M i n e S a f e t y I n v e s t i g a t i o n
U n i t
M i n e S a f e t y I n v e s t i g a t i o n
U n i t
Investigation
Report
Serious
injury
involving
a
fall
from
height
at
the
Perilya
Broken
Hill
Southern
Operation
on
6
November
2007
Report
prepared
for
the
Director
‐
General
of
the
Department
of
Industry
and
Investment
by
the
Investigation
Unit,
Thornton
Title: InvestigationReport,
Serious injury involving a fall from height at the Perilya Broken Hill Southern Operation on
6 November 2007
Author:MarkFreeman,Investigator,InvestigationUnit,Thornton
©StateofNewSouthWalesthroughDepartmentofIndustryandInvestment ‐2010 Thispublicationiscopyright.Youmaydownload,display,printandreproducethismaterialin anunalteredformonly(retainingthisnotice)foryourpersonaluseorfornon‐commercialuse withinyourorganisation.Tocopy,adapt,publish,distributeorcommercialiseanyofthis publicationyouwillneedtoseekpermissionfromtheManagerPublishing,Departmentof IndustryandInvestment,Orange,NSW.
Forupdatestothispublication,checkhttp://www.industry.nsw.gov.au/ PublishedbyDepartmentofIndustryandInvestment
FirstPublishedJune2011 ISBN
Acknowledgements Disclaimer
Theinformationcontainedinthispublicationisbasedonknowledgeandunderstandingatthe timeofwriting.However,becauseofadvancesinknowledge,usersareremindedoftheneed toensurethatinformationonwhichtheyrelyisuptodateandtocheckthecurrencyofthe informationwiththeappropriateofficeroftheDepartmentofIndustryandInvestmentorthe user’sindependentadvisor.
C o n t e n t s
Overview...3 Themine... 3
Thefixedplant...4
Themaintenancecrew...5
Theincident...6
Theinjuredperson...9
Actiontakenbythemine...10
Actiontakenbythedepartment...11
Theinvestigation...12
Findings...13
Strategiestopreventrecurrence...17
O v e r
v i e w
Theincident Atabout3.00pmon6November2007IanBattams,anunderground maintenanceworkeratthePerilyaBrokenHillSouthernOperations, fellthroughthehandrailofaraisedwalkwaywhilecleaningthescreens ofthemine’sdewateringfiltrationsystem.Hefellabout2.5metresto aconcretefloorsufferingseriousinjuriestohisrightleg,includinga brokenfemur.
The
mine
Themine: PerilyaBrokenHillSouthernOperations Minelocation: WentworthRoad
BrokenHill NSW 2880
(about3kilometressouthofBrokenHillCBD) Ultimateholding PerilyaLimited
company:
Operatorofmining PerilyaBrokenHillLimited operation:
Numberofemployees 760 (September2008theworkforcewasreducedto320) atminingoperation:
Production: 1.9milliontonnesperannumoflead,silverandzinc bearingore
Minelocation andproduction
ThePerilyaBrokenHilloperationsarelocatednearBrokenHill,NewSouth Wales,1160kmwestofSydney. Theoperationscover1,042squarekilometres ofprospectiveterrain. ThisincludesminingleasesincorporatingtheSouthern Operations,theNorthMine,thePotosiTrend,andthehistoricLittleBrokenHill andPinnaclesareas.
MiningattheBrokenHilloperationsuseslongholeopenstopingmethodof extractionintheremnantstopes,narrowlensesandcrownpillarsleftbythe previousoperations. Theproductionrateatthetimeoftheincidentwasabout 1.9MtpafromtheSouthernOperationand0.2MtpafromtheNorthMine. From this110,000tonneoflead/silverconcentrateand266,000tonneofzinc
concentrateareproduced. TheseproductsaresentbyrailtoPortPirieinSouth AustraliatobesoldtosmeltersandrefineriesinAustralia,KoreaandtheUSA.
PerilyaBrokenHillLimited(PBHL)managesandoperatesthePerilyaBrokenHill minesonbehalfofPerilyaLimited. PerilyaBrokenHillLimitedisawhollyowned subsidiaryofPerilyaLimited.
ThePerilyaBrokenHillSouthernOperationsundergroundworkingsandthe incidentsitearecontainedwithinConsolidatedMiningLeaseCML8(1973).
Thecompany PerilyaLimitedisanAustralianbasemetalsminingandexplorationcompany withaheadofficeinPerth,WesternAustralia. Alongwithitszinc,leadand silvermineinBrokenHill,thecompanyoperatestheFlindersProjectinSouth AustraliaandtheMountOxideProjectinQueensland.
PerilyaacquiredtheBrokenHillmineinMay2002. Itisoneofthelargestand mostrenownedzinc,leadandsilverminesintheworld,havingbeenin productionsince1885andproducedover200milliontonnesofore. InFebruary2009,ShenzhenZhongjinLingnanNonfemetCo.Ltd(‘Zhongjin Lingnan’),China’sthirdlargestzincproducer,acquireda50.1%interestin Perilya.
The
fixed
plant
Theplant: Pre‐screens
Location: Undergroundat23LeveloftheSouthernOperations Function: Dirtywaterfromthemineworkingsispipedtothepre‐
screenswereitisfilteredbyaseriesofscreensbefore beingsenttothe24Levelwerelargepumpsareusedto recyclethewatertothesurfaceforuseinoreprocessing andundergroundmining.
Datebuilt: TheplantwascommissionedbyPasmincoLimitedinabout 1991withthemaintenanceplatform(walkway)being addedin1992.
Constructionstandard: Theplant,atthattime,wasrequiredtobebuilttothe relevantAustralianStandards(SAAcodes),includingSAA CodeforFixedPlatforms,Walkways,StairwaysandLadders (AS1657‐1985).
23LevelPre‐screens (PhotobyInvestigator MarkFreeman)
The
maintenance
crew
Mineservices TheminingdepartmentoftheSouthernOperationsincludedamineservice division. Mineserviceslookedafterallplant,equipmentandmineservices associatedwiththeundergroundinfrastructurethatsupportsmining. This includesfixedplantforshaftsandwinders,ventilation,sandfillandground control.
Serviceteams Mineserviceswasthenfurtherdividedintospecificteamslookingafterfixed plant,projects,infrastructureandmineservices. Thefixedplantteamis responsibleformaintainingthefollowingplantandequipment:
Primary Loadingstation 21crusher 24crusher 24pumpstation 23pre‐screens Secondary Satellitepumps
Tru‐flo(Fitzroycrossing) Submersiblepumps Rockbreakers
T h e
i n c i d e n t
Startingwork OnthedayoftheincidentMrBattamsbeganworkatthePerilyaBrokenHill SouthernOperationsatabout7.00am. Heattendedastartupmeetinginthe FixedPlantCoordinator’sofficeandthenwenttoasafetymeeting.
Receivingthe day’s
instructions
Atabout7.40amMrBattams,withtheotherfourmembersofthefixedplant team,returnedtotheCoordinator’sofficetoreceivetheirworkinstructionsfor theday. Theteamthencaughttheshaftman‐cagefromthesurfacemarble archdowntothe24Level.
Atthe24Leveltheystoppedatthecribroomandofficetoputtheirlunches awayandhavecoffee. Theythenwenttotheirrespectivejobs.
Servicing24level pumps
MrBattamsmaintainedthe24Levelpumpstationregularlyeachshift.He inspectedthepumps,checkedtheoilandwaterlevels,andtookpressureand hourreadings,whichhenotedinabook. WhileatthepumpsMrBattams cleanedthesieves,ataskrequiringthepumpstobeturnedoffandisolated. He notifiedtheMineControlCentre(MCC)whenhedidthis.
Themaintenanceatthe24pumpstationwasajobthattooksometime. Mr Battamsdidnotfinishuntilabout12:50pm. Heperformedthisworkalone, whichwasusuallythecase.
Finalcheckon thepumps
Afterhavinglunchinthecribroom,MrBattamsreturnedtothe24pump stationtodoafinalcheckthatthepumpswererunningsatisfactorily. Thenhe wenttowheretheIntegratedToolcarrier(IT)wasparkedandcompletedapre‐
startcheck.
DrivingITto23 level
MrBattamsdrovetheITuptheinclinetothe23Levelmaintenancebay. He parkedtheITandthenwalkedbackpastthe23platintothepre‐screenarea. Onarrivalhedidaquickvisualcheckofhissurrounds.
Cleaningpre‐
screenfromfloor
Satisfiedtheareawassafefromrockfall,MrBattamsgotthenearbywaterhose andhoseddownthetwotroughsatfloorleveloneachsideofthepre‐screens. Whenhefinishedthefloorlevelcleanuphedraggedthewaterhoseuponto theraisedwalkwaysohecouldhosethescreens(seethefollowingphoto).
Left(front) access ladder Waste trucks Concrete floor Cleansscreens fromwalkway Stumblesand falls Laddertocrows nestandsign
Raised walkwayand handrails Right(rear access)ladder Waterhose
MrBattamsusedtheladdernearthesteamhighpressurecleanertoaccessthe walkway(seenonrightofphotoabove). Onthewalkwayhepickedupthehose andcleanedthestepsthatwereraisedabovethewalkway. Thatdonehehosed downthescreensstandingontheraisedstep,withthewastematerialfalling intothetrucksbelow. Eachsectionofscreenhasastrainerateachend. Mr Battamshosedonestrainerandthenturnedtostepbackontothewalkwayto gototheotherstrainer.
AccordingtoMrBattams,whilesteppingbackontothewalkway,hestumbled hittingthehandrailsoftheelevatedplatform. Hecouldnotexplainwhyhelost hisfooting. Ashefellitappearshegrabbedattheladderneartohimtostop himself,butapieceofladdercameawayinhishand(seefollowingphoto).
Brokenladder SectionofhandrailMr
andsign Battamsfellthrough
Screens
23LevelPre‐
screenswalkway
Missingsections (Photoby
ofhandrail
InvestigatorMark Freeman)
TheraisedstepMr
Battamssteppeddown
Fallstoground
Injuredandwaits forhelp Teambecomes worried Fitterfinds injuredco‐ worker Rescueteam arrive Ambulanceto hospital
ThehandrailgavewayundertheimpactofMrBattam’sfallingbodyandhefell about2.5metrestotheconcretefloorbelow.
Lyingonthefloor,MrBattamssawhehaddislocatedafingeronhislefthand. Althoughhecouldn’tseehisrightleghecouldwrigglehistoes. Butwhenhe triedtogetuphefoundthelegwouldnotsupporthimandhewasinpain. He laybackdowntoeasethepain,usinghishelmettosupporthishead.
MrBattamsgothiscaplampandshoneitupthedriveinthehopesomeone wouldseeitandcometohisaid. Hecheckedhiswatchandfounditwasabout 3.00pm.
Hemadehimselfascomfortableaspossibleandcontinuedtocalloutforhelp. Atonepointheappearstohavelostconsciousnessforsometime.
Byabout6.20pmtheotherteammembersbecameworried. MrBattams usuallyreturnedtothe24LevelwithhisITatabout6.15pm.
Amaintenancefitterwentinsearchofhim. HedrovehisToyotauteupthedrift fromthe24Leveltothe23Levelpre‐screenstocheckonMrBattams.
Whenthefitterenteredthepre‐screenshefoundMrBattamsonthefloorlying onhisleftsidefacingthescreens. MrBattamstoldhimhecouldn’tmoveashe hadinjuredhisrightlegandneededmedicalhelp. ThefitternoticedthatMr Battamsappearedtobeindiscomfortandwaswetandshaking.
MrBattamsaskedthefittertocallforhelpfromthe23Levelplatphoneasthe phoneatthepre‐screenswasnotworking. Thisthefitterdid. TheMineControl Centreaskedhimtostayatthe23Levelplatphone. Afterfinishingthiscallthe fittercalledthe24Levelofficeandalertedtherestoftheservicecrewtothe situation.
Inresponseservicecrewmembersandtheplatmanwenttothepre‐screens areatohelpandcomfortMrBattams.
Oneofthecrewreturnedtothe23platandthefittertoldhimtotakethecage uptothemarblearchtogettherescueteam.
Theminesemergencyprocedurewasputintoaction. Whentheminerescue teamarrivedtheygaveMrBattamspainreliefandplacedhisleginapositionfor transport. Ittookaboutanhourtogethimtothesurface. Oneofhisservice crewmatessaidthatMrBattamswasinconsiderablepainforthewholeofthe trip.
TherescueteamandMrBattamsarrivedatthesurfaceatabout7.45pmwhere anAmbulancecrewwaswaiting. TheyplacedMrBattamsintheambulanceand gavehimmorphinetoeasethepain.
HewastakentotheEmergencyDepartmentatBrokenHillBaseHospital. His familymethimonarrival.
diagnosed FlowntoSouth Australia Transferredto hospitalnear home
asafracturedfootandbrokenfemuroftherightleg,andbrokenboneand dislocatedfingerofthelefthand.
NextdaymedicalstaffdecidedMrBattamsshouldbeflowntoAdelaide,South Australia,forsurgeryandfurthertreatment.
ThesurgeryperformedinAdelaideinvolvedinsertingaplateintohisrightfoot, andarodandanumberofpinsrepairedhisbrokenfemur.
MrBattamswaslatertransferredtoMilduraBaseHospitalinVictoria,which wasnearhishome,forfurthercareandrehabilitation. Hewasreleasedfrom hospitalon23November2007tocontinueconvalescenceathome.
The
injured
person
Name: IanJamesBattams Ageattimeofincident: 53years
Sex: Male
Occupationattimeof Mechanicaltradesperson incident:
Miningexperience: 30yearsinthehardrockminingindustryatBrokenHill Taskexperience: 5years
EmployerPerilya BrokenHill
IanBattamswasemployedbyPerilyaBrokenHillLimitedasaMechanical Tradesperson.
Hehadworkedintheminingindustryforabout30years. Mostofhisworkwas attheBrokenHillmines,includingwiththepreviousmineoperatorPasminco BrokenHillMinePtyLimited. Heoperatedvariousminingmachineryduringhis career.
Returntowork MrBattamsreturnedtoworkinAugust2008performinglightduties. He workedinthesurfaceworkshopuptofivehoursaday,MondaytoFriday. At thatstagehisfracturedrightleghadnothealedandheneededametalcrutch toaidstandingandwalking. Hecontinuedwithrehabilitationand
physiotherapy.
InApril2009heresumedfulltimework,ona5‐dayroster.Hewasdoingminor repairstopumpsintheabovegroundsouthworkshop. Hisrightlegfracture hadnothealedandhecontinuedtoexperiencepaininhisleg,thighandknee. Althoughhewasnowabletowalkunaided. Hecontinuedrehabilitationat BrokenHillandwithaprivateproviderinMildura.
Current condition
AsatJune2010MrBattamswasabletowalkmorefreelyafterhavingametal screwremovedfromthetopofhisrightfemurwhichcausedpainand
discomfort. Hehadalmostregainednormalstrengthinhislegandtheleg fractureshadhealed. Hestillhadsomedifficultygettingupfromalay‐down positionandwithmountingsteps.
Duetotheincident,MrBattamsnolongerwantstoreturntoworking underground.
Action
taken
by
the
mine
Initialactions Theincidentsitewascordonedoffandthescenepreservedforinvestigation.
Corroded Theredundantladderwaytothecrowsnestabovethepre‐screenswas
steelwork removed,alongwiththewalkwaystructureanditsaccessladderways.
removed
Riskassessment Ariskassessmentwasconductedtoidentifyinterimmeasuresforcleaningthe screens. Theriskassessmentdeterminedthatascissorliftwouldbeusedto hosethescreens.
Structuralreview InJune2008Perilyahadanexpertengineeringcompanyconductastructural reviewofallundergroundsteelwork. Thiswasrequiredbyrecommendations identifiedduringthecourseofthisinvestigation.
Replacement Perilyarevieweddesignsforareplacementwalkwayforthe23Levelpre‐screens
walkwaydesigns inJune2008.
Newwalkway Followingtheincidenttheminereassessedthepre‐screensandbeganan
completed evaluationandupgradeproject. Pipeworkandotherstructureswerereplaced, withapermanentraisedwalkwayandaccessbeingcompletedinJune2010. The23levelpre‐screensareaupgradealsoincludedinstallingimprovedlighting, ventilationandcommunications.
Investigatingthe incident Feedbacktothe injuredworker Feedbackto MineSafety Operationsand minemanager Monitoring improvementsat themine
TheCobarofficeoftheDepartment’sMineSafetyOperationswasnotifiedby phoneoftheincidenton6November2007,anarrangementthatisinplace whennoInspectorisavailableinBrokenHill. TheBrokenHillofficewasnotified oftheincidentbyCobar’sInspectorofMines,whentheBrokenHillInspector returnedfromleave,on12November2007.
TheInspectorofMinesfromtheBrokenHillofficeattendedthemineon13 November2007. ThenextdayheissuedaSection91improvementnotice undertheOccupationalHealthandSafetyAct2000forremedialworkonthe23 Levelpre‐screensinfrastructuretopreventrecurrence. Thisnoticerequired Perilyatoassesstherisksassociatedwithworkingaroundtheplantandto implementsuitableriskcontrols.
AnoticewasissuedbytheInspectortotakethepre‐screensectionsofhandrails andladderstileasexhibits. Theseexhibitswheretakenintocustodybythe Investigatoron20November2007. TheexhibitswerereturnedtoPerilyaon16 April2008toassisttheirinvestigationoftheincident.
TheInvestigationUnitconductedadetailedandthoroughinvestigationintothe incident.Thisincludedexaminingthefixedplant,theemployer,andthesafety managementandmaintenancesystemsatthemine.
TheInvestigatormetwithMrBattamson29November2007athishomein Victoria. Atthismeetinghewasprovidedwithinformationregardingthe investigationprocessandhisrightsasapotentialvictim.
TheInvestigationUnitcontinuestoprovideMrBattamswithfeedbackonthe investigationanditsresults.
AnumberofissuesweredrawntotheattentionofMineSafetyOperationsand theminemanagerduringthecourseoftheinvestigation. Theseissuesincluded:
•
theinspectionandrepairoffixedplantandstructuresinthe undergroundenvironment
•
risksofpersonsworkingalone
•
theongoingtemporarymeasuresforthecleaningofthepre‐screens
•
useofintegratedtoolcarriersasman‐basketlifts
•
qualityofriskmanagementatthemine;includingidentifying potentialrisksandtheapplicationofthehierarchyofcontrols. MinesafetyoperationsofficersfromBrokenHillhadseveraldiscussionswith PerilyaBrokenHillmanagementregardingthestatusofremedialworkandthe proposeddesignforthereplacementwalkwayatthe23levelpre‐screens. InspectorsfromBrokenHillcontinuedtoreviewtheprogressmadebyPerilyain changestothepre‐screensarea,includingreviewoffinaldesignsforthe
Safetyalert The Department’s Authority Thelinesof inquiry Department officers inspectedthe incidentscene
Asafetyalert,SA08‐06Workerfallsthroughguardrailwasreleasedtoindustry bytheChiefInspectoron14April2008.
Thesafetyalertcontainedrecommendationsfortheminingindustryinregardto thetestingofhandrailsinaccordancewithpublishedAustralianStandardsand theneedtoundertakeeffectivepreventativemaintenance. Theissueof personsworkingalonewasalsoaddressed.
T h e
i nv e s t i ga t i o n
TheDepartmenthasauthoritytoinvestigatetheincidentasitoccurredatan undergroundmetalliferousmine.
TheDepartment’sinvestigatorwholedtheinvestigationintotheincident,Mark Freeman,holdsanidentificationcardissuedundersection48ofthe
OccupationalHealthandSafetyAct2000(OHSA).
Asaresult,InvestigatorFreemanisauthorisedtoexercisefunctionsunderthe OHSAwithrespecttoamine,andotherpremises,forthepurposeof
investigatinganymatterundertheOHSAinrelationtoamineandmining workplace.
InvestigatorFreemanwasgivencarriageoftheinvestigationon16November 2007.
Theinvestigationfocussedonthepre‐screenfixedplantanditsmaintenance, alongwithriskcontrolsforpersonsworkingalone.
Linesofinquiryincluded:
•
inspectionoftheundergroundfixedplant
•
obtaininginformationfromtheemployer,minemanagementandother mineservicestradespeople
•
obtaininginformationonthefixedplant,includingoriginaldesignplans
•
examinationofdocumentsandotherwrittenrecords;withafocuson pre‐screeninspections,maintenanceandrepairs,safework
arrangementsandsupervision.
On14November2007officersoftheDepartment’sBrokenHillofficeconducted asceneassessmentoftheincident.
InvestigatorFreemantravelledtoBrokenHillandvisitedthemineon21
November2007toconducthisownsceneassessment. Hetookphotographsof thesceneandoffixedplant.
observationof exhibits Conducting interviews System documentsand records Factsdetermined byinvestigation
thecorrodedhandrailandladderasexhibits. Theseexhibitswereexaminedby anindependentengineeringfacilitytoreportontheirconditionandprovidean opinionwithrespecttotheirstructuralintegrity.
TheInvestigatormetwithninepeoplefromtheminingcompanywhogave informationorevidencewithregardtotheincident.
Thedocumentsandrecordsexaminedduringtheinvestigationinclude:
•
miningleaseandownershiprecords
•
medicaltreatmentrecordsfortheinjuredworker
•
workerscompensationandrehabilitationreportsfortheinjuredworker
•
PerilyaBrokenHill’shealth,safetyandenvironmentmanagement system
•
miningandmaintenanceservicedepartmentssafetyandhealth managementplan
•
workplaceinspectionssheets,workordersandfixedplantfloorplans
•
safeworkproceduresandwritteninstructions
•
insuranceriskassessmentsreports
•
employeetrainingandassessmentrecords
•
OHScommitteeminutes
•
handrailmaintenanceandrepairsrecords
•
PerilyaBrokenHillLimitedannualreportsandHSEmanagement committeeminutes.
F i n d i n g s
Thefollowingfactsweredeterminedbytheinvestigation.
•
Theundergroundenvironmentatthe23Levelisacorrosiveone,with amplewaterandoxygenpresenttoreactwiththeironandsteel.
•
Thepre‐screenshadbeeninsuchanenvironmentsincetheywere constructedbypreviousmineowner,Pasminco,inabout1991‐2.
•
PerilyaBrokenHillLimitedhadasystemofinspectionsforplantthat shouldhaveidentifiedthecorrosiontothepre‐screenplant,andin particularthegalvanizedsteelpipeoftheguardrails.
•
Rustingonladdersatthepre‐screenswasidentified,reportedand includedasacorrectiveactioninthemaintenancesystem. However,no workwasundertakentoreplacethehandrailsandladdersasrequired bythemaintenanceworkorder.
Primarycause TheprimarycauseoftheincidentwasaslipbyMrBattamsthatcausedhimto fallagainstthehandrailwhichfailedunderloadanddidnotpreventhimfrom fallingoffthewalkwaytothefloorbelow.
Theinvestigationidentifiedthefollowingorganisationalfailingsandother factorsthatcontributedtotheincident.
Unsafeplant Thehandrailsprovidedatthepre‐screensraisedwalkwaytopreventpersons fromfallingoffwerefoundtobecorroded:
•
steelofthepipeofthehandrailwasfoundtobeverythin,offeringlittle strengthwhenaforceorloadwasapplied,and
•
inspectionsofthepre‐screensplantaftertheincidentbytheInspector andInvestigatorreadilyidentifiedsurfacerustandpossiblydeep corrosiononothersteelcomponentsoftheplant.
Furtherexamplesofunsafeplantandequipmentwereidentified,inparticular theladderthatwentfromtheplatformuptoacrowsnestneartheroofofthe cavern. Thisladderappearstohavebeenredundantforsometimeandhada signattachedprohibitingunauthorisedaccess.
AsMrBattamsfellhegrabbedattheladderhopingtostophisfall,onlytofind thatasectionoftheextremelycorrodedladderstilecameawayinhishand.
Failureofsafety PerilyaBrokenHillLimitedfailedtoadequatelyinspectthe23Levelpre‐screens
systemsandrisk toensuresafeplant.
management
Themine’soverarchingHSEsafetymanagementsystem,alongwiththeMining Department’sSafetyandHealthManagementPlan,hadriskmanagement processesforplantsafety. Theseincluded:
•
dailyworkplaceinspectionuponfirstentryofanundergroundwork area
•
safeworkprocedureonhowtoconductaworkplaceinspectionbefore startingwork
•
asafeworkprocedureforcleaningofthepre‐screens
•
plannedtaskobservations
•
formalinspectionsofthe23Levelpre‐screenstoidentifyhazards. Non‐conformancesorfailingsofthemanagementsystemwere:•
nospecificstandardforworkplaceinspectionoffixedplant
•
nosafeworkprocedureorwritteninstructiononhowtoperforman inspectionofhandrailsandladdersatthe23Levelpre‐screens
reportedbutnot fixed
Fixedplant standardnot maintained
thewalkwayatthe23Levelpre‐screenswererustyandreportedthisasasafety issuetohisco‐ordinator. ThereportwasenteredintoMaximo,themine’s maintenanceplanningsoftware,on10April2007.
MAXIMOisamaintenancedatabaseandworkordersystem.Itsupportedrepair andpreventativemaintenanceactivities,alongwithreportingofinspectionsand followupactions.
Thissystemgeneratedworkordersandthedailyfloorplanswhichlistplanned preventativeandcorrectivemaintenancetasksforplantandequipment. The23Levelpre‐screensworkorderwasgeneratedbytheMineServices PlanningCo‐ordinatoreachFriday.Itspecifiedinspectionsandcleaning. Thepre‐screensworkorderlistedworkplandetailsfortheweekincludingthe inspectionofhandrailsandladderways. Therewerenoinstructions,writtenor verbal,onhowtoconductthisinspection.
Itappearstheinspectionsofthehandrailsandladdersperformedbymine servicesemployeeswererestrictedtovisualinspections.Noattemptwasmade toperformnon‐destructiveorphysicaltestingofthestructures.
Thefloorplanthatlistedtasksforeachmaintenanceteamwasprintedfromthe Maximosystemforeachshifteachday. Thisfloorplanwasgiventotherelevant serviceteam. ThefixedplantservicesteamreceivedaplanforFixedPlant MechanicalMaintenance.
FloorplanssuppliedbyPerilyafortheperiod11April2007tothe6November 2007noteacorrectiveactionforthepre‐screensas:“Replacehandrailsand laddersthatarerusted.”
Ifworkwasundertakenagainstthisactionitshouldhavebeenrecorded. Ifthe actionwascompletedthetaskwouldberemovedfromthefloorplan. Thefloor plansnotedabovehadnorecordofworkbeingundertakenforthiscorrective action.
Thefitterwhoreportedthecorrodedladderssaidduringhisgivingofevidence thatnothingwasdonewithregardtotheMaximoentryrequiringreplacement ofthehandrailsandladders.
TocomplywiththerequirementsoftheMiningDepartmentSafetyandHealth ManagementPlantheMineServicesSuperintendentinspectedthe23Levelpre‐
screensandotherlocationswheremaintenanceworkunderhiscontrolwas undertaken.
AspartoftheseinspectionstheMineServicesSuperintendentrecallsinspecting thepre‐screenareaaboutmid‐August2007. Hemadeavisualinspectionofthe handrailsandfoundthemsatisfactory. Helookedatthehandrailsattheendof October2007andagainfoundthemsatisfactory.
TheMineServicesSuperintendentdidnotconductanyphysicaltestingofthe structureashedidnotconsiderthepre‐screenenvironmenttobecorrosive.
Personsworking alone,without supervision
Thisincidentinvestigationfoundthatkickplatesweremissingfromtheraised platformintheprescreensarea. KickplatesarerequiredbyAustralianStandard, AS1657‐1992:Fixedplatforms,walkways,stairwaysandladders ‐Design, constructionandinstallation.
Redundanthingesindicatedthatkickplatesmayhaveoncebeenfitted. Noonewhoworkedintheareaorperformedinspectionsonthewalkway noticedthekickplatesweremissing.
Thisfurtherindicatesthattheinspectionsystemappliedintheprescreensarea wasunabletoidentifyingnon‐conformancesandpotentialrisks.
Riskstoemployeesworkingatthe23Levelwereincreasedbythefacttheywere allowedtoworkaloneandunobserved.
Inaddition,thephone,theonlymeansofcommunicationfromthearea,was foundtobedefective. Ithadnotbeenworkingoffandonforsometime. MrBattamshadcleanedthe23Levelpre‐screensandmaintainedthe24level pumpforatleastthepreviousfiveyears. Generallyhedidboththesejobson hisownduringthattime.
Mostofthefixedplantteamworkalone,ofteninareaswherepotentialrisks werepresent. Otherservicepersonneldescribedworkingaloneinplaceswhere slipsortripscouldoccur.
ThisriskbecamearealitywhenMrBattamslayinjured,unabletoraisethe alarm,fornearlythreeandahalfhoursbeforesomeonenoticedhewasmissing. WhenquestionedthegeneralmanagernotedthatPerilyadidnothavea
procedureintheHSEmanagementsystemforworkingalone. Itwasindicated thattherewasaninformalpracticeforpeopleworkingalonetocontactthe MCCatregularintervals. Fromtheevidenceofthisincidentitappearsnotall employeeswereawareofthispractice.
Regularvisitsbyasupervisortoanareawherepeopleareworkingaloneisa waytomonitortheirsafety. MrBattams’supervisor,theFixedPlant
Coordinator,didnotvisitthe23Levelpre‐screens,andheinfrequentlywent underground.
ItappearsthelimitedfrequencyoftheCoordinatorsvisitsundergroundwasnot knowntocompanymanagersuntilaftertheincident.
Failureof structuresa knownrisk Identifywork environment risks Needtoreview andaudit maintenance systems
FailureofstructuresisidentifiedontheDepartment’sinternetsiteasa
mechanicalengineeringkeyrisk(Mechanicalengineeringkeyrisks:
http://www.dpi.nsw.gov.au/minerals/safety/resources/mechanical/key‐risks).
ThemajorityofmetalliferousminesinNewSouthWaleshavebeenoperating continuouslyforlongperiodsoftime,someforahundredyearsormore. Thisis particularlysoforminesintheBrokenHillandCobarminingdistricts.
NewownersofminessuchasthePerilyaBrokenHilloperationinheritplantand equipmentthatmayhavebeeninplaceforyears. Thiswassowiththepre‐
screensfixedplantwhichwasabout10yearsoldwhenPerilyabeganmining. Environmentalconditionsmustbeconsideredwhenidentifyingandassessing riskofplantandstructuralfailures. Exposuretoconditionsthatpromote corrosionandfatigueofstructuresmustberecognisedasahazard,notonlyat surfaceminesandprocessingplants,butalsounderground.
Minemaintenanceandotherrelatedsystemsmustbeauditedtomakesure theirassociatedrisksareeffectivelycontrolled. Thisistoensurethat:
•
Riskassessmentsidentifyallpotentialhazards. Theremustbe
recognitionofincreasedriskoffailureofplantthatisincreasinginage andislocatedinanenvironmentthatmaycontributetocorrosionand structuralfailure.Thismustnotberestrictedtooperationalplantand mustbeequallyappliedtolittleusedandredundantplant.
•
Structuralcomponentsthatarerequiredaspartofsafeplantand access,suchashandrails,guardrailsandladderways,musthavean inspectionandmaintenanceschedulethatisequalto,orofhigher priority,asthatoftheoperationalcomponentsofthatplant.
•
Fixedaccessladdersandguardrailinstallationsmustbeperiodically inspectedbyvisualandphysicalcheckingforrust,corrosionand structuralintegrity.Theymustbemaintainedingoodconditionso thatnoworkerisendangered.
•
Competentandqualifiedpeoplemustconducttherequiredtesting andinspectionstoensurestructuresdonotfail.
•
Recordsofinspectionsandmaintenanceoffixedstructures,including walkways,handrailsandladderways,mustbekeptandmaintained.
•
Theeffectivenessofdocumentedsystemsmustbeperiodically checkedbymonitoring,reviewandauditingbylineandsenior management.
Nosafework procedurefor workingalone Safework procedure requirements
Thisincidentinvestigationidentifiedthatnoformalsafesystemofworkfor personsworkingalonewasinplaceatthePerilyaBrokenHillSouthern Operations. Inaddition,theundergroundphonesystemwasunreliableand beyondthereachoftheinjuredworker.
Mostofthefixedplantmaintenanceteamworkedalone,ofteninareasthat hadhighpotentialforrisk. Inparticular,theywereexposedtorisksfromslips, tripsandfallswhileaccessingfixedplant.
Safeworkproceduresforpersonsworkingalonemustinclude:
•
appropriateworkingcommunicationsystems(suchasthePEDand RFIDsystemsthatareusedthroughoutthecoalandmetalmining industries)
•
regularcontactwithotherpersons,suchasthecontrolroomoperator, withregularreporting‐inandchecking
•
adequateandcompetentsupervision.
Further
reading
Relatedpublished
•
AS1657‐1992:Fixedplatforms,walkways,stairwaysandladders–resources Design,constructionandinstallation
•
AS1470‐1986:Healthandsafetyatwork–Principlesand practices,Section9.Machinery,plantandequipment
•
I&INSW,(2004)MineralsIndustrySafetyHandbook,Part5 Equipmentandmachinery,pp49‐51.
http://www.dpi.nsw.gov.au/minerals/safety/publications/workbo
oks/safety‐handbook
