Case study of three significant incidents involving dozers preparing shot ground

1. Bill McGlynn
Wednesday 11 September
Mobile Plant Rollovers
and Collisions

2. Coal mines Inspector Edward Morgan – 63-years coal industry experience.
Career began in the UK coal mines in January 1957.
Key safety message that Eddy consistently gives to coal mine workers:
❖ FOCUS ON THE TASK
❖ SITUATIONAL AWARENESS
❖ POSITIVE COMMUNICATIONS

3. Case study of three significant incidents involving
dozers preparing shot ground.
(NSW O/C Coal 2019 YTD)
❖ SITUATIONAL AWARENESS

4. Dozers preparing shot ground – Incident #34645, 17 May 2019 8:34pm
▪ Unplanned task
▪ JSA not completed with the work team
▪ Inadequate lighting
▪ Dusty conditions
Investigation Findings
▪ Direct Cause – Dozer not pushing at 90° to the edge, as per
procedure. The operator was not aware of their relative position.
❖ SITUATIONAL AWARENESS

5. Dozers preparing shot ground – Incident #35400, 26 August 2019 8:45am
Preliminary Investigation Findings
▪ Direct Cause – Dozer slid over large cap rock.
▪ JSA not completed and controls were not in place to manage the associated
hazards (steep drop-off and hard slippery floor conditions).
▪ Poor work planning. Previous shifts hadn’t been pushing off the overheight ahead
of the digger. This led to a tight work area and time pressure.
❖ SITUATIONAL AWARENESS

6. Dozers preparing shot ground – Incident #34877, 15 June 2019 11:15pm
Investigation Findings
▪ Direct Cause – The dozer operator could not see the edge of the bench
▪ Poor visibility – insufficient lighting.
▪ Incorrect tool for the job. Rocks too large for a D10.
▪ JSA not satisfactory. It did not identify the controls for the two points above.
❖ SITUATIONAL AWARENESS

7. Dozers preparing shot ground – Common findings
▪ Supervisors not conducting pre-task risk assessments (JSA, JHA...) or sufficient pre-task risk
assessments where there is clearly an elevated level of risk.
▪ Operators not stopping the job when they are unable to maintain situational awareness.
❖ SITUATIONAL AWARENESS

8. ❖ SITUATIONAL AWARENESS
Dozer sunk into void - Incident #33728, 24 January 2019 8:40am
The hazard of "bridging" over a closed reclaim valve had not been considered as a potential hazard for a
Dozer operator on a stockpile.
The Dozer had been operating on the stockpile without all the minimum required safety equipment. The
GPS was reported as defective and there was no other means to identify the location of the reclaim
shute gate

9. LV rollovers – Incident #35353, 18 August 2019 5:05pm
Operator stated that they could not see
due to sun glare while turning out into the
intersection. The light vehicle collided with
the centre road divider.
❖ SITUATIONAL AWARENESS

10. Four vehicle rolloversdirectly attributed to the
operator not focussing on the task.
(NSW O/C Coal 2019 YTD)

11. LV rollovers - Incident #35111, 11 July 2019 11:30am
▪ Primary Root Cause – Operator behaviour
▪ Secondary Root Cause – Speed was not controlled
effectively and / or operator was distracted.
❖ FOCUS ON TASK

12. LV rollovers - Incident #34701, 27 May 2019 7:50am
❖ FOCUS ON TASK
Driver was trying to stop a
rattle in the car while
driving along.
Sun glare also contributed.

13. LV rollovers - Incident #34815, 07 June 2019 2:45am
❖ FOCUS ON TASK
Operator and two passengers
travelling down a ramp when the
driver went to grab the 2-way radio
handpiece, dropped it on the floor
and then steered the vehicle up the
windrow while attempting to
retrieve the dropped handpiece.

14. LV rollovers - Incident #33972, 22 February 2019 11:07am
15-tonne stemming truck rolled after driving up the centre island on a haul road.
❖ FOCUS ON TASK

15. Light vehicle had been travelling at up to 105km/hr in wet conditions just prior to the incident
LV rollovers - Incident #34170, 16 March 2019 11:50pm

16. Truck reversed into another (Komatsu 785’s) at the loading platform. Operator had not been
following the site procedures and was operating contrary to the traffic management standard. In
the lead-up to the collision, the same contravention had been witnessed by colleagues on previous
loads.
From site ICAM Report:
Truck collision - Incident #34920, 21 June 2019 07:40am (NSW Non-coal)
Hazard reporting by operators could have prevented this incident

17. Four vehicle collisions attributed to operators not
using positive communications
(NSW O/C Coal 2019 YTD)

18. Incident #33598, 13 January 2019 5:30am
Dozer reversed into haul truck on dump.
Positive communication procedure had not been applied.
❖ POS COMMS

19. Large rock fell from excavator bucket on to a dozer- Incident #33948,
20 February 2019 4:15am
Positive communications failure when dozer working within swing radius of the excavator on the
same bench (top loading). The site standard also required improvement.
❖ POS COMMS

20. Positive communications not to standard. Also, intentions and confirmations not clearly
communicated.
Dozer and excavator collision - Incident #33526, 6 January 2019 10:04pm
❖ POS COMMS

21. ❖ POS COMMS
Incident #35463, 03 September 2019 10:00am
❖ SITUATIONAL AWARENESS

22. Roads and other vehicle operating areas – Planned Assessments
Some example findings so far on:
• Road standards
• Traffic management
• Operator Competency
General points around pre-starts, safe parking and positive communications.

23. Roads and work area standards
• Opportunities for segregation of heavy and light vehicles taken.
- Segregated roads.
- Permitting of LV operators (restricted permits or zones).
• Uninspected areas (non-active) not coned or windrowed off.
• Additional controls not implemented on higher risk dumps.
• Intersections.
• Poor visibility especially from LV driver position and where there are hierarchy rules in place.
• Y-intersections where there can be a 90° intersection.

24. Example of what is suppose to be a ‘90° intersection’ that doesn’t operate as intended.
It doesn’t require trucks to slow down and square up to look for oncoming traffic.

26. Traffic management
• Speed monitoring

27. Operator competency
• Training and assessments on emergency procedures inadequate e.g. for watercart operators
putting out fires (including tyre fires) and use of breathing apparatus on stockpile dozers (in case
of engulfment).
• Training for operating a haul truck in wet conditions not adequate.

28. ❖ FOCUS ON THE TASK
❖ SITUATIONAL AWARENESS
❖ POSITIVE COMMUNICATIONS
Key safety message to coal mine workers: