Root causes of coal mine accidents: Characteristics of safety culture deficiencies based on accident statistics

Process Safety and Environmental Protection 136 (2020) 78–91

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Root causes of coal mine accidents: Characteristics of safety culture deficiencies based on accident statistics Jiangshi Zhang a , Jing Fu a,b,∗ , Hongyu Hao a , Gui Fu a , Fangchao Nie a , Wenyue Zhang a a b

School of Emergency Management and Safety Engineering, China University of Mining and Technology (Beijing), Beijing, China College of Resources and Environmental Engineering, Jilin Institute of Chemical Technology, Jilin City, 132022, China

a r t i c l e

i n f o

Article history: Received 7 June 2019 Received in revised form 10 January 2020 Accepted 17 January 2020 Available online 22 January 2020 Keywords: Coal mine accidents Safety culture Accident statistic Safety communication Safety participation

a b s t r a c t Coal mine accidents pose a serious threat to miners and the surrounding environment. Despite a recent downward trend in the numbers of major accidents and casualties in Chinese coal mining enterprises, accident reoccurrence remains an on-going issue for the industry. This paper aims to identify the root causes, namely, the characteristics of safety culture deficiencies driving typical coal accidents. Using the accident analysis pathway of the 24Model and the logical thought of Why Because Analysis (WBA), 67 typical major accidents (gas explosion, gas outburst, flooding and fire) are analysed to identify the deficiencies in safety culture based on the determinations of the safety culture dimension and statistics of recurrent accident patterns. The related elements and occurrence frequencies of the deficiencies in safety culture can be inferred as follows: ignored safety laws and regulations (frequency is 100 %), unrealized safety priority (100 %), limited role of functional departments (86.6 %), and insufficient attention to safety education for special operation personnel and mining workers (80.6 %), among others. These characteristics are not concerned with accident types, and the most prominent characteristics are manifested in four aspects: unrealized safety priority, flaws in management actions towards safety, passive safety compliance and participation of employees, and imperfect work conditions. Specifically, we emphasize the role of departments, safety communication, safety participation and supervision climate in influencing and improving the safety culture to further reduce industrial accidents. © 2020 Institution of Chemical Engineers. Published by Elsevier B.V. All rights reserved.

1. Introduction 1.1. Background Coal mining is recognised as one of the riskiest operations worldwide (Khanzode et al., 2011; Nieto et al., 2014). Coal mining causes many severe problems for both coal mine workers and the surrounding environments (Shi et al., 2017; Mahdevari et al., 2014). In China, coal mine accidents still cause casualties and property losses, despite the recent application of safer modern underground mining methods (He et al., 2019). The results from the former SAWS (State Administration of Work Safety) (EMD, 2018) annual accident survey and reports revealed 495 major accidents and 10,546 fatalities in coal mine industry from 2001 to 2018 see Fig. 1. Coal mine accidents are complex occurrences resulting from the contributions of several elements (Sari et al., 2004). The occurrence of an accident is known to be a chain reaction of multiple adverse

∗ Corresponding author. E-mail address: [email protected] (J. Fu).

events (Fu, et al., 2018), like Heinrich’s Domino theory. The accident “mechanism” is a process by which different factors interact to cause or prevent accidents (Lundberg et al., 2009). To effectively prevent accident recurrence, reliable accident cause analysis is a vital process that can identify hazards in the system and reduce exposure risks, ultimately minimising accident losses and improving safety performance (He et al., 2019). For the analytic process, it is critical to identify root causes to prevent and avoid coal mine accidents from the organisational perspective. Many accidents have occurred because organisations have ignored the warning signs of precursor incidents or have failed to learn from the lessons of the past (Cooke and Rohleder, 2006). The occurrence of coal mine accidents is often interpreted as a result of dysfunctional safety management systems, which may be affected by safety culture deficiencies (Martyka and Lebecki, 2014). 1.2. Safety culture: the root cause of accidents Several studies have described the safety culture as a sub-facet of the organisational culture, which is generally acknowledged to be an important concept that is fundamental to an organisa-

https://doi.org/10.1016/j.psep.2020.01.024 0957-5820/© 2020 Institution of Chemical Engineers. Published by Elsevier B.V. All rights reserved.

J. Zhang et al. / Process Safety and Environmental Protection 136 (2020) 78–91

Fig. 1. Distribution by number of major coal mine accidents from 2001 to 2018.

tion’s ability to manage the safety-related aspects of its operations (Guldenmund, 2000; Cooper, 2000; Hale et al., 2010; Glendon and Clarke, 2015). Safety culture has been recognised as a crucial factor in influencing the state of safety in enterprises, which provides a global characterisation of some common behavioural preconditions for disasters and accidents in high-risk socio-technical systems (Martyka and Lebecki, 2014; Pidgeon, 1991). Hence, the safety culture as a means of reducing the potential for large-scale disasters and accidents associated with routine tasks has attracted the attention of many industries (Cooper, 2000). For coal mine industries with high risk characteristic in particular, accident investigations have revealed that the safety culture is the core of both accident causation and error prevention. Safety culture has held a much more prominent role in safety management in coal mines. Recently, a large amount of research has focused on the safety culture within high-risk industries for insight into the causation of industrial accidents (Martyka and Lebecki, 2014). Cox and Flin (1998) have indicated that an organisation’s safety culture can be related to accident and incident performance. In fact, after the Chernobyl accident, the safety culture was considered in investigations into the causes of major catastrophes (Martyka and Lebecki, 2014). Some scholars have paid more attention to the function of the safety culture during the process of analysing the cause of accidents (Cox and Flin, 1998). Professor Fu, who proposed the 24Model, an accident causation model, considered the safety culture as the root cause of accidents (Fu, 2013, 2016). It is necessary to adjust the analytic perspective of the coal enterprise safety culture, from the perspective of accident prevention, to explore the role of the safety culture within coal mining enterprises. Safety culture as a research subject, however, is associated with rejective or critical views (Le Coze, 2019). For instance, Le Coze (2017) considered safety culture to be confusing and has proposed that the organisational culture that influences safety is far more appropriate. Silbey and Susan (2009) argued against the mainstream approach of safety culture concerning its dominant rationale as expressed in companies. Some authors indicated the abstractness, subjective and speculative, and negative label effect of safety culture research (Kringen, 2009; Bye et al., 2016; Antonsen et al., 2017). In fact, doubts and arguments consistently exist in the process of any scientific research, which is the driving force for research progress. Some positive views show that the topic of safety culture is interesting and worthy of scientific inquiry given its importance (Guldenmund, 2000; Edwards et al. (2013); Cooper, 2000; Glendon and Clarke, 2015). A typical representative is Guldenmund, who differentiates versions of safety culture and advocates the idea of promoting complementarities rather than exclusivity (Guldenmund, 2000). Edwards et al. (2013); Henriqson

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Fig. 2. Structure of the paper.

et al. (2014), also think that safety culture is a very interesting topic to comprehend, try to understand, and to explain. Safety culture arose from the concept of organisational culture and is fundamental to an organisation’s ability to manage safety-related aspects of its operations (Guldenmund, 2000; Cooper, 2000). Safety culture is a guide to a correct way of thinking, feeling and acting in relation to safety (Krause, 2000; Lee and Harrison, 2000). Safety culture has been recognised as a crucial factor in influencing the state of safety in enterprises, which provides a global characterisation of some common behavioural preconditions to disasters and accidents in high-risk socio-technical systems (Martyka and Lebecki, 2014; Pidgeon, 1991). A positive safety culture can help prevent work-related injuries and major disasters (Frazier et al., 2013). With the goal of improving both occupational and process safety, various industries are exploring the approaches and means to create a fine safety culture. Some scholars have considered that culture might concretely refer to the way employees approach their work, in which the creation of a positive safety culture ultimately means improving on-the-job behaviour (Geller, 2005; Krause et al., 1999). Based on this idea, McSween (2003) proposed strategies on safety culture that often focus on improving Behaviour-Based Safety (BBS). This approach can aid in managing occupational risks and preventing injuries (Staehle et al., 2016). Aliyachen et al. (2016) emphasized that behavioural safety is essential for a safety culture, which can provide an organisational culture among employees to prove their core values towards safety. It is noteworthy that behaviours of employees are not seen as isolated incidences but as part of an organisational environment (McSween, 2003). From the organisational level, creating a positive organisational environment is beneficial for employees to work safely and achieve the purpose of improving enterprises’ safety performance. Therefore, to obtain a more comprehensive and scientific analysis result, our research focuses on the root causes of coal mine accidents to clarify the characteristics of safety culture deficiencies, both from individual and organisational levels (individual level: unsafe acts, habitual behaviours; organisation level: safety management system, safety culture). 1.3. Research frame Basically, measurements of the safety culture require in-depth investigations including an analysis of accident information. To identify critical defects of the safety culture within Chinese coal mine industries, it is necessary to determine a baseline based on statistical analysis of a large number of coal accidents with differ-

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Table 1 Safety culture dimension elements and related meanings. Level

Dimension

Safety commitment (SCo)

Management actions towards safety(MA)

Role of Safety rules and procedures Function of Line management and safety department Demand of Safety education and training Utility of Safety communication

Workers’ involvement (WI)

Ownership of safety Competence

Others (Os)

Importance of work environment Autonomous learning and improvement

Description

No.

The extent to which management is perceived to place a high priority on safety and communicate and act on safety issues effectively (Neal and Griffin, 2004). It refers to communication about safety, managerial participation in safety, support and guidance, allocating resources, policies and decision making, and involving workers (Fruhen et al., 2018). The extent to which safety procedures are perceived to be effective in preventing accidents (Neal et al., 2000), including safety procedures, safety policies and safety rules. Safety is a line responsibility and the safety organisation is a valuable asset in attaining excellence in safety (Stewart, 2002). This part refers to the extent to which the line department and subsidiary take responsibility for safety. (Fu et al., 2009 Fu, 2013). Well-organized and well-worked safety department. The extent to which training is accessible, comprehensive, and available (AQ/T9004-2008, 2009a; AQ/T9005-2008, 2009b). Multiple channels: Top-down and Bottom-up Communication; safety reporting; horizontal communication(Health and Safety Executive, 2005). Coworkers’ support and interaction (Brondino et al., 2012). Ownership of safety refers to an employee’s sense of responsibility for, and empowerment towards, safety (Health and Safety Executive, 2005). The general level of workers’ qualifications, skills and knowledge (Flin et al., 2000), involving risk perception, emergency capability, etc. Risk perception means self-reported risk taking, perceptions of risk/hazards on the work site, and attitudes towards risk and safety (Flin et al., 2000). Emergency capability is the ability of the organisation or staff to quickly recover from an emergency to a safe status (Fu, 2013). Personal protective equipment, workplace’s safety situation, machinery’s safety state and accident records and workers feelings about it (AQ/T9004-2008, 2009a; AQ/T9005-2008, 2009b). Consistent implementation of safety systems and sustained improvement of safety performance (AQ/T9005-2008, 2009b).

A

ent types in the past, from which safety management strategies are developed. The study is organized as indicated in Fig. 2. This paper explores the root causes of coal mine accidents to clarify the characteristics of safety culture deficiencies and propose positive suggestions based on the results of accident analysis. The first step aims to synthesize the existing disparate literature on safety culture and safety climate, focusing on information about dimensions, which is the basis for exploring safety culture deficiencies. The second step is data collection and statistics of coal mine accidents to determine the analysis sample and to clarify the present situation of coal mine accidents and necessity for the research. The most important step is to analyse the deficiencies in safety culture and then infer characteristic rules. The WBA24Model (combination of Why Because Analysis and 24Model), an analysis and investigation methodology of accident causation, is developed to explore the root causes of 67 serious coal mine accidents. We then discuss the influence of key characteristic factors in safety culture deficiencies for the overall safety culture of coal mining enterprises.

2. Methods 2.1. Safety culture dimension The determination of the safety culture dimension plays an important role in measuring the function of the safety culture within enterprises. The objective of this part was to develop a structure of safety culture. A comprehensive literature search was undertaken using Science Direct, Web Science, ELSEVIER, and CNKI as the host databases and then searching keywords such as “dimension, structure”. Additionally, we used Google Scholar to identify additional cross-discipline literature. A total of approximately 110 publications that contributed commentary, theory, or empirical research concerning the safety culture were selected. Sixty-eight foreign and Chinese publications with a strong correlation with this study were examined in detail.

B1

B2

B3 B4

C1 C2

D1

D2

Numerous literature has been devoted to measuring safety culture and identifying its relevant components (Cooper, 2000; Hurst et al., 1996). Since the 1980s, research has shown that several dimensions are important to consider when conceptualising and measuring the safety culture Barbaranelli et al. (2015). Safety commitment is the prime theme and has been mentioned in many studies. A secondary very broad theme is employee engagement, also be known as worker’s involvement. Moreover, concerns about the procedural features of the safety system (e.g., training, compliance, and communication) are included in these common safety culture dimensions (Lin et al., 2008). Factors related to the work environment appear in several surveys, as well as continuous improvement, which is now widely regarded as a crucial component of a sound safety culture (Mannan et al., 2013). Research now suggests that different types of industries are likely to have unique safety culture dimensions (Stemn et al., 2019). For Chinese coal mining workers, their beliefs, perceptions, attitudes towards safety and whole background cultures are different from workers in other industries and other countries (Lin et al., 2008). Therefore, the safety culture of the present organisation might well be different. We first combine previous measurement tools for safety culture with the Chinese background; then, we develop a tool to measure attitude and perception about safety as an indicator of safety culture among Chinese coal mining workers. The safety culture dimension was obtained from a great deal of domestic and foreign literature, which is not only in accord with international advanced research concepts but also meets the actual situation in Chinese enterprises. The safety culture dimension elements and related descriptions are presented in Table 1. 2.2. Data collection and statistics Because an organisation’s safety culture can be related to accident and incident performance (Cox and Flin, 1998), it is an effective means to find defects in the safety culture based on an accident analysis. An important technique to explore the root causes of accidents, as referred to by Andrew Hopkins (2006), is to uti-

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Table 2 Number and death toll of different types of major coal mine accidents from 2001 to 2018 (death toll ≥10). Type of accidents

Number

Death toll

Illustration (SACMS, 2018)

5692 1333 0 52 1741

Gas (coal dust) explosion (combustion, coal (rock) and gas outburst, hypoxic asphyxia and poisoning caused by gas.

Flooding accident

226 81 0 3 94

Fire accident Roof accident

37 13

757 148

Transport accident Blasting accident Other accident

8 3 30

107 41 675

Total

495

10546

Gas accident

Gas explosion Gas outburst Gas poisoning Gas asphyxia

lize the wealth of material assembled by inquiries into major accidents. Reason (1997) previously mentioned that multiplecase investigations are typical in determining the safety culture of organisations with high accident indicators, where serious accidents have occurred. Thus, we can obtain some accident information from accident investigation and analysis reports, which can be used to provide insights into the defects of a safety culture within an organisation. Although the mining processes in China have greatly improved during the past few decades, casualties and property losses still occurred in coal mine industry from 2001 to 2018. The number and death toll of different types of major accidents are shown in Table 2. Types of coal mine accidents are classified according to the requirements of “Report and Statistical provisions on casualties of Workers in Coal Industry” (RSPC, 1995), which focuses on the production characteristics of the coal mine industry. Accident statistics data and information can be found at the website of Ministry of Emergency Management about accident investigation reports, “Experts Comment on Chinese Coal Mine Accidents” and “Compilation of Coal Mine Accident Cases” published by State Administration of Coal Mine Safety. As shown in Table 2, the four types of major coal mine accidents (gas outburst, gas explosion, flooding and fire) happened 438 times, accounting for 88.48 % of all major accidents during this period. Therefore, in this paper, we have focused on the statistical data for these accidents. The statistical rule for the four types of major accidents (only considering the criterion of one death toll ≥10) from 2001 to 2018 is presented in Fig. 3. According to the statistical results, 310 serious gas accidents occurred and 7077 people died, accounting for 62.63 % and 67.11 % of the accident statistics, respectively, from 2001 to 2018. Gas accident control is the key to prevent serious accidents, which can serve as a pattern for case analysis. 2.3. Analytic method and cases In an effort to further reduce rates of major accidents, the root causes (safety culture deficiencies) associated with accidents need to be identified and then addressed. The accident investigation and analysis are often seen as rational processes of discovering causes and then fixing the most important causes (Lundberg et al., 2012). In the process of accident cause analysis, most accident information can be obtained from the official accident investigation reports. As the same accident cannot recur, we can only deduce some information via scientific analytic methods based on the investigation reports. These relatively true and reliable sources of information and data are very useful for accident analysis, via which we can directly identify unsafe acts and conditions. Other causes can also be partly found from the

Caused by surface water, gob water, geological water, industrial water and accidents caused by permeable yellow mud and quicksand Caused by spontaneous combustion of coal and gangue and external fire Roof fall, rib spalling, roof support collapse, rock burst, slope slip and collapse in opencast coal mine, etc. Transportation equipment (facilities) accident during operation. Blasting result in fatalities, trigger blasting Except for above 7 type accidents, such as coal dust explosion, carbon monoxide poisoning, Hypoxic asphyxia —

official investigation reports by searching for key terms, such as “lack of awareness of laws or regulations/risk perception. . .”, “limited operational/emergency. . .knowledge”, “management systems/ documents. . .training deficiencies” etc., which include flaws in safety knowledge, awareness and habits of individuals and deficiencies in safety management system and safety culture. However, because coal mine accidents possess some degree of uncertainty and variability in occurrence, it is impossible to obtain all the information by only reading text on the report. Another effective way to identify hidden causal factors is to conduct reasonable inferences. Lundberg et al. (2009) mentioned that accident investigation and analysis should focus on assumptions about how accidents happen and the important underlying factors. The sequential occurrences of multiple adverse events result in the accident, and the causal factors in different accident categories are identified using a specific process (Fu et al., 2018). The accident analysis procedure and pathway, named 24Model in Fu et al. (2017b,2018), suggests a systematic attempt to describe behaviours that cause accidents. Additionally, the logical inference process of accident cause analysis adopts the idea of WBA, which is a rigorous technique for causally analysing the behaviour of complex technical and sociotechnical systems (Ladkin, 2020). The primary application of WBA is in the analysis of accidents based on “one event or status is a causal factor in the occurrence of another”. This thought coincides with the basic idea of 24Model (Fu, 2015). Therefore, based on the information provided accident reports, applying accident analysis pathway of 24Model and the logical thought of WBA, a systematic logical inference process of accident causes analysis can be described, as shown in Fig. 4. Determination of analytical elements in each module is mainly based on the study of Fu (2013,2016). ISO45001, Work safety Law, Coal Mine Safety Regulation, Anti-outburst and other coal minerelated regulations are applied as criteria to restrict the scope and contents of the cause of the safety management system. The subcategory in the SMS module is shown in Fig. 5. Adhering to the analytic steps and causal categories, we take a coal and gas outburst accident as an example to analyse the deficiencies in safety culture. The analytic process can be described as beginning with bad outcomes and then examining individual and management causes until the safety culture weakness is identified (see Fig. 6). It is worth emphasising that unsafe acts refer to acts with a significant (direct or indirect) impact on the accident (Xueyu and Fu, 2018) . The generator of unsafe acts is not only the direct operator who caused the accident but also the staff at all levels of the organisation (Fu et al., 2017a). Manager violations during command, operator violations in blasting and gas inspector violations are considered unsafe acts, which are caused by inadequate individual competence, such as safety knowledge, safety awareness, and safety habits. Invalid implementation of “knowledge”,

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Fig. 3. Number distribution of the four types coal mine accidents from 2001 to 2018.

Fig. 4. The logical analytic process of accident causes.

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83

Fig. 5. The subcategory in the SMS module.

Fig. 6. Analytic process to identify safety culture deficiencies.

“qualifications”, “awareness” and “habits” could lead operators and managers to fail to control hazards (Fu et al., 2018). Deficiencies in organisational safety management systems can be further inferred. Flaws in safety knowledge and consciousness are due to a lack of safety training and education for every level staff in enterprises, in both form and content. This lack of safety training also resulted in a failure to implement rules and regulations, the ambiguous responsibilities of departments, etc (Xueyu, 2018). The issues in the management system indicated weaknesses in the safety culture, such as inadequate training and education processes, such as procedures and contents for employees, resulting in situations in which managers neither put safety first nor demonstrate a commitment to safety. All accident causes are ultimately attributed to safety culture deficiencies (Fu, 2013).

3. Results In accordance with the statistical information for accidents, 67 particularly serious coal mine accidents, consisting of four types (only consider the criterion of one death toll ≥30), are selected and systematically analysed to find the defective elements of the safety culture. The sample information for major accidents is shown in Table 3. According to the results of the accident cause analysis and other related information, the total frequency and ratio distribution of safety culture defective elements are shown in Table 4. The deficiencies of the safety culture can be described as specific performance forms through key words and phrases in accident reports. From accident reports, the concrete manifestation of each defective element of the safety culture is determined. The 67

84

Table 3 The basic information for accidents from 2001 to 2018 (death toll ≥30) (SACMS, 2018; Yin et al., 2017). Number

Percentage/%

Death toll

Percentage/%

Enterprise ownership type State- major

State- Location

Township

Gas explosion

44

65.67

2662

73.76

14

7

23

Gas outburst

7

10.45

269

7.45

2

0

5

Coal mine flooding

10

14.93

465

12.88

2

1

7

Coal mine fire

6

8.96

213

5.90

0

3

3

Total

67

—

3609

—

18

11

37

Province distribution

Accident site (Terms relating to coal mining (GB/T 15663-2008))

Shanxi(13), Heilongjiang(7), Henan(5), Shaanxi(4), Liaoning(2), Hebei(2), Jilin(2), Jiangsu(1), Sichuan(1), Guizhou(1), Anhui(1), Jiangxi (1), Xinjiang(1), Chongqing(1), Yunnan(1), Inner Mongolia(1) Henan(3),Yunna (1), Chongqing (1), Guizhou(1),Hunan(1)

Heading face: 16, Working face: 15, Gob: 5, Cross-cut: 2, Main haulage roadway:2, Sublevel roadway: 2, Drain sump: 1

Shanxi(2), Guangxi(1), Inner Mongolia(1), Henan(1), Guangdong(1), Jilin(1), Guizhou(1), Shandong(1), Sichuan(1) Heilongjiang(2), Shanxi(1), Guangxi(1), Jilin(1), Hunan(1).

20

Heading face:4, Return airway heading face:1, Working face:1, Haulage inclined shaft:1 Heading face:4, Heading face of return airway:3, Working face: 3

Vertical shaft:2, Sublevel roadway:1, Material storage:1, Underground substation:1, Horizontal shaft winch chamber:1.

J. Zhang et al. / Process Safety and Environmental Protection 136 (2020) 78–91

Category

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Table 4 The frequency and ratio distribution of safety culture defective elements. Level

Element

Key words and phrases in accident reports

Frequency

Percentage/%

Safety commitment

—

67

100

Management actions towards safety

Role of Safety rules and procedures

Failure to implement safety production policy and gas control policy; Safety is not the priority; Improper handling the relationship between safety and work; Ignore supervision orders, specifications and major hazards; Insufficient safety investment; Ignore the importance of safety education and training; Lower degree of valuing safety: high pressure for production (Arbitrary expansion of production; Cross-border mining; Production with overloading capacity, intensity and personnel). Failure to implement safety production responsibility system; Illegal cross-border mining; Illegal organisation production; Illegal risk-taking operation; Illegal use of equipment and processes prohibited by the State; Failure to comply with Safety Work Law, Coal Mine Safety Regulations, Rules for Management of Dust Prevention, Gas Prevention, Fire Prevention and etc; Unsound safety production responsibility system; Imperfect management system; Unclear duty assignment (multiple positions: group leader and technician or safety practitioners); Inappropriate organisation structure (Unreasonable post allocation system and insufficient special staff members, such as gas inspectors, bursting workers and etc., full-time safety practitioners and technical personnel); Imperfect emergency management system. Failure to implement technical management; Imperfect equipment and facilities operation management; Backward mining mode; Unreasonable allocation of duties and work contents for first-line personnel. Failure to implement safety management measure and hazard or risk identification and control; Management confusion; Not timely emergency response; Incomplete safety inspection (about operational aspect of ventilation facilities, explosion-proof performance of equipment and facilities, self-rescue equipment and other aspects); Only contracting and not managing for cooperative units. Insufficient education and training of special operators and underground operators; Lack of systematic job training; Inappropriate training contents.

67

100

58

86.6

54

80.6

24

35.8

56

83.6

52

77.6

18

26.9

50

74.6

Function of Line management and safety department

Demand of Safety education and training Utility of Safety communication

Workers’ involvement

Ownership of safety

Competence

Others

Autonomous learning and improvement Importance of Work environment

Misinformation; Concealing report; Missing report; Imperfect system of hazard reports, accident early warning report, emergency process, and production site issue report and feedback. Enterprise staff also contain workers of cooperation units: follow blindly (violation operation of workmates or contractor workers), subtle influence by following action: failure to perform safety duties and safety work, failure to abide by safety management system and operation rules of enterprise. Lack of compliance behaviour and responsibility: violation operation, not wearing self-rescuer, underground smoking, gas inspector leaves post without authorization, violation operation without opening ventilator; Failure to implement “burst with three phase inspections”; Failure to perform one’s duties; Special operators without license. Poor vocational skills and safety qualities; Low level of education; Lack of operational capability for special equipment; Low safety awareness and risk perception; Unaware of the importance of complying with detecting gas density regulation before powder charge, before burst and after burst; Ignore the environmental changes before accidents; Unknown the importance of wearing self-rescuer; Not understand the severity of violation burst; Ignore the forewarning of an accident and then violation operation, mining or commanding; Oversight of major coal mine hazards. Fail to implement requirements of new safety laws and regulations; Lack of continuous update of safety rules and procedures; The new safety theory and knowledge are not mastered in time. Work environment: Incomplete management test and repair of ventilation equipment& gas detection equipment; Imperfect ventilation system; Lack of explosion - proof facilities and installations; Unsurveyed hydro-geological conditions.

The extraction of key words and phrases in accident reports is based on the understanding and description of safety culture dimension, and the analysis and elaboration of the specific events in accident reports. For example, according to the idea of the safety commitment “safety is priority”, the description in the accident report “There is a foreboding of gas outburst, and it is still risky to organize tasks” can be condensed to “Ignore supervision orders, specifications and major hazards”.

major accidents mentioned above are liability accidents with the phenomenon of violating national laws and regulations. The characteristics of safety culture deficiencies in coal mining enterprises can be summarized as follows: Safety commitment deficiency Unrealized safety priority Leaders ignore safety laws and regulations Unawareness of the importance of safety production policy and gas control policy (namely, “safety first, mainly preventive, comprehensive management” and “first extracting then mining; monitoring and inspecting, ventilation capacity determine output”)

Neglecting safety in pursuit of economic benefits Unsound procedures and documents of the safety management system Flaws in management actions towards safety Unawareness of the importance to comply with relevant safety rules and procedures Limited role of functional departments (e.g., lack of management institutions, unclear responsibilities, insufficient staffing and lack of supervision of cooperative units) Insufficient emphasis on safety education for special operation personnel (gas inspectors, bursting workers) and mining workers

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Fig. 7. Discussion process of relevant elements.

Passive safety compliance and participation of employees Neglecting the importance of obeying rules, regulations and wearing labour protection appliances Unawareness of the importance of safety knowledge for improving self-protection abilities and safety quality Imperfect work conditions Unawareness of the importance of good equipment performance for safe production, usually with high satisfaction degrees (ventilation facilities, gas detection and other equipment) Oversight of the significance of personal protective equipment Unawareness of unsafe factors in the work environment Any potential defect of a single element will not necessarily lead to unexpected events, but an accumulation increases the probability of occurrence, which is a precondition for accidents. How do these elements affect the occurrence of an accident, what are the details and how is a positive safety culture developed to effectively prevent the occurrence of coal mine accidents? We will discuss these questions in the following sections. 4. Discussion Following the principle of ‘What-You-Find-Is-What-You-Fix’, it is important to clarify the discussion idea, relevance elements and solutions(Lundberg et al., 2009, 2012). We describe an analytic process (see Fig. 7) linking the safety culture and accidents via integration of the safety climate and safety pyramid models (Zohar, 2010; Reason, 1997). 4.1. Practical implications of safety commitment The most important factor determining the safety culture level in an enterprise is safety commitment, which determines the views and behaviours of employees in terms of safety (Griffin and Neal, 2000). Management commitment to safety is a hallmark of a positive safety culture (Lundberg et al., 2012). Management commitment to safety can also be considered essential for success in implementing safety work (Lundberg et al., 2009). The defection of safety commitment may result in a negative impact on enterprise safety performance, and it is found in nearly all statistical accidents. An analysis of statistical results revealed that in all 67 accidents, illegal mining or illegal organisation of production had occurred in enterprises, which was a manifestation of leaders’ failure to address the relationship between safety and production. Failure of the leaders to fulfil their commitment to safety investment resulted in inadequate safety resource allocation of funds, personnel, equipment, etc. The most prominent problems in 28 accident cases are the inadequate allocation of six major systems for coal mine safety and risk aversion (monitoring devices, personnel positioning systems, water supply and rescue facilities, pressure air self-rescue systems, communication and liaison systems, emergency systems). Another form of safety commitment defect is high

pressure for production (arbitrary expansion of production, crossborder mining, production with overloading capacity, intensity and personnel), which occurred in 39 accident cases and is often perceived as a risk factor. When leaders did not prioritize safety or demonstrate a safety commitment, it led to negligence of minor injuries or incidents and then the occurrence of major accidents with serious outcomes. As in the survey results of Rollenhagen et al. (2010), top management had a relatively strong influence on safety in the organisations. To improve safety commitment, leaders should enhance sensitivity to advanced safety ideas, digest the connotations of safety culture guidance, understand the significance of safety as a priority, understand the necessity of safety investments, and embrace behavioural control approaches, among others. It is also necessary for leaders to comply with safety laws and related regulars and then to fulfil these laws in practice. In addition, improvements of leadership and executive power of leaders in the safety management system and their actions are essential, because safety commitment is a process in which leaders fully recognize the importance of safety and implement it in practice. The analytic results of coal mining accident cases also support other research stressing issues related to management commitment to safety. 4.2. Role of management activities Safety culture guides the development and implementation of the safety management system and then affects management activities to directly impact safety (Fu et al., 2017b, 2019). Considering the opposite perspective, the expression of these “deficiencies” as safety culture elements can, perhaps, be seen through safety management practices. The issues in the management system indicate the weakness in the safety culture. Through a reanalysis of accident reports, it was found that the common problems in all accident occurrence enterprises were confused management conditions and less stringent compliance. The frequencies and percentages of specific element deficiencies about other management aspects are shown in Fig. 8. (B2*: Failure to implement an effective safety inspection; B3*: Lack of technology management; B3**: Insufficient managers and technicians; B4*: Lack of occupational training and education. B5*: Ineffective safety communication; “*” denotes an item in the corresponding dimension hierarchy) Effective safety management activities cannot be based on hindsight. These activities must be not only reactive but also proactive (Lundberg et al., 2009). To ensure the safety work of enterprises, line departments have the responsibility to strengthen equipment and technology management. Full exertion of the functional department role and efficiency can effectively reduce accidents and enhance the enterprise safety culture. The specific measures can be expressed as follows: External: between departments

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Fig. 8. Frequency and percentage of specific element deficiencies about management activities.

Distinct rights and responsibilities Effective communication Explicit affairs handover procedure Reasonable problem regulatory mechanism Internal: within departments Efficient organisational structure Reasonable allocation of rights and responsibilities Sound working system Reasonable staffing Perfect information communication Simplified affairs handle procedure Additionally, contractor unit management is also an element affecting enterprise safety culture. In 18 accident reports, it is explicitly mentioned that the enterprises neglect the management of subcontracting units. Random management activities of contract units will have negative impacts on the safety production of project units and then gradually destroy the original safety culture. Contractor unit management must be included in the scope of enterprise safety management. Additionally, it is necessary to maintain management consistency for contractor units and to ensure the supervision responsibility of the enterprise.

4.3. Safety communication A large amount of literature has referred to communication as an important factor affecting the organisation culture. Communication failure is the main human error leading to the accident (Yu and Wang, 2006). However, during the analytic process for coal mine accidents, it is just a simple description, with little mention or a lack of systematic in-depth analyses concerning communication within enterprises, such as hazard reports, accident early warning reports, emergency information transmission, safety conference activities, information on feedback and sharing, and safety suggestions, among others. Sixteen accident reports directly mentioned that workers still worked at risk after the occurrence of accidents, and dangerous information was not reported in a timely manner. Eight accident reports point out information-processing errors and direct feedback delays, which led to a delayed withdrawal of staff resulting in mass fatalities. In fact, more such situations may exist, and almost all accidents involved in risk-taking operations probably have the problem of poor information communication. In China, most state-owned coal mines are undergoing a process of actively constructing and improving the safety information communication mechanism. However, some township collieries, which are also major accident-prone enterprises (accounting for 56.6 % of the total number of statistical accidents), ignore the importance of safety information communication. These enterprises need to

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improve their communication modes and effectiveness of information transfer and feedback. It is useful to adopt an effective communication mechanism and to establish a multi-channel communication path. Single command or two-way command-feedback communication modes of the leadership, manager and staff levels should be transformed to multidirectional communication between, across, and within the hierarchy, and channels of information communication should be opened. An inevitable trend of information communication is to establish a systematic information communication platform and mobile terminal information communication system combined with big data information, based on traditional methods of meeting and talking, propaganda and education, documents and materials, and to supply the information via email, among other modes. Furthermore, some enterprises recognize the importance of coworker influence. Co-workers’ safety had a stronger mediating role in improving the safety culture of whole enterprises, which could promote the safety performance of employees and, in particular, safety participation, as mentioned by Brondino et al. (2012). This factor can be considered a typical form of communication between workers on safety. Perfect co-worker safety requires the participation of the whole staff, which can be motivated via building mutual trust cooperation and communication. The progression from co-worker safety to department safety to organisation safety is a natural influential process. It is our hope to create a perfect communication climate of quick information reporting, timely feedback, information transparency, and the involvement of all staff. As mentioned by Du et al. (2009), effective communication of safety information plays an important role in encouraging employees to participate in safety affairs, obtaining staff cooperation and support and enhancing positive construction of a safety culture in enterprises. 4.4. Effectiveness of employee participation Employee involvement is key for the construction and effective implementation of a safety culture, with the main function being the maintenance of the safety level and improvement of prevailing safety standards. (Martyka and Lebecki, 2014). As described by Geller (1996), during the process of changing the safety culture, shaping safe behaviours of employee is most important. To date, most investigations have shown that the behaviours of workers reflect numerous flaws in relation to the management of their organisation (Brondino et al., 2012). Employee involvement includes safety compliance and safety participation (Neal et al., 2000; Griffin and Hu, 2013), which may be considered as ownership of safety. Analysis of accident reports revealed that the majority of accidents are closely related to a relatively small number of safety behaviours. Based on analyses of 56 accident reports, the delectation of safety compliance can be clearly observed, such as ¨illegal ¨ ¨ operation¨, undetected gas concentration¨, not wearing self-help ¨ equipment¨, c¨ arrying fireworks privately¨, not opening ventilation device as prescribed¨, among others, resulting in a failure to comply with enterprises’ safety rules or regulations and to follow safety procedures. sSafety participation emphasizes the initiative of behaviour and promotes safety autonomy through participation in decisionmaking. Safety participation can be described as active reporting of safety issues, effective safety communication, autonomic learning and suggestions, among others. Sixteen accidents reports mention that employee continued to work at high risk without actively reporting the conditions or quickly evacuating when obvious signs were occurring. Some workers found accidents that had occurred in a local area and then notified other workers to quickly evacuate, reducing some casualties, as described in three accident reports. Employee violation acts of enterprises or contractors cause

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accidents; however, the other employees in the same group do not play a reminding or correcting role. Although autonomous learning and advice are not mentioned in the reports, it can be inferred that employees with passive safety compliance, autonomic learning and suggestions are most likely to have a lower level. Therefore, to take full advantage of the positive effect of employee involvement, it is necessary to stimulate employees’ thinking and wisdom and to enhance their satisfaction and sense of belonging by rationalization suggestion mechanisms, as used in the Toyota Production System. Likewise, certain organisations have also implemented incentives by adding them to the Key Performance Indicators (KPIs) of employees to improve management efficiency (Mohammadfam et al., 2017; Gerbec and Kontic, 2017). Support of incentive programmes to reward personnel at all levels who participate in effective communication and suggestions about updating safety information, hazard identification, early warnings of emergencies or accident investigation, and OHS development, among others, promotes a beneficial influence between workers and managers and subsequent improvements in communication satisfaction between staff at all levels. 4.5. Improvement of external supervision In addition to the above analysis, we also find that the external climate-like safety culture of the overall region affects the work safety situation within coal mining enterprises. Basic information on major accidents shows that Shanxi, Henan, and Heilongjiang are accident-prone areas. Additionally, the numbers of major accidents in these areas account for 51.5 % of the total. Related problems for regional governments or safety administration institutions are highlighted in accident reports, which can be described as not paying much attention to the safety work of coal mining enterprises in the jurisdiction area, a failure to implement the requirements of new safety laws and regulations, an absence of timely supervision and inspection for work safety, and oversight of major hazards. The safety culture of the overall region is not good, which could lead to a disregard of safety work by coal mining enterprises in the region and a poor enterprise safety culture. Furthermore, a poor safety culture of one enterprise will affect other enterprises and hence the safety culture of the whole region, ultimately resulting in a vicious circle. Therefore, the best solution to create a positive safety culture is from both the interior and exterior of the coal mine enterprise. It is important for regional governments to actively communicate and strictly implement relevant state laws and regulations, conscientiously carry out their own supervisory duties, strengthen investigations of major hazards, and then establish a long-term mechanism for safety management. 4.6. Comparison and illustration The purpose of the above discussion is to achieve risk control and accident prevention via the development of strategies to enhance the effectiveness of the safety culture. The safety culture (or deficiencies) is usually perceived as an important force driving safe (or unsafe) behaviours and practices (Lundberg et al., 2012; Sari et al., 2004, 2009) mentioned that in Turkey, the appropriate accident prevention policies, namely, to develop and employ an intervention programme, to take incentive measures and to formulate systematic education programmes for workers, have the potential to improve mine safety. Swedish scholar Nordlöf (2012; Nordlöf et al. (2015) proposed some countermeasures aiming to improve the safety culture and risk control effect, such as “following laws and legislations, adopting regular and systematic audits, using modern safety technology and equipment, with managements priori-

tising safety first.” Additionally, MINEX criteria, with a goal of “zero accidents”, “team-performance”, KPI policy, procedural intervention and other safety strategies, have been proposed for coal mines (MCA Minerals Council of Australia, 1999; Mohammadfam et al., 2017). From another perspective, McSween (2003) noted that application of the Behaviour-Based Safety approach to enhance the safety culture is essential, such as frequent safety discussions and communication, timely safety inspections, procedural documents, training and meetings, management review, feedback and involvement, among others. The aim of this approach is to make workers perform tasks safely to prevent injuries to themselves and others. Compared with the above research results, despite some differences in analytic points and discussion concerns, the realistic goal and certain measures are similar. In fact, there is a need for more effective methods to remedy cultural safety deficiencies, both from specific factor and organisational aspects, in addition to a need for better methods to explain accidents. As described by Rollenhagen et al. (2010), the tactics of organisational change do not simply follow from the causes found in the analysis, which is more important to consider in the organisational applicability. In addition to the mentioned specific aspects concerning strategies for improving the safety culture of coal mining enterprises as a complex organisational system, the operation mechanism needs to have the characteristics of performance variability. It is important to adjust the function of the safety culture from “reactive” to “proactive”, namely, from post-accident reaction to preventive measures with a safety priority. As advocated by leading mining companies or relevant researchers (Hollnagel et al., 2006; Hollnagel and Fujita, 2013; Lundberg et al., 2009; Frazier et al., 2013), organisation should be responsive, attentive, anticipatory and provide experiential learning at all times to promote a beneficial change for the safety culture of coal mining enterprises. However, it should be noted that the safety culture has features associated with resistance to change, such as resourceweak cultures, safety cultures with low priority, among others (Lundberg et al., 2012). Corresponding strategies or rules-of-thumb focus on aspects of remedial actions, thorough explanations, publicity, adaptation to follow-up, among others. The purposes of all the countermeasure activities are to enhance the guidance and preventative role of the safety culture and effectively prevent accidents. Lundberg et al. (2012) emphasized that when safety cultures exhibit multiple dimensions, it is also imperative to examine how the abovementioned strategies, alone or in combination, work in practice. Moreover, there are some more seemingly direct means to help coal mining companies achieve leading safety performance. It is obvious that some countries have been successfully controlling their catastrophic mining risks. America, Sweden and Australia have particularly made great achievements in the prevention of coal mine accidents (Cliff, 2012; Cliff et al., 2017; Chen, et al., 2013; Feng and Chen, 2013; Harris et al., 2014). Specifically, coal mines in America have taken some countermeasures to improve safety performance, which involve adequate safety investments, safety education and training manoeuvrability, advanced production technology and equipment (mechanized mining processes, multi-function computer monitoring systems for underground environments, and computer micro-seismic monitoring systems), better ventilation systems, safety supervision systems with specific authority, the structured hazard-centric system approach concerning the defence-in-depth principle, etc (Zhang and Wang, 2007; Joseph and Amy, 2011; Wei and Chao, 2011; Lööw and Nygren, 2019). Mining in Sweden is no longer a high-risk industry like it used to be (Lööw and Nygren, 2019). Mining safety can be improved by adopting smart mining, optimising mining environments, strengthening systematic health and safety management,

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and considering broader safety management strategies. In addition, practicing a safety culture, encouraging participation in safety, contractor safety and other measures were also used to improve mining safety (Lööw and Nygren, 2019; Lenné et al., 2012; Patterson and Shappell, 2010). With attentiveness from technique to human and organisational factors, safety in mining can be continuously improved. To achieve safer work outcomes, some effective approaches in coal mines in Australia have also been investigated. The New South Wales Mine Safety Operations Branch controls the physical work environment in mines by using only competent people, fitfor-purpose plants and equipment, and safe work systems. What we further find is a comprehensive regulatory framework, proactive powers for inspectors, specific regulations that address the technical engineering requirements, guidelines (standards and procedures) for controlling critical risks, conformance to legislative requirements, continuous safety training and education, careful mine planning, equipment selection and certification (Regan, 2015; Harris et al., 2014). Additionally, coal mining enterprises have also paid more attention to the application of occupational health management and risk control technology (such as workers’ safety behaviour control technology, risk management technology and dynamic warning control technology) and the integration of automation technology (Cao, 2012; Dudley and Mcaree, 2013; Parker et al., 2017). There is no doubt that the measures mentioned above are effective for preventing coal mine accidents. In recent years, mining safety has focused on the ability of organisational aspects to keep pace with continued technological improvements (Patterson and Shappell, 2010; Lööw and Nygren, 2019). The safety culture, as the focus of organisational measures, has a potential, long-lasting and inheritable influence on organisational safety (Cox and Flin, 1998;Hale et al., 2010). With the notion of Safety First being well accepted, some coal mines have introduced the concept of the safety culture with a number of associated practices. In light of the investigation results of the mental and behavioural elements of the safety culture obtained from three underground coal mines, Martyka and Lebecki (2014)stated that the safety culture improved the effect of hazard prevention in coal mining characterized by high risks. Griffin and Neal (2000) supported that the safety culture/climate was an antecedent to safety performance in organisations, which was based on a survey conducted in seven large manufacturing and mining organisations in Australia. As noted by Cox and Flin (1998), organisations with excellent safety performance are associated with more positive safety attitudes and visions. It goes without saying that we cannot exaggerate or ignore the role of the safety culture and its effective contributions to accident prevention and improving corporate safety performance. A positive safety culture is beneficial for improving accident prevention in enterprises characterized by high primary risk (Cox and Flin, 1998). It is important for enterprises to determine whether the implementation of sequential qualitative changes in a safety culture is necessary to achieve further progress regarding the safety condition and performance of the whole organisation. This approach does not mean that previous efforts are useless, but we can constantly stimulate organisational potential and extend the limits via repeated changes and adjustments, leading to the promotion of the quality of the organisational safety culture, which is a dynamic and cyclical process.

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may cause various industrial accidents. From the perspective of accident statistics and analysis, this article explores the characteristics of safety culture deficiencies in an attempt to determine which factors are more important for describing an organisation’s “state of safety”. We conducted an empirical study on coal mine accident cases to find concrete defective elements of the safety culture. With respect to the analysis of 67 typical coal mine accidents (death toll ≥30), the deficiencies in the safety culture are identified as follows: lower levels of safety commitment, unsound safety management system, failure to implement coal mine safety regulations and procedures, lack of appropriate safety training and education, lack of complete utilisation of the roles and responsibilities of the safety department and line department, flaws in worker competence, and imperfect state of equipment (personal protective, ventilation and gas detection equipment). These findings clearly demonstrate the characteristics of safety culture deficiencies, which can be summarized based on four aspects: safety commitment deficiency, flaws in management actions towards safety, passive safety compliance and participation of employees, and imperfect work conditions. To effectively improve the prevention of coal mine accidents, some suggestions are provided to create a positive safety culture. Focus on the implementation of safety commitment and enhancement of the role of functional departments, from both the inside and the outside. Full play is given to the advantages of safety information communication, concurrently with the multi-channel communication path, systematic information communication platform, mobile terminal information communication system and other effective communication modes. An important tactic for creating a positive safety culture is to enhance co-worker safety within the coal mine enterprise, which can be considered an embodiment of effective communication of safety information among employees. Promoting employee participation through incentives is also an effective safety strategy. Additionally, the influence of external supervision on the enterprise safety culture should not be ignored; it may force the existing safety culture to adjust. Analysis of the results obtained for 67 coal mine accidents show that the safety culture of the overall region will directly affect safety culture functions within enterprises. Of course, it is impossible to identify all the elements of safety culture deficiencies in coal mining enterprises by analysing limited accident cases, which will perhaps reveal only a part or even a small part of them. The obtained root causes of coal mine accidents are derived from results from a single angle. To gain more comprehensive findings, the follow-up study on this subject will focus on site surveys, interviews, enquiries and experiences of the actual production and management process of coal mining enterprises. Additionally, comparative studies on the safety culture characteristics of the other industries will be conducted to identify common themes. The results of this paper may provide implications for future empirical and comparative research. By constantly improving research results, we are committed to enhancing the construction level of the safety culture within the coal mine enterprise and further prevent coal accidents in China. Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

5. Conclusion Acknowledgement Safety culture is an organisational factor in safety cases, and it is also the root cause of accidents. Safety culture plays an important role in antecedents of enterprise safety conditions, of which defects

This work was supported by the Jilin High Education Scientific Project (NO. JGJX2019C35), Beijing Social Science Fund Project (NO.

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