A root cause failure analysis of coal dust explosion disaster – Gaps and lessons learnt

Abstract

Workplace accidents are mostly the result of a combined effect of unsafe acts and unsafe conditions which cause ultimate failure of the existing defenses in the system. The unsafe act or unsafe conditions, task environment and task conditions are the product of some dormant, passive and latent causes generated from the organizational factors. But in accident prevention strategy at the workplace, the major thrust is often put on human behavior behind the unsafe acts. In this paper, an in-depth analysis of a mining disaster in India, as to “Why” and “How” the accident did happen has been carried out and the sequence of events was shown by an Event Sequence Diagram.In this article, efforts have been made to identify the root causes of this accident using an accident causation model like the Accident Causation Tree (ACT) and the Swiss Cheese Model, thereby improving the understanding of the mechanism of the accident. The most important aspect of accident analysis, i.e. the key lessons learned from this accident, has also been identified for the benefit of the industry.