Dump truck overturned at Okke plant quarry 1 DUMP TRUCK(35TON) OVERTURNED AT OKKE PLANT QUARRY 12th...

Dump truck overturned at Okke plant quarry 1

DUMP TRUCK(35TON) OVERTURNED AT OKKE PLANT QUARRY

12th May 2010, 10.15 amContractor – Joongang co.

2

Title Descriptions

i) Incident Description

ii) Profile of Victim

iii) Immediate action

iv) RCA

- Team

- Chain of Event

- Sequence of Action

- Relevant Photos

- Root Cause Analysis (RCA)

- Main causes of the Incident

- System and Management Related Causes

v) Corrective and Preventive Action

vi) Key Learning Lesson


Date and Time of Incident : 12th May 2010, 10:15 a.m.

Person involved : (51 years)

for the past 10 years as a dump truck operator

Company :

Type of injury sustained : Crack of two ribs (Injured worker is stable as

reported after medical check at Gangneung Asan Hospital)

Incident Description : At 10:15 am, Dump truck(No.1222) was overturned

at the limestone stock pile because the crest of stock pile was collapsed.

Based on the interview, dump truck reached crest of stock pile to dump the

limestone as backward.

The dump truck was slid and overturned when the operator was about to

dump limestone at the crest of stock pile.

Incident Description

4

Profile of Victim

Victim Name : ************ Position : Dump Truck Operator Age : 51 years old Family Situation : Married and 2 children Year of Experience at ******* : 10 Years Driving License Category: 1st grade certificate for heavy truck

Work Location Quarry 2 Centre

Work Activities Transporting limestone to stock piles

Type of Injury The injured worker had crack of 2 ribs after medical check up and came back to his work now.


Immediate Actions by Plant Team

No.No. Corrective ActionsCorrective Actions Action PartyAction Party Time Time lineline

1 - Stop all stock pile work

Industrial Director

&Plant

Management Team

12thMay

2 - Sharing accident information to all teams

3

- Inspection of the condition of 9 stock piles located in quarry site and improved stockpiling method : “Preferred” Stockpiling : 2 → 7 “Secondary” Stockpiling : 3 → 2 (Discussed with ATC : we have determined what is the status and possible action for the remaining 2 stockpiles where "secondary dumping method" is applied) “Prohibited” Stockpiling : 4 → 0

4

- Conference call with regional safety coordinator and ATC : Further investigation by technical point of view, develop communication material for the other BU to avoid any recurrence


Root Cause Analysis

No.No. NameName DesignationDesignation

1 JongGoo Moon Industrial Director

2 SungRae Chung Plant Operations Manager

3 SeYong Lee Production Manager

4 WeonGyoo Kim Mining Team Leader

5 KwanKyo Chung Mining Team Engineer

6 JunYong Pyun Mining Team Engineer

7 YongIn Woo Contractor - Joongang Co.

8 DongGun Park Contractor (foreman) - Joongang Co.

9 WonWai Kim Contractor - YeGun Co.

10 SangWoong Lee Contractor - DaeLim Co

11 TaeHun Kim Contractor - SooKwang Co.

12 SooChang Kim Plant Health & Safety Coordinator

RCA Team

7

Chain of Event (Before the Incident)

Time Activity

08:10 am The injured worker conducted visual inspection of dump truck before operating

08:30 am The injured worker drove first load to the stock pile from bench(B-0) at quarry 2 central

10:14 am Dump truck reached the stock pile to dump 8th limestone transporting

10:15 am Dump truck reached the crest of stock pile as backward and was about to dump

10:15 amDump truck was slid and overturned at the crest of stock pile when the operator was about to dump limestone due to collapse of the crest(Stockpile height : 10m)

10:15-11:20 am

The accident was witnessed by inspector (Mining manager) and the driver rescued by contractor’s foreman (DongGeun Park). Then transferred to the hospital by 119 (Emergency Ambulance) at 10:40 a.m. The truck driver arrived at the hospital at 11:20 a.m. - Mining manager and Foreman : First Aid trained - 119 : Korean rescue staffs by government (Branch office is located in Okke)


Sequence of Action Before Accident - Sketch

B-0 Working place

Transporting limestone

The operator reached the crest of stock pile as backward and was about to dump limestone but the crest of stock pile was collapsed and dump tuck was overturned.

Along the Hauling Road Dump truck was Overturned

Limestone loading by excavator

B-0 Working Place

Accident Area

Point 1

Level 1 Point 2

Point 3

Level 2

350 m

Limestone was loadedby excavator

Transporting limestone

The operator reached thecrest of stock pile asbackward and was about tobegin to dump limestone

The material has been taken at the bottom on May 11th .


Photos

Safety berm

backward

Berming 10M

Sliding and overturned


Photos


Photos

Safety Berm gave away

truck moving backward


Accident Figure at Limestone Stock Yard

Safety Berm

Sliding and overturned


Root Cause Analysis

RCA FILE

• The daily inspection of the dump truck was conducted by operator before

starting the work including breaking system and there was no defects

found.

The regular preventive and specific inspection was conducted by

maintenance workshop in quarry.

• The dump truck has safety facilities like rear camera, frontal mirror,

reversing alarm and seat belt.

• The condition of operator was in normal.

• The operator was fasten seat belt.

< Vehicle Inspection and operator’s condition >


Root Cause Analysis

Dump truckoverturned

Crest collapseWeak dumping

area andunstable slope

Material taken atthe toe

Fine materialpiled on theupper slide

Wet and untightslope due toprevious rain

Weight of dumptruck

approx.52t

Direct dumpingat the crest

Misunderstood ofdumping method

in advisory Cause2 Mistranslation

Immoderatebackward

Witness

Lack of riskawareness about

change ofworking

environment

Cause3Insufficient

training of riskmanagement

The weightturned to one

sideWitness

Lack of riskObservation/

Assessment inreal time

Cause4Lack of risk

assessment skill

Insufficienttraining of riskmanagement

Dump truckfailure

Daily work logInadequate

SOP Cause5

Not fullyunderstandingof Advisory

Cause 1, physical conditionof the stockpile

<System &Management

related causes><Behavior related cause>


Main cause of the Incident (Based on the RCA)

Misunderstanding of working method : Main cause of the incident is misunderstanding of "where " with "when"

According to stock pile advisory,

“Secondary” Method of Stockpiling involves dumping a load directly over the crest of the pile. For this method to be performed safely, adequate berms must be maintained ~ ….

It is critical to ensure that material is not removed from the toe of the pile when dumping is taking place at the top of the pile. → Applied

“Prohibited” Method of Stockpiling involves ~ …. ~

where material has been removed from the toe is prohibited. → Not applied

Root Cause Analysis


System and Management Related Causes

Lack of risk assessment : Risk assessment of dumping work did not make

complex working condition which clearly identifies all potential & practical

risks (for example, multiple visible inspection for stable repose angle from

the pile upside and downside)

Lack of real time inspection system : Real time inspection needs to check

the risks of working condition and unsafe behavior depending on the

working environment and weather condition

Inadequate SOP : SOP of dumping work is in place but there is inaccurate

application for dumping work due to misunderstanding of stock pile

advisory

Insufficient communication : Lack of communication between inspector

and dump truck operators about the risks observed by inspector

Root Cause Analysis


Behavior related causes

Mistranslation of the Advisory : Stock piling methods are not correctly translated to cause incorrect application of stock piling method.

Insufficient training of risk management : Workers are not skillful of risk recognition and assessment because of insufficient training of risk management including refresher training.

Not fully understanding of the Advisory : Especially stock piling method is not fully understood by workers even though repetitive training due to the mistranslation.

Root Cause Analysis


Good/ Positive Risks / Issues

• Experienced 10 years

• Safety training – MEA, Stock & Surge pile, Standard & Advisory, etc.

• Emergency Evacuation : quick

• Protection canopy of the truck

• Seat belt

• Camera installed in the rear

• Vehicle – good condition

• Inspection, shift check

• No alcohol, Day worker, Looked okay

• No overloading (35 ton)

• Reconsider the remaining 2 stock piles method – under review

• Need front-end loaders – if we want preferred stock piles method

• Location of truck at crest & toe (2m – 10m)

• Flexible movement of the dump point & Stock pile & crest (3 or 4 times within 6 months/ 2-3-5-8m)

• Rain-wet material impacted compact

• Incorrect method used prohibited – understanding (how come for years happening?)

• Risk assessment – awareness on changing environment & situation / supervision & real time

• communication – joint assessment of risk

Root Cause Analysis


Risks Safety Measures

Fog/Snow/Rain _ situation change

Frequent monitoring by supervisor in real time and sharing information of working condition

Floating rocksManagers conduct specific inspection of bench face considering climate change more frequently while raining or snowing (install buffer zone or isolate the risky area)

Flying rocks Changing current blasting direction to safety area where no risk zone from blasting when drilling work

Communication processEstablish robust communication system to share all risk situation in real time using radio.

Road condition (Gradient/Width)

Gradually improve the gradient and width of the roads

Falling risk of equipment _ side berm

Install strong side berm

Other risks in Quarry

21

Corrective and Preventive Action (Immediate)

No Corrective Action By Whom By When Status

1 Stop all stock piling work Plant Mgr. Immediate Done

2 Sharing accident information to all teams and Regional H&S director and Relation director.

Industrial Director Immediate Done

3

Inspection of stock pile condition (stopped 4 activities on prohibited stock piling and changed 1 activity from secondary methods to preferred stock piling).According to the inspection of all berms for road side, condition was good.

Industrial Dir.Plant Mgr.

WG KimImmediate Done

4Conference call with regional safety director & relation director. Technical support was coordinated by ATC geo-mining manager.

Industrial Director

Immediate Done

5 Removed unstable steep slope of the accident stock pile. YongIn Woo 13-5-2010 Done

6 Training of the revised Stock Piling method was conducted to all workers in quarry.

Contractors 13-5-2010 Done

7

Safety inspection of all working areas in quarry and immediate actions for improvement were taken until May 14th, such as ;· Installation of buffer zone at Q2T· Expanded entrance road at Q2T development area· Removed floating rocks at Q2C· Expanded transporting road at Q2C

WG KimContractors 14-5-2010 Done

22

Corrective and Preventive Action (For Improvement)

No Corrective Action By Whom By When Status

1Develop risk assessment of dumping work which clearly identifies all potential & practical risks under support of ATC geo-mining manager.

ContractorsJY Pyun 20-5-2010

On-going

2

Effective inspection system should be established with a series of visits at suitably frequent intervals to ensure that work activities are monitored and that any unsafe acts and conditions are observed and corrected

ContractorsJY Pyun Done Done

3Improve communication between inspector and dump truck operator about risks observed in real time

ContractorsKK Chung 25-5-2010 Done

4

Revise standard & FHRA of dumping work and training (revision of SOP)

- Material should be pushed by loader or dozer to the crest of stock pile where material is removed from the toe.

- If dozer or loader can’t operate, prohibit the dumping directly. Otherwise dumping work should be done at the toe of stock pile

ContractorsWG Kim 24-5-2010 Done

5Training of risk management skills and stock pile advisory in detail to make sure all contractors fully understanding

ContractorsJY Pyun 31-5-2010 Done


Key Lessons Learned

Workers should clearly understand Standard and Advisory (e.g.If you take materials at the toe of the pile direct dumping is strictly prohibited)

In order to set up a SOP, it should be based on the Group Safety Standard & Advisory fully understood by workers.

The risk management system including inspection, risk assessment and communication system should be working effectively on-site to control not only formal & visible risk but all potential & practical risks in real time and regular monitoring should be followed to make sure the system is working

All employees and non-employees that operate or ride in any mobile equipment or vehicle shall fasten seat belts at all times.

Dump truck overturned at Okke plant quarry 1 DUMP TRUCK(35TON) OVERTURNED AT OKKE PLANT QUARRY 12th...

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