What are the top 10 pattern causes of death and serious harm at work?

The following article is a news item provided for the benefit of members. Its content does not necessarily reflect the views of the Australian Institue of Health & Safety.
Thursday, 2 May, 2019 - 09:30
Industry news

There are 10 top pattern causes of death and serious harm at work, according to Michael Quinlan Emeritus Professor of Industrial Relation in the School of Management at UNSW.

Quinlan examined a large array of work-settings and found they applied to everything from aircraft or shipping disasters to amusement parks like the Dreamworld incident as well as Pike River.

He found that the 10 top pattern causes of death and serious harm at work are:

  • Design, engineering and maintenance flaws;
  • Failure to heed clear warning signals;
  • Flaws in risk assessment;
  • Flaws in management systems and changes to work organisation;
  • Flaws in system auditing;
  • Economic/production and rewards pressures compromising safety;
  • Failures in regulatory oversight;
  • Supervisor and worker expressed concerns prior to the incident;
  • Poor management/worker communication/trust; and
  • Flaws in emergency procedures and resources.


“I found the failures also applied to single-fatalities not just multiple fatalities and this point has been reinforced by people I have met, researched with or worked with,” said Quinlan, who was speaking ahead of the Safety Institute of Australia’s 2019 Dr Eric Wigglesworth AM Memorial Lecture, which will be held on Tuesday 21 May at Sydney’s Darling Harbour.

“The 10 pattern failures apply because in a way they represent the generic failure points within human organisation, where and why the elaborate defence mechanisms were built breakdown and therefore what we need to target to avoid this.”

There are a number of steps to follow in building safer workplaces across a range of industries, Quinlan added.

“First, failure can be a great teacher of how in practice human organisations fail and why,” he said.

“Problem solving relies on identifying patterns/repetition because in terms of risk-management we can only deal with patterns not entirely aberrant events.”

Quinlan said the problem is major incident investigations are too often treated as unique and while every incident has some distinctive feature it is the commonalities, the similar events in the past, that help to identify what is critical if things are too change.

“I am not a fan of the Black Swan hypothesis,” said Quinlan, who also wrote Ten Pathways to Death and Disaster: Learning from fatal incidents in mines and other high hazard workplaces (Federation Press, Sydney).

“In all the incidents I have examined the incident was predictable and prevention practical – almost all involved clear warning signals prior to the event and compromises to key systems due to a combination of profit/production overriding safety, disorganisation and failures in existing regulatory oversight.”

Second, Quinlan said the 10 pathways also provide an audit-checklist which can be used to identify, investigate, assess and redress limitations known to cause serious harm.

This includes determining what needs to be done to build more robust and sustainable safety programs – which can also be extended to the area of health.

“Reasons notion of latent failure and his Swiss-Cheese model is a valuable tool in understanding how catastrophic events occur even where defence in depth is in place,” he said.

“What my work does is identify which latent failures are repeatedly responsible for such disasters helping to focus attention.”

Quinlan explained that industry, regulators, training providers and unions are using 10 pathways to do this, and demonstrating it is practical.”

Third, as Andrew Hopkins has noted, the more thorough the investigation into incident, the more pattern failures are found.

“Pike River is a good example – it was thorough and found all 10,” said Quinlan.

“The more you have the more likely the incident is and the more ‘catastrophic’ the organisational failures.”

Having said this, two failures – namely production/cost pressures and regulatory failure – can be seen to contribute to other failures such as ignoring warning signals.

Quinlan said these failures are hard because they require courage and application, and a commitment to social sustainability “which might annoy some powerful interests”.

“However, we need to address all the failures, not just the easier ones,” he said.

Quinlan’s book also warned about the need to distinguish between routine and catastrophic risk in terms of minimising harm, and the limitations of both top-down systems and an over-emphasis on behaviour management.

“While the latter are popular, especially given how fashionable psychology is today, and have their place if you don’t deal with the underlying structural causes no amount of behaviour modification will paper over this over,” he said.


Michael Quinlan Emeritus Professor will be speaking ahead at the Safety Institute of Australia’s 2019 Dr Eric Wigglesworth AM Memorial Lecture, which will be held on Tuesday 21 May from 6.00pm – 8.30pm at Park Royal Hotel in Sydney’s Darling Harbour. The Dr Eric Wigglesworth AM Memorial Lecture is presented in conjunction with the SIA’s Annual Education Awards. This year, the lecture coincides with the SIA National Health & Safety Conference which will be held from 22-23 May at the International Convention Centre Sydney. For the full interview with Professor Quinlan please see the June edition of OHS Professional magazine.