If just one of the trivial incidents had been prevented, people would be alive today.

Not the least of the tragedy is the continued obfustication by all. I do not understand BC's inquest process, so I do not presume to predict the thoroughness of its investigations, but you know it will not be smooth sailing when the most entertaining spectacle is university professors dueling in public. This is not the way it should be. The inquest should be thorough, public, well documented, and should place blame where blame belongs, which in this instance sadly appears to be almost everywhere.

Meanwhile I cannot help but wonder if the families of those killed have retained lawyers. Serves us all right if they have to in order to get to the truth and to get recompensed. This story reminds me of a picture book from my early boyhood. It was a series of colorful pictures of ten kids running free and happy; then they stopped to play around a palm tree; they joined hands and circled the tree; faster and faster they went in the increasing heat; and hotter and hotter the day became; and soon enough they all melted to a pool of pure yellow butter; and the tiger came and slurped up the butter and went away with a smile on his face. You draw the parallels if you will, or post a comment below.