Analysing coronial inquests into mining fatalities: A systems thinking approach

• The mining sector consistently ranks among the industries with the highest fatality rates globally. • This study adopts a systems thinking models and methods to gain a deeper understanding of the complex safety dynamics within the mining industry. • The analysis identified 89 distinct contributory factors and 173 relationships between factors across the system. • The majority of contributory factors were identified at the level of frontline staff and other operational personnel. • Recommendations focus on options for system reform. The mining sector consistently ranks among the industries with the highest fatality rates globally, largely due to the frequent exposure of workers to high-risk environments as part of their job. These conditions underscore the need for a fundamental shift in how worker injuries are prevented. The current body of research into mining fatalities has heavily focused on the direct cause of the incident causing death, with recommendations focusing on controlling human error and updating technology. This perspective fails to consider the indirect risk factors that may contribute to the fatality from different levels of the mining system. This study proposes the application of systems thinking models and methods to gain a deeper understanding of the complex safety dynamics within the mining industry. The study adopts a systems thinking framework to (1) map the contributory factors identified in publicly available coronial inquests that are associated with the levels of the mining system and (2) identify the relationships between contributory factors to inform recommendations addressing systemic issues. A qualitative template analysis was conducted on 17 coronial inquests from a state in Australia. A systems thinking incident review taxonomy was applied to categorise contributory factors, resulting in the identification of 89 distinct factors and 173 relationships across the system. As predicted, the majority of contributory factors were identified at the level of frontline staff and other operational personnel. However, the Accimap analysis identified that these risks were influenced by systemic issues originating from higher levels, particularly the absence of clear standards and guidelines from regulatory bodies. Additionally, the analysis showed a differentiation in the exposure to risks for contracted workers compared to company employees. This study recommends guidance for employers on interpreting the standards and guidelines that govern the industry, with the goal of protecting both contracted and non-contracted staff.