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Accidents analysis and prevention of coal and gas outburst:

Understanding human errors in accidents

Fu Gui, Xie Xuecai, Jia Qingsong, Tong Wenqing, Ge Ying

PII: S0957-5820(19)30964-4
DOI: https://doi.org/10.1016/j.psep.2019.11.026
Reference: PSEP 2000

To appear in: Process Safety and Environmental Protection

Received Date: 24 May 2019

Revised Date: 22 October 2019
Accepted Date: 21 November 2019

Please cite this article as: Fu G, Xie X, Jia Q, Tong W, Ge Y, Accidents analysis and
prevention of coal and gas outburst: Understanding human errors in accidents, Process
Safety and Environmental Protection (2019), doi: https://doi.org/10.1016/j.psep.2019.11.026

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Accidents analysis and prevention of coal and gas outburst: Understanding
human errors in accidents

Fu Guia, Xie Xuecaia, Jia Qingsonga, Tong Wenqinga, Ge Yinga

a. School of Emergency Management and Safety Engineering , China University of Mining and Technology(Beijing), Beijing
100083, China

Abstract:Coal is an important energy resource internationally. However, accidents have severely restricted the clean and safe
production of coal resources. Among such accidents, coal and gas outburst accidents are a kind of coalmine disaster with high

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destructive power. Previous research on coal and gas outburst accidents mainly focused on gas factors but ignored the role of human
factors. This paper analyses the coal and gas outburst accidents in China from 2008 to 2018 and studies its macroscopic laws. To
better understand the causes of coal and gas outbursts, this paper uses the 24modelel to analyse coal and gas accidents and suggest

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measures for accident prevention from the two aspects ‘gas’ (risk control) and ‘humans’ (behavioural safety). Macroscopic law
research found the following: (1) March, May, July, and August are the predominant months for accidents. (2) The second to fourth

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hours of the working hours and the first hour before the end of work are the peak periods for accidents. (3) Guizhou, Hunan, Henan,
Sichuan, Yunnan, and Chongqing are the provinces with the most coal and gas outburst accidents. (4) An overall 75.82% of accidents
occurred in the driving face, and 81.08% of accidents occurred in coal and gas outburst mines. (5) Blasting, drilling, driving, and coal
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falling are the main inducing factors. Case analysis of accidents found the following: (1) Human error is the leading cause of
accidents. Among the errors, the lack of strict enforcement of outburst prevention measures, illegal command, and the illegal
operation of miners are the main unsafe acts. (2) Safety knowledge and awareness of miners is not generally high, and serious
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habitual violations and unsafe psychologies exist. (3) The gas comprehensive prevention system and supervision system in the coal
mine safety management system (SMS) can be easily operated improperly, and the safety training system and emergency
management system can be absent. (4) Coalmine enterprises seriously lack safety culture.
Keywords: Coal and gas outburst; Accidents analysis and prevention; 24modelel; Human errors; SMS; Safety culture
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1. Introduction

Clean and safe energy production has always been a goal of people. Considering global energy development, coal resources are
still a mainstay of global energy (Xie et al., 2019). In many coal mine accidents, coal and gas outburst accidents have caused mass
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casualties, which has resulted in widespread concern (Tu et al.2016; Xu and Jiang, 2017). The hazards of coal and gas outbursts
mainly manifest as follows: (1) Propelled coal rocks have substantial energy, which can directly lead to casualties among
underground workers or the destruction of equipment. (2) The airflow formed by the high-pressure gas that is instantaneously ejected
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can cause the mine to be turbulent. (3) The high concentration of gas is difficult to dilute in a short time, causing workers to suffocate.
(4) If the outburst gas concentration reaches the explosion limit and encounters an open flame, it may cause an explosion (Lama and
Bodziony, 1998; Nilufer and Mustafa, 2019). In addition to coal mines, coal and gas outburst accidents often occur during the
construction of tunnels. Jin et al. (2016) found that half of the world’s coal and gas outburst accidents occurred in China, which
significantly hindered the clean and safe production of coal resources.
Many scholars have researched the causes of coal and gas outburst accidents to prevent them. Initially, research focused on the
mechanisms for coal and gas outbursts. The mechanisms generalisation is divided into the single factor hypothesis and the
comprehensive action hypothesis (Liang et al., 2017). The single factor hypothesis is mainly described from the perspective of
causing a prominent accident, such as gas factor and geostress factors (Paterson, 1986; Beamish and Crosdale 1998; Jin et al., 2018)

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and geostress factors etc (Noack, 1998; Li et al ., 2018). The comprehensive hypothesis, such as theories such as dynamic theory
(Farmer and Pooley 1967), combined-effects-driven theory (Hodot 1966), and spherical shell destabilisation theory (Jiang et al.
2015), has been widely accepted considering the synthetical effect of outburst factors. With the advancement of technology, scholars
have conducted more in-depth research on the outburst mechanism from the perspectives of seepage (Peng et al., 2012; Zhao et al.,
2018), gas adsorption (Nie et al., 2015; Liu et al., 2016, 2018), and so on. Because of the complexity of the causes of coal and gas
outburst accidents, no clear and accurate mechanism has been established.
According to the theory of energy transfer (Gibson, 1964; Haddon, 1964, 1968, 1973), the most effective way to prevent
accidents is to remove energy, that is, to conduct gas extraction. The earliest country to record gas extraction was the United
Kingdom, after which gas extraction began to develop around the world (Jin, 2016). Generally speaking, gas drainage has
experienced five stages: gas extraction in high permeability coal seams, gas drainage in adjacent layers, gas drainage in low
permeability coal seams, comprehensive gas extraction, and three-dimensional gas extraction (Hu et al., 2015; Wang et al.,
2016;Yuan, 2016; Zhang et al., 2017). A gas extraction system with complete extraction methods has been developed, such as
adjacent layers, coal seams, graves, and surrounding rock gas extraction (Hu et al., 2015; Sreekanth et al., 2018; Zhou et al., 2018).
Gas drainage reduces the amount of gas in the coal seam and reduces the occurrence of coal and gas outburst accidents. However, in
some areas, the extraction effect is poor because of the low permeability of the coal seam or the low gas content.

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Predicting coal and gas outbursts is also a way to prevent accidents. Prediction is mainly divided into contact and non-contact
methods (Liang et al., 2017). Contact prediction includes methods such as the drill cuttings gas index method, the composite index

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method (D and K), and the R-value index method (Xie et al., 2019). This type of method has a large workload and a long prediction
time, which has a certain impact on production. Since the critical values of the mines are difficult to define, prediction errors have
occurred in applications (Xie et al., 2019). Non-contact methods include gas emission prediction, electromagnetic radiation, acoustic
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emission, ultrasonic tests, micro-shock technology, and other methods (Marta ,1997; Lu et al., 2012; Wang et al., 2015; Chen et
al.,2017; Qiu et al., 2018). This type of method is simple and convenient. However, due to the influence of coal and rock, the
prediction error is large. Some scholars combined mathematical algorithms to make prominent predictions, including grey correlation,
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support vector machines, fuzzy mathematics, regression algorithms, the neural network method, structural equation modelelling, and
other methods (Carr and Tah, 2001; Karacan, 2009; Li et al., 2015; Nilufer and Mustafa, 2019; Xie et al., 2019). The application of
these methods improves the efficiency and accuracy of the prediction. However, because of the lack of raw data, the actual
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application is more difficult. Overall, there is no accurate and efficient prediction method for coal and gas outbursts.
The leading cause of accidents is unsafe acts and unsafe conditions. However, in coal and gas outbursts, human error research is
deficient. People realise gas extraction, prediction, and early warnings. In this process, human error leads to adverse consequences.
As shown in Figure 1, people often only see accidents or unsafe acts. However, defects in human safety capabilities (such as
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knowledge, awareness, habits, and psychology), SMSs, and safety culture are often overlooked. The best method is to systematically
analyse the causes of coal and gas outburst accidents using the accident causation modelel.
The main cause of accidents is the unsafe acts and unsafe conditions (Heinrich, 1931). But in the coal and gas outburst accident,
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the human error research is very deficient. Gas extraction and prediction and early warning are realized by people. In this process,
human error will lead to adverse consequences. As shown in Figure 1, people often only see accidents or some unsafe acts. However,
defects in human safety abilities (such as knowledge, awareness, habits, psychology), SMSs and safety culture are often overlooked.
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The best method is to systematically analyze the causes of coal and gas outburst accidents using the accident causation model.

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Fig. 1. Human factors iceberg theory in accidents

This paper uses this modelel to conduct statistics on coal and gas outburst accidents in China from 2008 to 2018 and studies the
macroscopic laws of accidents. It also applies the 24modelel to analyse two accidents that occurred in the Pingyu No. 4 Mine because

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of unsafe conditions, unsafe acts, SMS, and safety culture. We also propose preventive measures based on this case study. It is hoped
that this paper will help more people realise that human error is the most important cause of coal and gas outbursts. It is also hoped
that this research will help prevent coal and gas outburst accidents.

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2. Statistical analysis of accidents
Mastering the macroscopic laws of accidents helps prevent accidents. Greenwood and Woods (1919) first analysed industrial
accidents based on the frequency of accidents occurring in fixed intervals of time. Since then, scholars have used accident statistics to
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study the macroscopic laws of accidents (Maguire et al., 1952; Jarret, 1979; Loader et al., 1992; Wang et al., 2014; Yin et al., 2017;
Zhu et al., 2019; Ren et al., 2019 ). To understand the macroscopic law of coal and gas outburst accidents, this paper analyses these
statistically in China from 2008 to 2018. The statistical data are mainly derived from the national coal mine accident analysis report
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(National Coal Mine Safety Administration, 2008, 2009, 2010, 2011, 2012, 2013, 2014, 2015, 2016), the accident investigation report
issued by the national and provincial government (National Coal Mine Safety Administration, 2018), typical coal mine accident cases
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(Compilation of typical accident cases of coal mines from 2008 to 2018, 2018), and the accident statistics on the network. To ensure
accuracy, every accident was verified so that the statistical results are reliable.
2.1 Year
Between 2008 and 2018, there were 148 coal and gas outbursts in China, resulting in 1,230 deaths. The number of coal and gas
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outburst accidents and the number of deaths decreased between 2008 and 2018 (Cf. Fig.2). The figure also presents a slight decline in
the RDA, which refers to the ratio of the number of deaths to the number of accidents. The number of deaths and accidents in 2018
was 9.85% and 18.75% in 2008, respectively, and RDA was reduced to a historic low of 4.5. This shows that China’s coal and gas
outburst accidents have been effectively prevented in the past ten years.
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Fig. 2. Distribution of fatal accidents by year.

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2.2 Month
Figure 3 shows the accident information by month. May and August are the months with the most accidents, followed by March
and July. The number of accidents in these four months accounted for 47.47% of the year. March, May, and August are the months
with the most deaths, accounting for 40.08% of the year. The higher RDA data is in March, October, and November. Since there have
been two accidents with substantial deaths in October and November, there are special reasons for the high RDA in these two months.
Therefore, it is necessary to pay attention to March, May, July, and August. March is the first working month after the Chinese New
Year, and May has a long Labor Day holiday. Therefore, the alertness of the workers in these two months is scattered, and their safety
attitude is imperfect. July and August are the hottest periods in China and the most exhausting period for workers in the middle of the
year. High temperature and fatigue can easily lead to a decline in workers’ safety awareness (Liao, 2012; Wang et al., 2014).
Similarly, construction accidents (Shao et al., 2019) and gas accidents (Wang et al., 2014) follow the same pattern. Similar patterns
exist in the United States (Hinze and Gambatese, 2003) and Iran (Amiri et al., 2016) .

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Fig. 3. Distribution of fatal accidents by month.
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2.3 Day of week (DW)
Figure 4 shows accidents by week. Overall, the number of accidents and deaths per day is nearly identical, which is also in line
with the law of the accident. Although the miners work on weekends, their supervisors are resting. Consequently, there is no effective
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supervision on the weekend, resulting in slightly more accidents and deaths.

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Fig. 4. Distribution of fatal accidents by DW.

2.4 Time interval of day (TD)

Coal mining in China implements the ‘three-shift system’. As shown in Figure 5, in the first shift (0:00–8:00), 1:00–4:00 is
interval for the first peak of the accident, and 5:00–7:00 is interval of the second peak of the accidents. In the second shift (8:00–
16:00), the first peak was at 9:00–12:00, and the second peak was at 15:00–16:00. In the third shift (16:00–24:00), the first peak was
at 17:00–21:00, and the second peak was at 23:00–24:00. From this, we can infer that the second to fourth hours after work is the
first peak of accidents. The proportion of accidents during this period was 48.73%, and the proportion of deaths was 46.50%. The
first hour before the end of work was the second peak. Workers are the most exhausted during this period, and therefore safety
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awareness is reduced.

Fig. 5. Distribution of fatal accidents by TD.

2.5 Provinces

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In Fig. 6 the geographical distribution of fatal accidents is presented in various colours. The darker the colour of one region, the
higher the number of accidents that have occurred in that region. The number of deaths in each province is also marked in the figure.

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Guizhou, Hunan, Henan, Sichuan, Yunnan, and Chongqing were the provinces with the most accidents. The total number of accidents
in these six provinces accounted for 82.28% of the country’s total. Guizhou, Hunan, Henan, and Yunnan had the highest number of
deaths. The total number of deaths in these four provinces is 73.98% of the country’s total. The highest RDA was in Henan (14.00)

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and Yunnan (10.79). In the above areas, the gas content is high, and the geological conditions are complex. Simultaneously, technical
equipment is relatively backward, professional talent is scarce, and illegal operations often occur. Therefore, these provinces are
prone to coal and gas outburst accidents.
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Fig. 6. Geographical distribution of fatal accidents by province.

2.6 Severity of accidents（SA）

In China, accidents are divided into four levels according to the number of dead. Figure 7 shows the proportion of four accident
levels per year. Since 2012, accidents of more than 30 deaths have not occurred. The proportion of accidents involving three to ten
deaths is decreasing. This shows that China’s coal and gas outburst accidents have been well controlled. However, we still need to
recognise that the proportion of accidents with ten to 30 deaths is still high (average 19%), and there is no downward trend. Next, we
need to reduce this ratio. Statistics show that accidents involving more than 30 deaths occurred in Henan, Yunnan, and Chongqing.

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Of the ten to 30 deaths, 66.36% occurred in Guizhou, Henan, and Yunnan. These regions are the worst-hit by outburst accidents.

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Fig. 7. Distribution of fatal accidents by SA.

2.7 Accidents location

Of the 158 accidents, 153 accident investigation report shows the accident location. As shown in Figure 8, 75.82% of the

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accidents occurred in the driving face, 10.46% of the accidents occurred in the work face, and 7.19% of the accidents occurred in the
headentry. The main causes of the accidents occurred in the head face are as follows: (1) The original stress structure of the coal seam

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was destroyed during driving, and therefore the gas stress was relieved by weakness at the excavation site, making it prone to
accidents. (2) Driving causes the coal body to expand and break deep into the coal, and the coal seam permeability is increased.
Simultaneously, substantial gas in the coal body is quickly desorbed because of depressurisation. High-pressure airflow is formed
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instantaneously, causing serious collapse and destruction of the coal seam, which causes coal and gas outburst accidents. (3) It is easy
to encounter areas of geological structure and coal thickness change during the driving process. The stress and gas distribution in
these areas are uneven and prone to accidents. (4) The environment for driving work is poor, and there are many illegal commands
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and operations in action. Thus, prevention focuses on coal and gas outbursts in the driving face.
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Fig. 8. Distribution of fatal accidents by accidents location.

2.8 Gas grade

China’s coalmine gas ranks are divided into coal and gas outburst mines, high gas mines, and low gas mines. Coal mines that
have experienced coal and gas outburst accidents, or coal mines identified as having coal and gas outburst possibilities, are known as
coal and gas outburst mines. In addition to coal and gas outburst mines, mines in which gas emission is greater than 10m3/t or
absolute gas emission is greater than 40m3/min are called high gas mines. Without these, what remains is a low gas mine (National
Coal Mine Safety Administration of China, 2009).
Of the 158 accidents, 111 accident investigation report shows the gas grade of the mine. As shown in Figure 9, 81.08% of the
accidents occurred in coal and gas outburst mines, and 10.81% occurred in high gas mines. It can be seen that the gas factor is a

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prerequisite for an accident. Therefore, coal mining should be conducted in strict accordance with the requirements of the
Regulations on Prevention and Control of Coal (National Coal Mine Safety Administration of China, 2009) and Gas Outburst and
Coal Mine Safety (National Coal Mine Safety Administration of China, 2009).

Fig. 9. Distribution of fatal accidents by gas grade

2.9 Induction factors
Of the 158 accidents, 110 accident investigation report showed the induction factors of the accident. As shown in Figure 10,

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blasting, drilling, driving, and coal falling, which induced 78.18% of accidents are the main accident induction factors. Blasting,
drilling, and driving are prone to disturbing the coal body and creating cracks, which induce coal and gas outbursts. Roofing, sheeting,

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or support failure will cause the coal to fall. The collapse of the coal body causes uneven stress distribution and is prone to accidents.

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Fig. 10. Distribution of fatal accidents by induction factors

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3. Materials and methods

The accident causation model shows the relationship between the cause and effect of the accident (Qureshi, 2007). The
application of accident causation modelel in accidents analysis can show the vulnerabilities in the process of accident occurrence,
thus helping prevention.
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3.1 Accident case

Located in Xuchang, Henan Province (Cf. Fig. 11), Pingyu No. 4 Mine is a coal and gas outburst mine. The mine has witnessed
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13 coal and gas outburst accidents since it was built. Among them, the two most serious accidents occurred on August 1, 2008
(referred to as ‘8.1’ accident) and October 16, 2010 (referred to as ‘10.16’ accident). The accident process is shown in Figure 12 and
Figure 13, respectively.

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 The ‘fitcherin’ phenwarningon occurred during the driving
operation of the 12190 working face. The supervisor driller
(Liu) reported the situation to the duty leader (Yang). Yang 16 o’clock classes on July 31
believed that this phenwarningon had occurred earlier, and
hence did not report it to the mine leaders..
Hold a pre-class meeting and assign tasks in the 12190
working face. There were 14 people working here .roadway.
0 o’clock classes on Aug 1

The rig to construct the pre-extracted gas drainage hole begins to 0:30 on August 1
be used.

1:02 on August 1
Workers Guo and Zhao heard a few ‘coal guns’ and
saw coal powder coming in. They ran into the
nearby refuge chamber and immediately reported
the accident to the dispatch room.
At this time, the safety monitoring system found that the gas
concentration of the 12190 working face had increased
sharply, the T1 gas sensor had broken, and gas overruns had
occurred in many places, leading to the accident occurred.

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Captain Zhu reported to the dispatching room that the wind 1:05 on August 1
flow of the 12160 working face was reversed.

Yang immediately launched the emergency rescue plan and took

After that corresponding emergency measures. Meanwhile, the accident

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situation was reported to the relevant sections in time.

Verification revealed 14 deaths and nine

After that
missing.
5:40 on August 2

All 23 deaths were found and the rescue work was over.
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Two survivors were rescued.

20:55 on August 11
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The accident resulted in 23 deaths and direct economic loss of 8.3 million yuan.
The outburst coal volume is 2,555t, and the gas volume was 2.6×105m3.
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Fig. 12. ‘8.1’ coal and gas outburst accident process in the Pingyu No. 4 mine
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The gas drainage system is defective. Previously

8 o’clock on October 15 It was found that the gas concentration was too high.

The deputy chief engineer Liu led the team to work but production continued.
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underground, and 276 people were on duty. 23 o’clock on October 15

0 o'clock on October 16 Twenty

Twenty miners
miners arrived
arrived at
at the
the 12190-working
12190 working face
face to
to work
work on
on
drilling
drillingholes
holes to
torelease
release gas.
gas.
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Liu went to inspect the 12190-working face. 0:50 on October 16

Safety officer He reported that the gas concentration exceeded the

After that standard to the ground ventilation dispatching room. The response
was to continue working.

Liu sensed abnormal air flow in the mine, reported to the

dispatching room, and organised evacuation. 5 o’clock on October 16

6:03 on October 16

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 8 o’clock on October 17 Twenty-six dead miners found.

All 32 dead miners were found and the rescue work was over. 7:35 on October 19

The accident resulted in 37 deaths and direct economic loss of 22.74 million yuan.
The outburst coal volume was 2,500t, and the gas volume was 1.8×105m3.

Fig. 13. ‘10.16’ coal and gas outburst accident process in Pingyu No. 4 mine

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Fig. 11. Position of the Pingyu No. 4 mine in China
3.2 Accident analysis modelel
Unsafe acts and unsafe conditions are the immediate causes of an accident (Heinrich et al., 1980). Individuals’ safety knowledge
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(Neal et al., 2000), awareness (Fu et al., 2013; Nektarios et al., 2018), habits (Zhang et al., 2016; Fu et al., 2016, 2017), and their
mental and physiological status (Wiegmann and Shappell, 1997, 2003; Xie and Guo, 2018) can influence human acts. At the
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organisational level, accident prevention is mainly conducted through the SMS (Kennedy and Kirwan, 1998). Safety culture, which
reflects the concepts, values, and attitudes shared by the workers regarding safety (Kennedy and Kirwan, 1998), guides the
development and implementation of SMS. Accordingly, Prof. Fu Gui conducted a more detailed study on the cause of accidents and
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proposed the 24modelel (Fu, et al, 2013, 2014, 2017). In the 24modelel, the cause of the accident is attributed to two levels
(Individual and organisational levels) and four phases (Immediate cause, Indirect cause, Radical cause, and Root cause). Today, the
24modelel has been widely used in accident analysis (Wang et al., 2016; Fu et al.,2016, 2018, 2019; Suo et al., 2017; Xue and Fu,
2018 ). Figure 14 is the latest version of the 24modelel.
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Safety knowledge Safety acts

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Safety Safety Safety awareness

Safety Event Consequences
management Safety habits
culture
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system Safety conditions

Psychological status
Root Radical causes Physiological status
Indirect causes Immediate causes Event Consequences

causesⅣ:
Phase Phase Ⅲ: Phase Ⅱ: Phase Ⅰ:
Result of behaviors Consequences of event
Directing behaviors Operational behaviors Habitual behaviors One-time behaviors and conditions
Level Ⅱ: Organization level Level Ⅰ: Individual level Result of behaviors Consequences of event

Fig. 14. The latest version of 24Mode (Fu et al., 2019)

4. Accident analysis
4.1 Unsafe conditions
In coal mining, the presence of unsafe conditions increases the probability of coal and gas outburst accidents. The main

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contributors are geological, coal, and gas factors (He et al., 2010; Xie et al., 2019).
4.1.1 Geological factors
Geological structure area refers to the area where faults, folds, coal seam thickness changes, and the coal seam structure are
damaged. Studies have shown that more than 90% of coal and gas outburst accidents are concentrated in geological formations (Zhai
et al.,2016; Mark, 2018;Li et al., 2018). The geological report of the production mine of the Pingyu No.4 Mine (2006) found that a
fault has a profound effect on it. As shown in Figure 15-a, the Hutoushan fault (F1) and its two branch faults (F1-1 and F1-2) exist in
the Pingyu No.4 mine. The report shows that it is affected by the Hutoushan fault, and the gas near the fault has a certain means of
escape. However, as the mine extends south, this effect lessens. The two accidents analysed in this paper are in the southern part of
the mining area, and geological factors have little impact on them.
4.1.2 Lithology of roof and floor rocks
The gas in the coal seam has two states of being free and adsorbed, and the two states can be transformed into each other. The
free gas can escape through the top plate with better gas permeability. Generally, well-permeable rock layers such as sandstone and
conglomerate are favourable for gas to escape, while poorly permeable rock layers such as mudstone and shale can prevent gas from
escaping. The roof of the Pingyu No. 4 Mine is dominated by sandstone with good permeability, and the local area is muddy with
poor permeability. The thickness distribution of the roof mudstone is shown in Figure 15-a. As can be seen from the figure, most of

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the mudstone thickness is less than 3m. Regression analysis showed that the influence of roof lithology on the occurrence of gas in
most areas of the mine was not obvious (Zhang, 2014).

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4.1.3 Gas factors
The accumulation of gas in coal seams is a prerequisite for coal and gas outbursts. Taking the F 1-1 fault as the boundary, the gas
content in the east of the fault is 3.21–10.21m3/t and the gas content in the west of the fault is 2.43–13.32m3/t. The absolute outflow
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of mines was 8.19m3/min (2009) and 6.37m3/min (2010), and the relative gushing amount was 15.81m3/t (2009) and 9.07m3/t (2010)
(Zhang, 2014). The gas content of the mine is low, and therefore the gas factor is not the leading cause of the accident.
4.1.4 Coal factors
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Coal seam thickness and stability can directly affect the content of gas in coal seams. Generally, the greater the thickness, the
higher the gas content. Large changes in coal thickness are prone to form gas accumulation areas. The greater the buried depth of the
coal seam, the greater the ground stress, forming a high-pressure gas accumulation zone. The coal thickness of the Pingyu No. 4
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Mine is 0.41–9.61m and the thickness of coal varies greatly; therefore, the gas distribution in the area is uneven. The buried depth of
the coal seam in the east of the F1-1 fault is about 480m, and the maximum buried depth of the coal seam in the west of the fault is
about 760m. Regression analysis shows that the coal seam gas content increases, as does coal seam depth, and the correlation
coefficient is greater than 0.9. It can be seen that the buried depth of the coal seam has the greatest influence on the gas content
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(Zhang, 2014).
4.1.5 12190 working face factor analysis
The 12190 working face is located west of the F1-1 fault, and this is where the accident occurred (Cf. Fig 15-b). Its roof is
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dominated by sandstone, and its lithology has little effect on the occurrence of gas. The coal thickness is 1–6m, and the coal seam
depth is 519–625m, which is the largest working face of the coal seam depth in the mine, though its gas content is 4.42–11.32m3/t.
However, because of the influence of ground stress, the maximum gas pressure in this area is 2.18Mpa, and a high-pressure gas
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accumulation area has formed. The solidity coefficient (f) of the coal seam here is about 0.11, and the initial velocity (ΔP) of gas
emission is about 26, which is prone to prominent accidents.
Considered together, the main factors contributing to the 12190 working face are the coal seam depth and coal thickness.
However, the geology of the Pingyu No. 4 Mine is in good condition easily drains gas. Strict implementation of comprehensive
preventive measures can completely prevent accidents.

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a. Map of fault and roof mudstone thickness in Pingyu No. 4 mine b. Map of gas concentration and pressure in 12190 working face

Fig. 15. Map of geological parameters in Pingyu No.4 mine

4.2 Unsafe acts

The concept of accident proneness is used to indicate that some individuals have more accident-related characteristics than
others (Greenwood and Woods ,1919; Farmer and Chamber, 1929; Haight, 2001). This is the earliest discussion of the human factors

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that cause accidents. Heinrich (1931) first proposed that the direct causes of an accident were unsafe actions and unsafe states in
Industrial Accident Prevention. Zabetakis (1967), Surry (1969), A. R. Hale and M. Hale (1970), Lawrence (1974), Reason (1990),
and Stewart (2013) believe that human errors or unsafe actions are the direct cause of accidents. Simultaneously, many scholars have

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studied human error in accidents. Heinrich (1931) found that unsafe actions caused 88% of accidents, and unsafe actions and unsafe
states caused 10% of accidents. Kletz (1991) found that 50–90% of accidents are due to human failings. The National Safety Council
found that unsafe human actions caused about 90% of accidents, and DuPont found that people account for 96% of all injuries.
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However, the accuracy of this information has not been determined. However, it is undeniable that human errors or unsafe acts cause
most accidents. In the HFACS framework, unsafe acts are divided into errors and violations (Wiegmann and Shappell, 1997, 2003).
Reasons for unsafe acts can be divided into skill-based, rule-based, and knowledge-based factors, and intentional and non-intentional
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acts (Cf. Fig 16).
The unsafe acts of the Pingyu No. 4 mine are shown in Table 1. First, it is known that illegal commands are the most serious
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unsafe acts. The main manifestations of these are as follows: (1) Pingyu No.4 mine is a coal and gas outburst mine. According to
Regulations on Prevention and Control of Coal and Gas Outburst (National Coal Mine Safety Administration of China, 2009) and
Coal Mine Safety Regulations (State Administration of Work Safety of China and National Coal Mine Safety Administration of China,
2016), the mine must conduct ‘regional comprehensive prevention measures’ and ‘local comprehensive prevention measures’, and
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each stage must be tested for its effectiveness. The two accidents in the Pingyu No. 4 Mine did not strictly implement comprehensive
preventive measures, and the consequence was not eliminate the danger of coal and gas outbursts. This behaviour is a seriously
unsafe act, creating a hidden risk of an accident. (2) The dispatching room is not sensitive to outburst signs. During an accidental
warning, there was no reporting to the leader and no order was withdrawn；Second, illegal operations were a factor. The main factors
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are: (1) The dispatching room did not report outburst signs. There occurred violation of the operation of mechanical equipment in the
working surface with the possibility of accidents. (3) Arrange the mining when the monitoring system cannot be used. (4) Miners’
safety training is insufficient, and their safety knowledge and awareness are poor. (5) There are no emergency rescue measures and
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teams. Third, the decision was made in error. The ventilation system had poor resilience and did not account for wind reversal.
The accident pyramid (Heinrich, 1931) tells us that the arbitrarily occurring unsafe acts will eventually lead to accidents, and
chipping away at the minor incidents forming the base of the pyramid will necessarily prevent large accidents. Therefore, the
prevention of accidents begins by reducing the number of unsafe acts. This paper proposes to control unsafe acts from the individual
level and the organisational level. Control measures are shown in Figure 16.

Errors Violations Reason Subjective

Category Intentionality
● Routine violations
● Decision errors
● Exceptional violations
● Skill-based ● Intentional acts
● Skill-based errors - 11 -

● Rule-based ● Non-intentional acts

● Perceptual errors

● Knowledge-based
 ● Illegal command

● Illegal operation

● Violated discipline
Unsafe

Individual level
Acts Organization level
● Safety knowledge ● Positive safety culture
Learn management knowledge and skills knowledge.
● Perfect SMS
● Safety awareness
● Implement safety laws and regulations and industry standards
Safety first, and forming a positive safety awareness.
● Correct supervision and inspection
● Safety habits

Operate according to the regulations and develop correct safety habits. ● Sufficient safety education (ideology, management, skill)

● Psychological status ● Behavior Based Safety

Respect life and develop correct safety habits.

● Use advanced technology and equipment

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● Physiological status
● Improve the working environment
Develop the right habits and work in the right positions.

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Fig. 16. Performance of unsafe acts and its improvement measures

4.3 Indirect cause analysis

Knowledge, consciousness, habits, psychology, and the physiology of human acts – these five factors can be understood as
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habitual behaviours. In the 24modelel, these factors are summarised as indirect causes of accidents. The relationship between the
various factors is shown in Figure 17.
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Safety Ability

Safety knowledge
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Safety awareness
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Safety habits
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Psychological status
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Physiological status

Fig. 17. Influence relationship between indirect cause factors (Pictures from the Web)

4.3.1 Safety knowledge

Safety knowledge refers to the collective term for theoretical knowledge, experience, skills, and so on related to safety.
Insufficient safety knowledge can lead to unsafe movements or activate unsafe conditions. Table 1 shows the unsafe behaviour of
coal and gas outburst accidents in the Pingyu No. 4 mine. Analysis of the causes of unsafe actions shows that insufficient safety
knowledge at the Pingyu No.4 mine contributed to the following: (1) the danger of coal and gas outburst; (2) laws and regulations

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and industry standards for coal mine safety; (3) coal and gas outburst prevention measures; (4) coal mine safety rules and regulations;
(5) safe use of equipment; (6) post standard operation; (7) information transmission and emergency response to accidents. ‘Risk
awareness and control’, ‘laws and regulations and industry standards’, ‘safety standardisation operations’, and ‘accident hazard
information transmission and emergency response’ are most needed for accident prevention.
In China, miner qualifications are relatively low, and the acquisition of safety knowledge depends on safety training. Therefore,
leaders, safety managers, and new workers should conduct safety training. Figure 18 summarises the aims, content, and duration of
coal mine safety training. Coal mining enterprises should establish a safety training file for miners and make detailed records of the
training time and content. Trainers can be tested to examine effectiveness. Simultaneously, the government safety management
section must also train and test mine leaders and safety managers. The safety knowledge of miners has increased, and accidents have
gradually decreased.

Safety education content

Safety person in charge • Hazard recognization and control

Education time
• Laws, regulations & industry standards
• First ≧48h

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• Safety management knowledge

• Safety production skills • Retraining ≧16h

Safety
• Safety protection measures

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Safety manager
Knowledge • Equipments use and maintenance

• Emergency management and rescue

New miners
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• Occupational hazards and protection

• Accident statistics and investigation

Education time

• First ≧72h
• Safety status and safety discipline
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• Retraining ≧20h
• Safety rights and obligations

• Accident case and rescue case

Fig. 18. Coal mine safety education content framework
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• Other training requirements

4.3.2 Safety awareness
Good safety awareness can regulate miners’ behaviour and reduce accidents (Ayana et al., 2017; Nektarios et al., 2018). Usually,
safety awareness has three states: non-awareness, semi-awareness, and Fully-awareness (Cf. Fig 19). Non-awareness is having no
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perception of the existence of danger. Semi-awareness is to understand the risks, but not understand the risk predisposing factors and
preventive measures. Fully-awareness refers to familiarity with predisposing factors and preventive measures. In China, most miners
are in a state of semi-awareness. The purpose of safety training is to accord miners fully-awareness (Chang and Liao, 2009).
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Negative safety awareness Three kinds of safety awareness Attitude Education

Aware of the hazards, ● The seriousness of the accident.
● Fluke type Semi- but not Fully-aware
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Awareness of the inducing ● Safety is everyone's responsibility.

factors and accident
● Irresponsible type
results. ● Insufficient safety awareness may
Completely unaware
● Self-reliance type Fully-aware of the lead to accidents.
of hazards, hazards, inducing
accident-inducing Safety factors and ● Zero accident awareness
● Muddleheaded type
factors and Awarenes accident results.
s Knowledge Education
● Exhausted type accident results.
Non- Fully- ● Enhance safety awareness education
● Insufficient knowledge type Awareness Awareness
● Strengthen risk recognition
Correct performance ● Establishing safety culture
Three aspects of safety awareness
● Safety first
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● Leadership’s “safety responsibility awareness” corrections (Persuasion, criticism,
punishment)
● Precaution crucial ● Manager's “safety management and supervision awareness”
● Standardize safe behavior
● Employee's “self-safety awareness”
● Compliance with safety regulations
Fig. 19. Safety awareness classification and improvement measures

Regarding accidents, the workers in the Pingyu No.4 mine are aware of the existence of risks, but do not understand the
inducing factors and possible consequences, and do not know how to conduct emergency measures. The performance of insufficient
safety awareness is as follows: (1) awareness of risk perception and pre-control; (2) awareness of safety supervision; (3) awareness of
emergency escapes.
Companies should have three types of safety awareness: senior leader’s ‘safety responsibility awareness’, middle manager’s
‘safety management and supervision awareness’, and frontline miners’ ‘self-safety awareness’. Figure 19 shows how to increase
safety awareness. First, attitude education—allow miners to know the seriousness of the accident and form a ‘safety first’ awareness.
Second, knowledge education—allow miners to learn substantial safety knowledge and cultivate their awareness of risk and safety
responsibility (Paul and Neville, 2013). Miners’ safety awareness has increased, and accidents have decreased.

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4.3.3 Safety habits
Safety habits refer to a way of dealing with safety, which workers form in their daily work. The study found that good safety
habits can reduce accidents (Melanie and Patricia, 2019; Konstantinos et al., 2017). Habitual violation of regulations is the most

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likely of unsafe habits to cause accidents. Habitual violation is not only a manifestation of fluke psychology but also a manifestation
of a lack of safety knowledge. It usually has three forms: illegal commands, illegal operations, and violated discipline (Cf. Fig 20).
The Pingyu No. 4 Mine has had several coal and gas outburst accidents, and senior leaders still do not implement
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comprehensive preventive measures strictly. This is a manifestation of habitual violations. Repeatedly ignoring warnings of accidents
and making miners operate in the working face with a danger of coal and gas outburst is also a manifestation of habitual violations.
Miners operating illegally on the working surface is another habitual violation. Table 1 summarises unsafe habits.
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Good safety habits form a positive attitude and help guarantee the prevention of accidents (Loosemore and Malouf, 2019). The
reason for poor safety habits is that miners do not work according to industry standards, labour discipline, job operations, and they
lack effective safety supervision. It is the performance of workers’ safety attitudes. Figure 20 shows 11 ways to develop safe habits at
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the individual and organisational levels. At the individual level, miners must actively learn safety knowledge and maintain correct
safety attitude. At the organisational level, safety supervision and the correction of unsafe habits should be carried out efficiently and
methodically. Unsafe habits can be corrected through safety training, pre-class meetings, team corrections, and accident drills. Within
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the company, the Senior Leader leads in developing safe habits and develops a good safety culture. All miners must work per the post
standards, and habitual violations should be strictly prohibited.

Safe culture

Safety Safe education

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knowledge Standardized operation

Safety
awareness Illegal Inspection and supervision
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command
Group guidance and correction
Safety
Habitual Illegal
habits
Psychological Violation operation Pre-class meeting deployment

status Physiological Violated Behavior Based Safety

discipline
status
Accident prediction and exercise

Action explanation

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 Action drumbeating

Rewards and penalties

Fig. 20 Unsafe habits and improvement measures

4.3.4 Psychological status

Safety psychology refers to the characteristics and laws of people’s psychological activities in the process of production.
Studying the psychological laws of people in accidents can improve people’s unsafe behaviours and, thus, help to prevent accidents
(Wang et al, 2018; Mohammad et al., 2019; Jason and Carolyn, 2019). The theory of accident proneness tends to mean that people
with certain personalities or characteristics are prone to accidents, and such people include those who are prone to unsafe
psychological conditions (Greenwood and Woods, 1919; Farmer and Chamber, 1939; Haight, 2001). As shown in Figure 21, there are
eight kinds of common unsafe psychologies.
Fred et al. (2014) argued that strengthening psychology will establish safety barriers. As shown in Table 1, each unsafe

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behaviour is accompanied by unsafe psychology. These include paralysis, fluke, and convenient psychologies. Paralysis is mainly
due to insufficient attention to accidents and the relaxation of vigilance. The main reason for this is the lack of safety knowledge and
insufficient awareness and prevention of danger. Fluke psychology is a kind of gambling, which is the main psychology that causes

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illegal command and operations. Convenient psychology is a manifestation of a habitual violation. Numerous accidents have
confirmed that unsafe psychology can lead to errors, and an increase in human error eventually leads to accidents.
The study found that countering unsafe psychology can effectively improve the safety situation (Jarle et al., 2012; Arlene, 2013;
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Kjersti et al., 2015; Matteo et al., 2016; Rachael et al., 2019). Figure 21 shows some unsafe psychological corrections, the most
important of which is the education of safety attitudes. Coalmines should correct unsafe psychologies. Measures, such as case studies
of accidents and virtual reality experiences, can be taken. Establishing a mine safety culture is also very effective in cultivating safety
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psychology.

Attitude Education Psychological correction

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Methods Paralysis Fluke ● Establishing safety culture

● Safety training psychology psychology ● Strengthen risk recognition

● Video learning
● Safety education
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● Accident display and explanation

Irresponsible Adventure ● Team care support
● Safety knowledge contest
psychology psychology ● Psychological rescue
● Accident Virtual Reality Experience
Unsafe
● Accident theme activity ● Leadership
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Psychological
Curious Convenient
Main content ● Safety activities
psychology psychology
● The seriousness of the accident.
● Warning propaganda
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● Safety is everyone's responsibility.

● Improving environment
● Safety first，precaution crucial. Nervous Flaunt
● Reasonable rest
● Unsafe psychology lead to accidents. psychology psychology

● Safety is integrated into daily work. ● Rewards and penalties

● Compliance with safety regulations. ● Cultivate the right safe will

● Safety creates economic benefits.

Fig. 21. Unsafe psychological and improvement measures

4.3.5 Physiological status

Safety physiology refers to the physiological factors related to safety. As shown in Figure 22, human physiological factors
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include congenital causes and acquired factors. Gavin et al. (2019) and Zheng et al. (2019) have shown that assessing and adjusting
the psychological state of workers can effectively improve safety. Therefore, the physiological factors of the workers should be fully
considered. To improve the working environment and rest time, workers are strictly prohibited from drinking and being sick and
fatigued. Workers should strengthen their knowledge learning and eliminate the formation of unsafe psychology. Since this study
focusses on accident investigation reports and does not describe physiological states, it does not analyse the physiological reasons for
accidents.

Physiological Status
Height Weight Hearin Vision Environment Knowledge Awareness
g

Perception Congential Olfactory Drinking

Acquired Noise

Reactivity Gender Tactile Temperature Fatigue

Taste Dust Odor Sick

Sensitivity Adaptability Character Biological law Illumination Psychological

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Fig. 22. Component factors of psychological status

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Table 1 Accident analysis of coal and gas outbursts at the individual level in the Pingyu No.4 mine application of the 24modelel
Accident No Unsafe acts Personnel Unsafe action Safety capability

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category category Knowledge Awareness Habits Psychological
‘8.1’ 1 Comprehensive regional preventive measures not taken. Senior Leader Illegal command ● Hazard recognition and control ● Semi-awareness ● Habitual violation ● Paralysis psychology

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accident ● Safety regulations ● Fluke psychology
● Safety measures ● Convenient psychology
2 No effect test. Senior Leader Illegal command ● Hazard recognition and control ● Non-awareness ● Habitual violation ● Paralysis psychology
● Safety regulations ● Fluke psychology
● Safety measures ● Convenient psychology
3 Yang Zhongshen, the duty leader, believed that ‘the card Middle Manager Illegal operation ● Hazard recognition and control ● Non-awareness ● Habitual violation ● Paralysis psychology

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drill had happened in the past’ and did not report the ● Safety regulations ● Fluke psychology
accident to the leader. ● Safety management system
4 The driving team worked on a surface with a danger of Middle Manager Illegal command ● Hazard recognition and control ● Non-awareness ● Habitual violation ● Paralysis psychology
coal and gas outbursts. ● Safety regulations ● Fluke psychology
● Adventure psychology

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5 The rig was used in violation of the working face with a Frontline Miner Illegal operation ● Hazard recognition and control ● Non-awareness ● Habitual violation ● Paralysis psychology
danger of coal and gas outbursts. ● Safety regulations ● Fluke psychology
● Equipment and technology ● Adventure psychology
6 The mine ventilation system has poor resilience, which Senior Leader Decision errors ● Hazard recognition and control ● Semi-awareness ● Habitual violation ● Paralysis psychology
leads to the reversal of the wind flow in the 12160 coal ● Safety measures ● Fluke psychology
● Safety skills

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mining face, which causes accident expansion.
7 Safety education is not in place, resulting in insufficient Senior Leader Illegal operation ● Hazard recognition and control ● Semi-awareness ● Habitual violation ● Paralysis psychology
knowledge of mine safety and weak safety awareness. ● Safety regulations ● Fluke psychology
● Safety management system ● Convenient psychology
● Safety skills
8 No emergency measures and rescue teams. Senior Leader Illegal operation ● Safety regulations ● Non-awareness ● Habitual violation ● Paralysis psychology
● Safety management system ● Fluke psychology
● Safety skills ● Convenient psychology
‘10.16’ 1 No effect test was taken. l Senior Leader Illegal command ● Hazard recognition and control ● Non-awareness ● Habitual violation ● Paralysis psychology
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accident ● Safety regulations ● Fluke psychology
● Safety measures ● Convenient psychology
2 Before the accident, the gas monitoring system could Middle Manager Illegal operation ● Hazard recognition and control ● Non-awareness ● Habitual violation ● Paralysis psychology
not be used for many days. ● Safety regulations ● Fluke psychology
● Safety management system ● Adventure psychology
● Safety measures ● Convenient psychology
3 The safety officer reported the gas concentration to the Middle Manager Illegal command ● Hazard recognition and control ● Semi-awareness ● Habitual violation ● Paralysis psychology
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dispatching room but was asked to continue working. ● Safety regulations ● Fluke psychology
● Safety management system ● Adventure psychology
● Safety measures ● Convenient psychology
4 During the local comprehensive preventive measures, Middle Manager Illegal command ● Hazard recognition and control ● Non-awareness ● Habitual violation ● Paralysis psychology
the miner was required to adjust the coal cutter. ● Safety regulations ● Fluke psychology
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● Safety management system ● Adventure psychology

5 The pilot illegally commissioned the shearer. Coal Frontline Miner Illegal operation ● Hazard recognition and control ● Non-awareness ● Habitual violation ● Paralysis psychology
cutting disturbs the coal body and induces coal and gas ● Safety regulations ● Fluke psychology
outbursts. ● Equipment and technology ● Adventure psychology
6 Safety education is not in place, resulting in insufficient Senior Leader Illegal operation ● Hazard recognition and control ● Semi-awareness ● Habitual violation ● Paralysis psychology
knowledge of mine safety and weak safety awareness. ● Safety regulations ● Fluke psychology
● Safety management system ● Convenient psychology
7 No emergency measures and rescue teams. Senior Leader Illegal operation ● Safety regulations ● Non-awareness ● Habitual violation ● Paralysis psychology
● Safety management system ● Fluke psychology
● Safety skills ● Convenient psychology

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4.4 Radical causes analysis
The SMS is the operational system of risk management and control, and it is also a safety assurance system. When there are
loopholes or defects in the SMS, a series of hidden dangers often occur. In the 24modelel, the root cause of an accident is
summarised as a defect in the SMS. SMS mainly consists of safety policy, organisational structure, and process files. Usually, a
complete SMS consists of several subsystems (Jesús et al., 2018; Nicole et al., 2019). The purpose of the SMS is to achieve process
risk control and human behaviour safety (Widener, 2015; Tullo, 2019).
There are two problems in the SMS: improper system operation and lack of a subsystem. The main reasons for the improper
system operation are lack of program files, unreasonable system settings, unreasonable staffing, and so on. The lack of subsystems
means the lack of corresponding safety management sections. Although the corresponding SMS was formulated in the Pingyu No.4
mine, a related safety team was established. However, as shown in Table 2, the SMS of the mine has serious problems.
Table 2
The insufficiency of SMS in the Pingyu No. 4 mine
Category No Responsible section Subsystem Unsafe acts
Improper 1 Anti-burst section Anti-burst system Comprehensive preventive measures are not strictly implemented.
system 2 Dispatching Room Anti-burst system Accident signs were not reported to leaders, and miners were required to
operation

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continue working.
3 Safety supervision section Anti-burst system Did not respond correctly to the outburst signs.
Safety supervision section Supervision system The illegal commanding behaviour of the driving team was not corrected.
Safety supervision section Supervision system The illegal operation of the frontline miners was not corrected.

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Safety supervision section Supervision system The failure monitoring device was not replaced.
4 Ventilation section Ventilation system Mine ventilation system was poor in disaster resistance.
Lack 1 Coalmine safety Information How do you transmit information when there is an accident sign? Who has the
of committee transmission right to order the evacuation? Who has the right to command the evacuation?
subsystem
2

3
Coalmine safety
committee
Coalmine safety
system
Safety training
system
Emergency
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There is no section dedicated to safety training.

There is no emergency command section, no emergency rescue measures, and no

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committee management emergency rescue team.
system

In preventing coal and gas outburst accidents, improper system operation is mainly seen in the anti-burst section, the dispatching
room, the safety supervision section, and the ventilation section. There are many reasons for the above phenwarningon. First, the
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deputy mine manager responsible for preventing coal and gas outbursts has not implemented the leadership responsibility system,
and there is also dereliction of duty by the management of the section. Second, most of the section staff are non-professional
technicians who lack relevant professional knowledge. Third, in the daily work of the section staff, there is no effective guidance and
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supervision of the frontline staff miners.

Additionally, the information transmission system, safety training system, and emergency management system of the Pingyu
No.4 mine were missing. The consequence of the lack of an information transmission system is that, after the hidden dangers expose,
the emergency command is chaotic. The lack of a safety training system is caused by the lack of safety knowledge of all miners, and
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it is prone to low safety awareness, poor safety habits, and unsafe psychology. There are many loopholes in the formulation and
implementation of the SMS. The lack of an emergency management system will result in insufficient emergency rescue preparation
and lack of emergency rescue teams.
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Typically, sections should be responsible for the safety of their field. The safety section should be an assisting section to inspect
and guide hidden dangers. As shown in Figure 23, in China, the safety of the enterprise is directly managed by the safety
management section, while other sections are not responsible for safety. This has caused major hidden dangers in safety management.
The specific performance is as follows: (1) The safety section is responsible for discovering the hidden dangers of the entire
enterprise, and the workload is enormous. (2) Because the safety inspection section is separated from the business section, safety
inspectors need to have more knowledge and be familiar with various sections and technical processes. (3) The safety section cannot
follow the business section constantly. Therefore, the unsafe acts of the workers may not be discovered in time. This leads to the
following consequences: (1) The safety inspection workload is high, and the hidden dangers are not discovered promptly. (2) The
safety section is not valued within the enterprise, and the treatment is not high. (3) The safety section is under enormous pressure,

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and safety managers are reluctant to engage in the work. Over time, it will cause a vicious circle of safety management.

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Fig.23. Chinese enterprise organization framework

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4.5 Root cause analysis
The term ‘Safety Culture’ was first introduced in the International Nuclear Safety Advisory Group’s (INSAG) Summary Report
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on the Post-Accident Review Meeting on the Chernobyl Accident, published by the International Atomic Energy Agency (IAEA) as
Safety Series No.75-INSAG-l in 1986, and further expanded on in Basic Safety Principles for Nuclear Power Plants, Safety Series
No.75-INSAG-3, issued in 1988. It was explicitly explained in Safety Culture, Safety Series No.75-INSAG-4, printed in 1991
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(INSAG-1, 1986; INSAG-3, 1988; INSAG-4, 1991). The first proposition presented by INSAG is the definition of safety culture:
Safety culture is that assembly of characteristics and attitudes in organisations and individuals which establishes that, as an
overriding priority, nuclear plant safety issues receive the attention warranted by their significance (INSAG-1, 1986). In INSAG-3,
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it was stated that Safety Culture ‘refers to the personal dedication and accountability of all individuals engaged in any activity which
has a bearing on the safety of nuclear power plants’. It was further stated to include as a key element ‘an all-pervading safety
thinking’. which allows ‘an inherently questioning attitude, the prevention of complacency, a commitment to excellence, and the
fostering of both personal accountability and corporate self-regulation in safety matters’ (INSAG-3, 1988; INSAG-4, 1991).
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Nowadays, this is a consensus which safety culture is a collection of safety concepts, attitudes, commitments, motivations,
responsibilities, and awareness of organisations and individuals (Fu, 2013).
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Fig. 24. Safety performance improvement

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 Although first introduced in 1986, the real development of safety culture began in the 1990s. Figure 24 shows the safety
performances of different periods since the last century. In the past 30 years, safety culture has been deemed as a significant
component of SMSs of many safety-critical industries, including energy (Rosen, 1997; Y. G. Kim, et al., 2018; Robert etal., 2018), oil
and gas (May, 1998; Niresh, 2019), transportation (Payer, 1998; Czech et al., 2014; Michael et al., 2016), food safety (Lone et al.,
2019; De et al., 2019), nursing (Rolsanna, 2018; Cheryl et al., 2019; Christian et al., 2019), mines (Eric, 2019). To emphasise the
guiding role of safety culture in ideology, psychology, consciousness, and acts in the 24modelel, safety culture is regarded as the root
cause of accidents and independent of SMS.
Eric et al. (2019) found that mines with lower incidence rates consistently had higher safety culture maturity scores than mines
with higher incidence rates. Barry (2015) found that examining company actions and decisions directly after an accident can allow
investigators to infer safety culture at the time of the accident. In China, Fu (2013) has classified safety culture into 32 elements.
Therefore, this paper applies this safety culture element table for accident analysis. The insufficiency of safety culture is shown in
Table 3.
Table 3

The insufficiency of safety culture in the Pingyu No. 4 Mine

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No Category Safety culture elements
1 Safety ● Safety Importance
Concepts ● All incidents are preventable
● Good safety is good business

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2 Safety ● Safety and Management Integration
Discipline ● Safety Awareness
● Primary Responsibility for Workplace Safety
● Safety Investment

3 Safety
Responsibility
● Safety Regulations
● Safety Values
● Safety Responsibility of Managers
● Role of Safety Section
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● Individual Involvement in Safety
● Demand of Safety Training
● Responsibilities for Safety in Every Section
4 Safe ● Role of SMS
Measures ● Safety Meeting
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● Formation of Safety Rules

● Enforcement of Safety Rules
● Injury and Incident Investigation
● Workplace Audits-Inspections
● Safety Organization
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● Emergency Capability
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Fig. 25. The development level of safety culture in different regions

According to the analysis of the Pingyu No. 4 Mine accident, the mine’s safety culture construction is deficient. Their
construction of safety belief, discipline, responsibility, and enforcement are seriously inadequate. Consequently, there is no safety
climate, and unsafe actions such as illegal command and operation are frequent. Michael et al. (2016) found that safety culture
interventions can drop at-risk behaviours by 80% and the rate of derailments and other incidents by 81%. Therefore, establishing a
mature safety culture and conducting effective assessments can effectively prevent accidents (Katarzyna and Andrzej, 2016; Niresh,
2019). As can be seen from Figure 25, although China’s safety culture has developed rapidly in recent years, it still lags behind the
USA, England, Netherlands, Australia, and other countries. Figure 26 shows the clustering results of safety culture. Clustering results
show that the most important application of safety culture is food and medical safety culture, while safety culture in the mining
industry needs to be strengthened. Safety culture focuses on the areas of management modelels, safety climate, patient safety,
environmental and occupational health, operational research, management science, and so on.

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Fig. 26. Clustering results of safety culture

5. Coal and gas outburst accidents prevention

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The direct causes of an accident are unsafe conditions and acts (Heinrich, 1931; Fu et al., 2017, 2018, 2019). There are many
ways to prevent accidents. On the basis of DuPont’s safety management philosophy, this paper proposes the prevention of coal and
gas outburst accidents from ‘gas’ (risk control) and ‘humans’ (behaviour safety) (Cf. Fig27).
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Gas extraction Safety acts and safetyability

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Geological exploration Gas Human Safety management system

Prediction & Warning Safety culture

Fig. 27. Coal and gas outburst accidents prevention measures

5.1 Gas risk control

5.1.1 Gas extraction

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 Gas is not only a major disaster source for coal mine accidents but also a major participant in the greenhouse effect. It is a
valuable clean energy source. China’s gas resources are extremely rich, being about 3.15×10 13m3. Therefore, the realisation of
high-efficiency gas extraction is key to gas prevention and control technology and the need for China to achieve clean use of
resources. Despite significant progress in China’s coalmine gas drainage technology, there are still some factors that restrict the
efficient extraction of gas. (1) Gas extraction technology for low permeability coal seams. In some areas, coal seams have low gas
permeability and poor gas drainage. Therefore, measures need to be taken to increase the permeability of the coal seam before
extraction. However, existing methods such as deep-hole pre-split blasting, hydraulic fracturing, hydraulic slitting, hydraulic
punching, and dense drilling and extraction methods have achieved certain effects. Moreover, the process is more complicated, and
the workload is large. Therefore, it is necessary to develop an anti-reflection technique with simple operation and obvious effects. (2)
Improve gas extraction equipment. Regarding development and mining, long drilling directional drilling technology is the
development direction of gas drainage. China should accelerate research on domestic directional drilling rigs and develop more
efficient long drilling techniques and equipment. (3) Research on gas drainage technology for surface drilling. Compared with
traditional gas drainage technology, surface drilling gas drainage technology is a new technology for coal and gas co-production.
However, this method still has some restrictive technical problems in its application. Therefore, China needs to increase the research
and development and application of the technology, and achieve coal and gas co-production across the country.

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5.1.2 Geological exploration
In addition to gas factors, geological factors and coal factors are also important factors affecting coal and gas outburst. Presently,

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it is necessary to conduct exploration work of gas geology. Simultaneously, research in the following areas should be focused on: (1)
Research on gas enrichment and flow law. Combined with gas flow characteristics, mining influence, and gas flow law under
extraction conditions, the coal seam gas flow field modelel under multi-physics coupling conditions are established to predict the
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gas-enrichment area accurately. (2) Accurate detection technology for geological structures. Today, small geological formations in
coal seams are still difficult to detect. These small geological formations often form high-pressure gas zones. It is easy to cause small
coal and gas outburst accidents. (3) Accurate measurement technology for gas content. Accurate gas content determination can
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provide powerful help for gas drainage. It also helps to solve problems that are not easily detected in small high-pressure gas areas in
coal seams. (4) Microseismic monitoring technology. The pressure of the coal seam under the action will change, which will lead to
the flow and enrichment of gas. Microseismic monitoring technology can detect changes in the coal seam and surrounding rock stress
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and provide a reference for gas flow.

5.1.3 Prediction and warning
Prediction and warning are important ways to prevent coal and gas outburst accidents. In practical application results, there is no
accurate and efficient prediction method for coal and gas outbursts. With the advent of the era of big data and artificial intelligence,
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how to achieve the intellectualised prediction of dynamic load monitoring (electromagnetic radiation, acoustic emission, microseism,
and so on), static load monitoring (gas adsorption index, drilling cuttings volume, and so on), gas monitoring (gas content, gas
pressure, and so on) requires a focused study. Simultaneously, it is necessary to develop a gas warning system that can realise
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real-time information collection, intelligent evaluation, and automatic alarms. Additionally, emergency rescue assistance
decision-making, mine emergency communication and personnel precise positioning, emergency escape guidance, and emergency
response and rescue technology need to be further developed.
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5.2 Human behavioural safety

5.2.1 Safety acts and Safety ability
Correcting unsafe acts can prevent accidents. This paper demonstrates that illegal command and operation are the most
important unsafe acts. Figure 16 gives recommendations for improving unsafe acts. Regarding coal and gas outburst accidents, this
paper proposes the following specific measures: (1) Strict implementation of gas comprehensive prevention measures. Numerous
accidents demonstrate the strict implementation of gas comprehensive prevention measures as the most important cause of accidents.
The hidden dangers of gas have not been eliminated, and the subsequent work processes are dangerous. Figure 28 shows the flow of
comprehensive gas prevention measures (National Coal Mine Safety Administration of China, 2009). (2) Arrange work tasks per
regulations and industry standards, and eliminate illegal command. (3) Standardise job operation standards and procedures, and
prohibit illegal operations.
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 Improving the safety ability of workers counters unsafe acts. (1) As shown in Figure 19, safety awareness should be established
within the enterprise, especially to increase the safety awareness and importance of the leadership (Nicole et al., 2019). Only when
the leadership considers safety can the enterprise’s safety management be efficiently conducted. (2) Cultivate correct safety habits by
standardising the system and job procedures. Proper safety interventions are needed to overcome the poor safety habits of frontline
workers (J. Chang et al., 2019). (3) As shown in Table 1, the occurrence of paralysis psychology and fluke psychology is the main
unsafe psychological factor that leads to accidents. To prevent accidents, we should establish correct safety psychology. (4) Last but
not the least is to enhance workers’ safety knowledge. Workers have a wealth of knowledge and a deeper understanding of accident
prevention. Figures 18 to 21 propose corresponding measures for the construction of safety capabilities.

Regional comprehensive prevention measures Local comprehensive prevention measures

of Danger
Danger area

Working face outburst

Danger working face

prevention measures
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Effect test
prevention measures
Regional outburst

Excavation after implementation of safety precautions

Danger area

Effect test

Non-Danger
Working face prediction
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Regional prediction
Outburst Coalmine

Non-Danger area

Danger
every driving 10~50m
Area verification for

Non-Danger working face

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Coalmine outburst risk assessment

Non-Danger area

Non-Danger
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Outbrust Coal
Seam
Non-Outburst Coalmine

Outburst Coal Seam

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implementation of
Identification of

safety precautions
Excavation after
Non-Outbrust

Safe mining
Coal Seam
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Fig. 28. Prevention of coal and gas outburst measures(National Coal Mine Safety Administration of China, 2009)
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 5.2.3 SMS
As shown in Table 2, the coal mine SMS is prone to problems such as improper system operation and lack of subsystems in the
operation process. For the coal and gas outburst accident, this paper establishes an SMS, as shown in Figure 29. The safety
management process is as follows: (1) Coal mining enterprises must have correct safety policies and complete program files. The
absence of program files is not conducive to the guidance and supervision of safe work. (2) Complete sections and safety systems.
For coal and gas outburst accidents, the necessary sections are the coal mine safety committee, safety supervision section, anti-burst
section, ventilation section, and so on. The proper safety system is the anti-burst system, ventilation system, supervision system,
safety training system, information transmission system, emergency management system, and so on. (3) Adequate numbers of
professional staff. The lessons of the accident tell us that non-professionals lack knowledge in related fields, which is not conducive
to the guidance, supervision, and implementation of the SMS. (4) Clear the rights and obligations of the sections and staff. (5)
Commence work. All sections and staff work per their responsibilities and are responsible for safety in their working field. (6)
Implement supervision. All sections must conduct safety supervision in their working field. The Safety Supervision Department
supervises and guides all safety of the coal mine. The Mine Safety Committee assumes full leadership responsibility for the safety of
coalmine.

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Safety policy and
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Coalmine safety committee
Process files

Safety supervision section Dispatching center

Senior Leader
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(safety responsibility awareness)

Organizational Technology section Anti-outburst section

structure
Middle Manager Ventilation section Training section

(safety management and

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supervision awareness) Geodesy section Driving team

Adequate
professional
Frontline Miner
(self-safety awareness) Rights and responsibilities of each staff
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Clear rights and

Physiological health Rights and responsibilities of each department
responsibilities
Good safety habits
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Correct safety psychology Each section works according to their duties

commence to work
Strengthen safety knowledge Each section are responsible for safety within

their own work areas

SMS

Implement The safety section supervises and corrects the

hidden dangers
Safety culture supervision

Fig. 29. Coal and gas outburst accident behavior control and SMS

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 5.2.4 Safety culture
As a high-risk industry, the coal industry has always been characterised by its struggle against unsafe factors, which has
determined that coal companies must put safety first. As shown in Figure 24, as a high-level stage of modelern enterprise safety
management, safety culture must establish a set of self-improvement, self-discipline, and continuous improvements of safety
management mechanisms to encourage workers to form correct safety concepts and safety habits.
As shown in Table 3, the lack of safety culture in coal mining enterprises is mainly reflected in safety concepts, safety discipline,
safety responsibility, and safety measures. (1) Safety concepts can also be understood as the company’s safety policy or safety wishes.
‘All incidents are preventable’ and ‘good safety is good business’ is a widely recognised safety concept. Enterprises must allow
workers to understand and recognise these safety concepts, and truly integrate safety beliefs into their work. (2) Safety discipline.
The safety disciplines observed in daily work include laws and regulations, industry standards, technical specifications, and corporate
rules and regulations. The formation of a safety culture familiarises workers with safety disciplines and integrates them into safe
production and management. (3) Safety duties mainly refer to the implementation of the SMS, including leadership responsibility,
departmental responsibilities, and employee participation. (4) Safety measures are the methods adopted to ensure safe production,
including safety training, safety meetings, and emergency capabilities.
Senior leaders are the most important supporters of enterprise safety culture construction. The middle managers are the most

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important implementers of enterprise safety culture construction. The frontline miners are the most important participants in the
construction of corporate safety culture. Let all workers invest in the construction of safety culture. The construction of safety culture

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should be diverse. It can be spread by various means of communication, such as text, video, and sound. It can also hold
safety-themed activities, safety competitions, and case shows.
Conducting a safety culture assessment can help improve a company’s safety culture (Katarzyna and Andrzej, 2016; Niresh,
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2019). Through the safety culture assessment, we have a detailed understanding of the overall safety level of the workers, as well as
the construction of each safety culture element. The construction of safety culture should be a dynamic process. Safety culture should
constantly be improving.
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6. Discussion
This paper finds that human errors are the main cause of accidents, and the senior leaders’ errors are the most unsafe acts that
are difficult to correct. Additionally, the lack of accident information transmission systems and emergency management systems and
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the lack of safety training are also important causes of accidents. These three problems commonly exist in accidents, and urgently
need to be resolved. However, these three problems are challenging to solve. This paper discusses these three problems and hopes
that more readers will realise better solutions.
6.1 How to correct the human errors of senior leaders?
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The senior leadership is the decision-making level of the enterprise. They often play a decisive role in the choice of the
production process, the construction of SMS, and safety investment. They are at the top of corporate rights. When they do not focus
on safety, or they take wrong decisions, terrible consequences may occur. The main reason for the coal and gas outburst accidents
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analysed in this paper is the slack implementation of comprehensive gas prevention measures by the leadership. Nicole et al. (2019)
found that training leaders have an important role in improving safety.
Human errors of senior leaders can be corrected through the following measures: (1) Safety attitude and safety awareness. Only
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by increasing the safety attitude and safety awareness of the leadership can corporate safety be improved (Laura et al., 2019). (2)
Safety knowledge and legal awareness. When the leadership has safety knowledge and legal awareness, they will consciously
implement the safety responsibility system and consciously increase their safety investment (Sarah et al., 2013). (3) Government
supervision and management. This is the most effective method. The government safety management department should check the
safety of the enterprise and train the leadership. For leadership that does consider safety, it is necessary to impose economic penalties
and sanctions. Only when the leadership considers safety is the safe production of the enterprise guaranteed.
6.2 How to establish a hidden danger information transmission system and emergency management system?
The hidden danger information transmission system and emergency management system are important components of the SMS.
They are the safeguard procedures for the emergency handling of accidents. Unfortunately, in most companies in China, these two
systems are problematic. (1) The system construction is chaotic. There are serious unsafe acts such as false negatives and false
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reports. False negatives and false reports impede accident information transmission. (2) The transmission of hidden danger
information is still based on people. Realising the awareness and transmission of intelligent disaster information is the future
development direction. (3) The hidden danger information transmission program is too cumbersome. Some accidents may take only a
few minutes from a warning to an occurrence. The process of reporting by level affects the efficiency of information transmission. In
China, the Coal Mine Safety Regulations (State Administration of Work Safety of China and National Coal Mine Safety
Administration of China, 2016) stipulates that ‘the team leader, the gas inspection worker, and the mine dispatcher have the right to
order the on-site operators to stop operations and power off the evacuation.’. However, in reality, it is difficult for them to have the
right to make a withdrawal order. (4) Lack of professional emergency rescue team and rescue technology.
This paper believes that improvements can be made from the following aspects: (1) The state should demand the construction of
two systems from point of view of regulatory and industry standards, giving the two systems a higher safety status. (2) Regulations or
industry standards should clearly define the process of accident information transmission and give frontline workers more rights. (3)
Intelligent research on the perception and transmission of disaster information to achieve efficient disaster information
decision-making should be strengthened. (4) The company should establish an emergency management system and an emergency
rescue team and establish cooperative relations with local emergency rescue forces. (5) The government should organise scientific
research forces to research and develop early warning and rescue technologies for major disasters. The research results should be

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promoted and applied nationally. (6) Regional mine rescue teams should be established nationwide.
6.3 How to conduct safety training?

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Conducting safety training is an obligation and responsibility of the company. In China, Coalmine safety training regulations
(State Administration of Work Safety of China, 2018) required training time for coalmine leaders, safety managers, and works. There
are four main problems in current safety training: (1) The current Coal mine safety training regulations are too succinct for training
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content. (2) Because of the lack of supervision and inspection, the actual first training time and retraining time of the coal mine is
insufficient. (3) The content of safety training does not meet the requirements set by the state. The current safety training mainly
educates on safety attitude, awareness, and psychology. Workers generally lack knowledge of laws and regulations, technical
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standards, safety expertise, hidden danger identification, and emergency rescue. (4) Safety training fraud.
Safety training is critical to the safe production in a company. This paper believes that the current chaotic safety training
situation should be rectified. (1) Combined with the characteristics of coal mine disasters, it is necessary to introduce more specific
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safety training programs and assessment standards. (2) Education in professional knowledge such as laws and regulations, technical
standards, safety system construction, hidden danger identification, and emergency rescue knowledge should be strengthened. (3)
Coal mining enterprises should formulate annual training plans, training content, and training time and establish enterprise safety
training files and training files for miners. (4) The government safety management department should check the training time and
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training content of the coal mines, and the workers should be assessed for training knowledge. Penalties should be imposed on
companies that fail to meet training standards and fraud. (5) The government safety management department should organise the
safety training of company leaders and the safety manager. Their safety awareness, safety attitude, and safety responsibility should be
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improved.
7. Conclusion
To clarify the macroscopic laws of coal and gas outburst accidents, this paper conducted a statistical analysis of 148 coal and gas
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outburst accidents in China from 2008 to 2018. The research results are: (1) China’s coal and gas outburst accidents and deaths are
decreasing year by year, and March, May, July, and August are the main times for accidents. (2) The second to fourth hours of work
and the first hour before the end of the work are the peak periods of the accident. (3) According to the statistics of the week, the
probability of daily accidents is evenly distributed. (4) Guizhou, Hunan, Henan, Sichuan, Yunnan, and Chongqing are the most
important provinces for accidents. (5) 75.82% of accidents occurred in the driving face, and 81.08% of the accidents occurred in coal
and gas outburst mines. (6) Blasting, drilling, driving, and coal falling are the main inducing factors.
To understand the causes of coal and gas outburst accidents in more detail, this paper applies the 24modelel to analyse coal and
gas outburst accidents. The accident case analysis found that: (1) Human error is the most important cause of accidents. The main
unsafe acts are the lack of strict enforcement of outburst prevention measures and the illegal command and operation of miners. (2)
The most needed knowledge at present is ‘risk awareness and control’, ‘laws and regulations and industry standards’, ‘safety
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standardisation operations’, and ‘accident hazard information transmission and emergency response’. (3) Habitual violations are the
most serious unsafe habits of miners. (4) Paralysis, fluke, and convenient psychologies are the most serious unsafe psychologies. (5)
The comprehensive gas prevention system and supervision system in the coalmine SMS can be readily operated without proper care,
and the safety training system and emergency management system are easily overlooked. (6) Coalmine enterprises seriously lack
safety culture.
This paper proposes preventive measures for coal and gas outbursts from the two aspects of ‘gas’ (risk control) and ‘human’
(behavioural safety). Regarding gas risk control, preventive measures are proposed from three aspects: gas extraction, geological
exploration, prediction and warning. Regarding unsafe human acts, control is proposed from three aspects: safety acts and ability,
SMS, and safety culture.
Finally, this paper discusses three common problems that need to be resolved in an accident: (1) how to correct the human errors
of a senior leader; (2) how to establish an accident risk information transmission system and emergency management system; (3) and
how to conduct safety education. Thus, the suggestions and measures are put forward.

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Conflict of interest statement

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We declare that we do not have any commercial or associative interest that represents a conflict
of interest in connection with the work submitted.

Acknowledgments
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This work was supported by the National Natural Science Foundation of China (Grant No:51534008) and the Chinese
Fundamental Research Funds for the Central Universities (Grant No:2010YZ04). The authors are grateful to the editors and
anonymous reviewers for their suggestions in improving the quality of the paper.
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