NSW Mine Safety Investigations Update

25th Mechanical Engineering Safety Seminar

9-10 September 2015

NSW Mine Safety Investigations Update – Tony Smith – Senior Investigator – 10 September 2015

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NSW Mine Safety- industry report 12 month period from 1 July 2014 to 30 June 2015

(excludes petroleum)

2,097 notified incidents to NSW Mine Safety

• Serious injuries 34 (coal) and 14 (metals & other) • 2 fatal incidents at surface extractives mines

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The incident triangle for 2014-15

48 serious injuries 31 fractures 7 amputations 1 injection of fluid 9 other types of injuries 308 reported outcomes of injuries 71 hospital admissions 29 medical treatment 7 lost consciousness

2,097 reported incidents 1,491 underground 606 surface

2 fatal incidents Excavator roll over at a quarry - 9 September 2014 Electric shock in a residence - 27 August 2014

All incidents notified to NSW Mine Safety for 2014-15

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Fatal electric shock in a residence 27 August 2014

A person was found deceased in a house near a quarry at Cudal (Orange), NSW. The house was supplied with electricity from the quarry’s electrical supply system.

Industry information release http://www.resourcesandenergy.nsw.gov.au/__data/assets/pdf_file/0009/542475/IIR15-01-Fatality-at-house-near-quarry.pdf

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Fatal crush in an excavator tip over 9 September 2014

An excavator operator was using a track-type excavator above a quarry bench near Karuah, NSW. The excavator was on uneven ground with a cross-gradient. The excavator tipped over.

Industry information release http://www.resourcesandenergy.nsw.gov.au/__data/assets/pdf_file/0009/534069/IIR1406-Investigation-Information-Release-Karuah.pdf

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Conference theme

Evolution of Mechanical Safety Investigation case study Mobile elevated work platform

Incident review High pressure energy release during maintenance

Mobile equipment interaction

Maintaining plant explosion protection systems

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Conference theme

Evolution of Mechanical Safety Investigation observations

Primary reliance placed on lower order hierarchy of risk controls - the easier option o training, administrative controls, PPE

Risk assessments are not effectively identifying and implementing higher order mechanical engineered risk controls – the harder option o Hard mechanical barriers to isolate

uncontrolled energy ‘Reasonably practicable’ mechanical

engineering risk controls are not being implemented

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Case study- Mobile elevated work platform Fatal incident – 21 May 2014 at a mine construction site

Risk controls relied upon: Plant unintended activation design Plant supplier risk assessment Operator held RTO training

qualifications for the specific MEWP NSW Workcover high risk licence held Site verification of operator

competency on the specific MEWP Plant pre-start checks Generic task/plant risk assessments Generic safe work procedures Working at heights permit Spotter present near the MEWP base

The Incident: MEWP operator (Rigger) received a fatal head and neck crush injury in a pinch point between the platform console frame and the underside of a steel beam.

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Investigation report findings

Ultimately the lower order risk controls relied upon failed to prevent the crush injury.

Whilst the specific causation cannot be identified the most likely cause of the platform to rise:

- A person located on the walkway adjacent to

the platform gave the operator a verbal warning about the platform moving upwards under the beam just prior to incident

- Operator, stopped the platform, then:

- likely he leant forward over the controls and his body contacted a switch

- or he incorrectly operated a control device

- Engineered controls on the platform to

reduce unintentional operation: - Operator active decision to engage the

covered footswitch - Timed seven second console activation

window then no movement is possible - Raised molded guard against each

console switch

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Damaged rubber cover on joystick control and corrosion found on electrical board

A damaged rubber cover

(boot) on the lift swing joystick control device had not been identified by any pre start or maintenance inspection. Corrosion was found on the hall-effect electrical control board of the joy stick. Investigation testing conducted to Australian Standards could not prove that the less than optimal condition of the lift swing joystick electrical control board caused an unintended upwards movement of the platform.

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Secondary guarding devices use in Australian access industry

Secondary Guarding Device A device in addition to primary guarding to reduce the risk of entrapment. • Physical barriers • Pressure sensing devices February 2013 OEM advertised to Australian industry a Secondary Guarding Device was available July 2013 European standards EN280:2013 MEWP required secondary guarding options and allowed an 18 month transition to Jan 2015 14 May 2014 OEM sought Australian Design Registration (ADR) for the secondary guarding device 21 May 2014 Fatal incident at the mine 10 June 2014 ADR awarded by Worksafe WA for the device

The OEM had provided quotes to Australian access industry to supply the secondary guarding device but no orders had been received.

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Mobile elevated work platform Recommended practice for industry – in proximity to fixed structure

1. MEWP access in proximity of fixed structures – hierarchy of control • Are there safer alternate access methods – scaffolding • Selection of MEWP – don’t rely entirely on generic risk assessments • Use secondary guarding devices on MEWP

2. Work Permit System - Pathway of MEWP moving in proximity to fixed structures • Specific task assessment with the MEWP operator and spotter doing the task - similar process to a

crane lift (AS2550.10 MEWP safe use) - supervisor sign off • Identify the access pathway – plan complex three dimensional movements of platform sequence • Establish ‘No Go Zones’ with visual marking devices – flagging tape, electronic warning systems • Determine acceptable clearances for the task

• Do operators crouch down or lean over the platform controls in a tight location? • What is an acceptable proximity distance to the platform or boom?

3. Plant - fit for purpose checks • Pre-start checks to include inspection for damaged joystick rubber covers. 4. Training and competency of operator • MEWP operators to be challenged with complex move sequences to prove ‘Verification of

Competency’. Does every operator ‘pass’ VOC. Prepare a competency ‘failure’ re-training process 5. Industry information • Update training guidelines by access industry groups and regulators • Australian Standards should be reviewed with European Standards

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Safety Bulletin and Investigation Report published

May 2015 August 2015

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Incident review – High pressure energy release during maintenance. Comparison of Mechanical vs Electrical energy incidents for 2014/15

Electrical: 16 contacts with high voltage energy Mechanical: 147 escapes of high pressure fluid HP energy isolation, guarding and pressure removal systems during maintenance are available Issues with operator competence with the HP system Several incidents with Apprentices placed at risk in the energy release

Data range 1 January 2013 to 12 May 2015

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High pressure energy release during maintenance. Reported issues

Maintenance people struck by hydraulic fluids, air and water Staples still a problem - falling out and intentional removal, engineered

alternatives to staples are available Residual energy isolation system failures during maintenance Failure to ensure HP guarding systems in place for maintenance

Data range 1 January 2013 to 12 May 2015

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High pressure energy release during maintenance

Are your maintenance people required to remove staples ? - Do they use hard barriers to isolate any energy release ? - Have they dissipated and confirmed release of stored energy ?

Fatal incident on a longwall pump station on 26 July 2006. Removed a staple with a shifter on a energised hydraulic line at 300 bar Safety Alerts SA06-16 SA06-18, SA14-03, SB13-01, SB12-03

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Incident review – Mobile equipment interactions 2014/15

Collisions 82 events Underground = 28 Surface = 54

Unplanned movement or unintended activation 202 events

Underground = 109 Surface = 93

WHSMR14 commenced 1 February 2015 Surface includes open cuts, processing plants and exploration

Investigation Report published Consider higher order engineering design risk controls: - Light vehicle (LV) to heavy vehicle (HV) roadway segregation - Road and intersection design – sight lines at intersections - Improve HV truck tub visibility at night time for the LV driver consider the headboard and sides of tub - Proximity detection systems

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Incident review – Maintaining plant explosion protection systems 2014/15

Gas trips/detections for underground coal 369 events Failure of Ex. protection systems for underground coal 309 events

Maintaining the integrity of higher order engineered risk controls for explosion protection systems: General issues: - Water scrubber tank test failures - Incorrect bolt types found in Ex. Plant - Non compliance of Ex. with plant serviced by registered workshops returning to site - Refer to Safety Bulletin SB12-01

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Conference theme

Evolution of Mechanical Safety In summary Review your site risk assessments for over reliance placed

on lower order hierarchy of risk controls – taking the easier option

Question why site risk assessments are not effectively identifying and implementing higher order mechanical engineered risk controls – the hard isolation barrier option

Encourage a ‘paradigm shift’ in risk assessment outcomes to

move towards higher order hierarchy of risk controls at your mine site.