Coal Age

JAN-FEB 2017

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48 January-February 2017 legally speaking Let's Wake Up to the Dangers of Drowsiness by avi meyerstein Late one night this past September, two miners at a West Virginia coal mine got into a Ford F-150 to head home at the end of their shift. As they traveled down the mine access road, the driver apparently lost control of the truck. The truck collided with the roadside berm and rolled over, injuring the driver and kill- ing the 46-year-old passenger. It was 2:25 am. Earlier that same month, a 23-year vet- eran haul truck operator at a granite quarry in North Carolina showed up at work hap- py but tired. He reportedly told co-workers that his daughter had just given birth to his first grandchild, and he had been up all night. Later that afternoon, he was driving his Caterpillar haul truck back to the pit when suddenly the truck "veered from the right side of the haul road to the left." The 33-ton truck traveled through the haul road berm, over the highwall and down 150 feet into the pit below. The truck landed upside down, throwing the 58 year-old driver from the cab and killing him. MSHA said its investigators couldn't find anything wrong with the truck. They said it is likely that the tired driver fell asleep or became distracted. Nonetheless, based on past investigations, it is unlikely that MSHA's final conclusions, when com- pleted, will find fatigue as the cause. These are just two examples in one month of how deadly miner fatigue can be. With advances in safety technology making cars, trucks, and machines safer and more reliable mechanically, it is increasingly the human factor, including errors by drowsy or distracted operators, that remains the greatest safety challenge. With shift work, round-the-clock op- erations, and ample heavy equipment, one would expect the dangers of fatigue at mines to be at least as significant as in other sectors. But, search for "fatigue" or "sleep" on MSHA's website, and one might be sur- prised by how little the issue comes up in accidents and guidance. MSHA has published a handful of periodic reminders, information sheets and training modules about preventing sleep-related accidents. These materials of- ten advise taking frequent breaks, rotating jobs and cross-training workers to avoid boredom, adding crew members to provide relief, providing sufficient time off for em- ployees to rest, and monitoring employees for signs of fatigue or stress. What is remarkable about these ma- terials is that they seem to lack any actual data about fatigue's effects in mining. They cite statistics about the general American workforce, U.S. highway accidents, and even workplace accidents in Germany. But, they offer no information about how fa- tigue causes incidents at U.S. mines. In fact, the data may not even exist. There appears to be few mentions of fatigue or sleep-deprivation in MSHA fatal accident reports online; only a half-dozen such re- ports appear to even touch on these issues. Those few that do seem to sidestep the sig- nificance of fatigue as a true root cause of an accident. When evidence emerges that a miner was exhausted, operating on very little sleep, and/or observed by co-workers falling asleep at work, MSHA seems to ulti- mately conclude that the root cause of the accident was that "management failed to ensure" training, monitoring, or that the per- son "could safely operate" the equipment. Why isn't fatigue more visible an issue, and why doesn't it seriously emerge in acci- dent investigations? Experienced mine op- erators might speculate that MSHA seems forever reluctant to conclude that an indi- vidual miner may have made a mistake or succumbed to physical human weakness as a cause of an accident. Many mine oper- ators believe that MSHA approaches every accident as someone's fault, particularly the mine operator's fault. This is not about "blaming the min- er." Rather, it is about identifying the root causes of accidents so everyone can work to prevent similar accidents in the future. It is certainly reasonable to expect that management and system failures would be responsible for some accidents. But, it is unreasonable to assume they are always the cause and that simple human error or physical impairment never is. Whatever the motivation, it appears that MSHA simply may not be looking for fatigue issues. MSHA's classification of dif- ferent types of accidents doesn't seem to include a category for any sort of fatigue, inattentiveness, distraction or user error. The pickup truck running off the road in the middle of the night is classified as a "powered haulage" accident, rather than a case of drowsy driving in a personal pick- up truck. Indeed, the agency instructs its inves- tigators to identify the "direct," "indirect" and "root" causes of accidents. But, MSHA's Accident/Illness Investigations Procedures Handbook's discussion of causation makes no mention of fatigue or inattention. "Hu- man actions or inaction" can only be con- sidered as indirect causes of an accident. In MSHA's world, root causes, by con- trast, are all about management failures, even when the accident is obviously at- tributable to an unsafe action by a miner. MSHA's handbook says, "Most root causes can be attributed to one of the following lapses in the operator's safety management program." Last on the list of those individu- al failures-turned-management violations is a failure of "capacity," including "physical ability," "concentration" or "habits." To be sure, sleepiness at work is a tough problem to crack. It's difficult to know ex- actly when someone has crossed the line into dangerous drowsiness, and it can be extremely challenging to prevent. Each person needs different amounts of sleep. Many are drowsy from restless or interrupt- ed nights despite making every responsible effort to get sleep. Many are tired for entire- ly virtuous reasons, such as working hard and taking care of their families. Drowsiness is even more difficult for an outside observer to detect, especially after the fact. Unlike drugs and alcohol, there is no widely accepted standard for testing or determining impairment (al- though some tools are available and under study). Without looking for fatigue, raising awareness about its dangers, and calling it out when it occurs, it will be very difficult to increase vigilance by mine operators and miners alike.

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