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Report into a fatality at the Newlands Mine Coal Handling and…

- - - - Health - passed industrial medical
      - competent with his job activities
      - Had completed an induction
        
        Induction for the Glencore mine site which would include the Glencore processes the contractors had to follow
    - - JSA did not include the removal of the deck plates
        
        FAILURE by crew in not including all of the equipment they had to repair in their work activities
      - FAILURE in the procedure for not getting their supervisor to review and sign off on the JSA but another UGL supervisor
- - - - Initial decision was to replace the parts
        
        Company to source parts from the original parts manufacturer
        
        Unable to get the parts in time for the scheduled maintenance
        
        Job was changed to repair instead of replace
        
        Had to be repaired. Waiting would have kept the system offline and reduced production
    - - FAILURE: No formal documentation for handovers during shift changes
  - - - UGL supervisors used as supervisors for the maintenance activities
      - DECISION: Immediate supervisor for the crew did not have any involvement in their JSA or sign off on the JSA
        
        JSA reviewed and signed off by another UGL supervisor
        
        While not incorrect, it is preferable for the immediate supervisor to review and sign off on the JSA
    - - Night crew signed onto the JSA
        
        Night crew did not notice the absence of deck plate removal on the JSA
        
        UGL night shift supervisor did not review or sign the JSA
      - Communication between shifts was verbal during start of shift meetings