Soma: Need for Independent Accident Investigation Commission
Najmadin MeshkatiAfter the recent national disaster, the tragic mining accident in Soma that killed more than 301 miners, there are forceful demands for investigations by existing, traditional entities in Turkey. However, this approach, when it comes to the investigation of an accident with this magnitude and dissemination of its lessons learned, and the prevention of future ones, is neither sufficient nor fruitful.
As experience has shown, government regulatory agencies and parliamentary inquiries are not effective accident investigation mechanisms, and the ones in Turkey will not make exceptions. An independent Soma mine safety and accident investigation commission provides the only way that Turkey can make sure that those 301 precious lives were not lost in vain.
Drawing on my research and teaching over the last 25 years on complex technological systems’ reliability and failures at the University of Southern California (USC), serving as member or technical advisor on several national panels in the United States investigating major accidents, as well as my studies of major mining accidents in the U.S., such the Upper Big Branch Mine in West Virginia that killed 29 (2010), and the Sago mine in Utah (2006) that killed 12 miners, I would like to share the following observations that may have important implications in this context for Turkey.
Major man-made accidents, which are often characterized as “low probability, high consequence events,” are mostly caused by confluence of several root-causes that collectively breach defenses for system safety. Research has shown that on many occasions, the error, “negligence” and their resultant failures are both the attribute and the effect of a multitude of factors, which include: poor workstation and workplace designs, unsafe working conditions, faulty maintenance, disproportionate attention to production, ineffective training, lax oversight and inadequate enforcement of safety regulations, and an overall weak safety culture.
The three most noteworthy recent examples and precedence for creation and empowering such national accident investigation commissions in the world include:
v The “National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling,” established by President Obama in response to the human and environmental disasters resulting from the explosion of the Deepwater Horizon drilling rig in the Gulf of Mexico in April, 2010; which killed 11, seriously injured 16, and the oil flow continued for nearly 3 months, during which, nearly 5 million barrels of crude oil spilled into the Gulf of Mexico. Co-chaired by (former) U.S. Senator Bob Graham and Mr. William K. Reilly (former Administrator of the US Environmental Protection Agency).
v The “Committee on the Analysis of Causes of the Deepwater Horizon Explosion, Fire, and Oil Spill to Identify Measures to Prevent Similar Accidents in the Future,” established by the U.S. National Academy of Engineering (NAE) and National Research Council (NRC). Chaired by the Honorable Dr. Donald C. Winter (former U.S. Secretary of the Navy).
v The “Fukushima Nuclear Accident Independent Investigation Commission,” established by the Parliament of Japan (called “National Diet”) in the wake of the earthquake and tsunami of March 2011. This Commission, the first one in Constitutional Democratic Japan since 1945, was chaired by Dr. Kiyoshi Kurokawa, an internationally renowned and most distinguished statesman and public policy expert in Japan.
The executive and legislative branches of the Turkish government should embark on the immediate creation of an independent Soma independent investigation commission/panel. This interdisciplinary commission should be chaired by a nationally renowned and prominent statesman or scholar, with members selected based on their expertise from related disciplines in academia, industry, professional societies, trade unions, etc., be empowered by the subpoena power, charged to conduct a comprehensive, systematic and interdisciplinary accident investigation and write the most technically-sound report on the root-causes of this tragedy. It should also ensure the lessons learned are understood, disseminated and implemented.
Turkey has paid a big price for them in terms of death and injury to its citizens, as well as damage to its national pride. More importantly, Turkey owes taking these bold accident investigation and safety improvement steps to the legacies of the 301 perished miners, whose lives were not lost in vain and are watching from the heavens…