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Fatality at Goonyella Riverside Mine 2017 (System Parts (Staff (Training…
Fatality at Goonyella Riverside Mine 2017
Workplaces
Workplace factors
Staff are under pressure to ensure that all repair and maintenance jobs are managed efficiently.
Mandatory "hot training" wasn't completed.
Active Failure / Pre- Condition
Fixed plant design allowed 3 buckets to be in the workshop at once.
No documented plan was set prior to removing the wear plates
Work environment
Gouging out the wear plates required Mr Springer to be in close proximity of the wear plates.
Testing was carried out post the incident proving that in the event of a 'spring-back', he would not have anytime to move out the way.
The lighting in the workshop may have also contributed to Mr Springer not seeing the wear crack in the plate
Equipment design
Active Failure- Design Failure
2014- Workers had modified bucket #1 external wear plates without record of a modification or service log.
Design flaw / Pre-Condition:
Mr Springer was required to remove external heel shoes and remove external wear plate.
The tasks that were set, affected the safety of Mr Springer
Equipment Design Failure:
Plate Design had been modified from original equipment manufacturer design, without any log of modification**
Management policy / Procedure failure:
Workers failed to conduct a sufficient risk report nor did they check previous maintenance reports**
Management / Organisation failure:
Shift Supervisor was not present
Mandatory training wasn't completed **
A Terex RH340 Excavator is designed to dig and hold around 34 cubic metres of ground material at a time. The bucket requires regular maintenance as cracks can appear in the steel overtime.
Latent Failure
There was no consultation with the original design manufacturer when modifying the buckets external wear plates. Which resulted in the fatality of a worker. (Dep. of Natural Resources, Mines and Energy 2019)
Workers where unaware of the great potential a spring-back would have in the event that it would occur on the modified buckets.
People
Individual factors
Independent Mining Service (IMS)
Contractor Management
The name that is on the IMS contract with Goonyella Riverside mine stated that he didn't believe he was the contract owner. **
Senior Site Executive
Appointed SSE wasn't the most senior officer employed at the coal mine.
Couldn't ensure he had the competencies required to carry out his responsibilities
Daniel Stringer
Latent Failure
Did not review previous maintenance records** Didn't complete JSA correctly
Worked within close proximity of the bucket when spring-back occured
Latent Failure- Management/ organisation failure:
Mine records show he hadn't completed the 'hot work' competency
Co-Worker
Heard several cracking noises and verbally spoke to confirm with Mr Springer that he was okay.
Carried out required shift hand-overs, permits and JSA's with Mr Springer prior to work
Step-Up shift supervisor
Active Failure, Inadequate Information Transfer:
Didn't read emails and was unaware that he was meant to be filling in for the shift supervisor while he was away.
Confusion of roles and responsibilities
BHP
Latent Failure:
Prior to modifying the buckets, no risk assessments were conducted.
Safe Work Australia 2019, states the WHS Regulations require the person that commissions construction work to consult with the designer of a structure about safety matters and to give the designer and the principal contractor for the project information about safety matters.
Team factors
Active Failure- Management/Organisational Failure
JSA didn't include in the event of a spring-back
Management allowed workers to conduct work how they wanted to because they were the experts in that field.
Buckets were modified due to costings
Latent Failure
Economical value over the safety of workers
Management
Job design
Working in close proximity of machinery
Lack of communication with the original equipment manufacturer (OEM) and staff at the BHP mine site allowed room for error.
Crew were unaware of the greater potential force a spring-back would have.
Latent Failure - Organisational
Modifications were not assessed or recorded
Precursor- lack of investigation by management
Consulting with the OEM would cost the business time and money
Organisational factors
Task requirements
Tasks that were set out for workers were required to have reports on previous modifications, servicing etc. However these reports weren't present. Staff had conducted JSA's and pre-start reports however they had also been filled out incorrectly.
Latent Failure
Management decisions
Management did not conduct the required 6 step procedure when conducting the modifications on the buckets in 2014. A risk assessment in particular was meant to be conducted however was never done.
Management / Organisational factors-Latent Failure
Supervisors
Active failure- Inadequate information transfer
Communication errors occurred when the step-up field maintenance shift supervisor wasn't aware of his role until the incident occurred.
Under the Work Health and Safety Regulation 2011 section 34, it states a duty holder, in managing risks to health and safety, must identify reasonably foreseeable hazards that could give rise to risks to health and safety.
Emergency Response Team
Contacted via two-way radio and attended immediately
Information transfer
The field maintenance shift supervisor for A crew was on leave at the time of the incident
The step-up shift supervisor was unaware that he was taking over due to not receiving the email.
Active Failure
Unclear of roles and responsibilities-
Management and Organisational- Latent failure
BHP and previous staff members were aware of the modifications but failed to inform new/current workers.
Management Failure
System Parts
Terex RH340 Excavator bucket
External wear plates
Wear plate #1 / Wear plate #2
External heel shoes
Staff
Roles and responsibilities
Training
Mining records show that Mr Springer hadn't undergone required training at the mine site.
Set tasks
Supervisors
Organisational systems/ Management and regulators
Training
Failure to follow protocols
No documented maintenance reports
Culture
Organisational systems
Policies and procedures
Rostering / shift work
Cost
Accountability
Workshop at Mine
Capable of holding up to 3 buckets at one time
Repair and maintenance capabilities
Accessibility / Location
Emergency Response Team
Effective work design can benefit both the company and workers however, failure to considering this can result in poor risk management and loss of opportunities too improve the efficiency and effectiveness of work. It can also lead to breaching WHS law. (Safe Work Australia, 2019)
Event Sequence leading up
October 2014, excavator bucket #1 was sent to get modified from the original design. December 2014, the bucket was returned to Goonyella Riverside Mine. (Dep. of Natural Resources, Mines and Energy 2019)
July 2017, Engineering consultants provided Riverside mine with a condition monitoring report on excavator bucket #1. Independent Mining Services (IMS) commenced work at Goonyella Riverside Mine, carrying out boilermaker work mostly in the bucket maintenance shop. (Dep. of Natural Resources, Mines and Energy 2019)
2 August 2017, Mr David Springer and co-worker commenced work with IMS at Goonyella. After completing an area familiarisation at the mine site they then commenced work in the maintenance shed. (Dep. of Natural Resources, Mines and Energy 2019)
Event sequence day of
6:15pm on 4 August 2017, Mr Springer and co-worker attended a shift pre-start meeting at the main maintenance workshop. (Dep. of Natural Resources, Mines and Energy 2019)
Mr Springer and co-worker conducted work on bucket #1. He removed the last heel shoe and began grinding the wear plates out. The co-worker heard cracking noises and constantly checked in with Mr Springer. (Dep. of Natural Resources, Mines and Energy 2019)
4 August 2017, Mr Springer and co-worker arrived at Goonyella mine to start night shift at approx. 5:50pm. They completed Hot Work Permits and Job Safety Analysis (JSA) around this time. (Dep. of Natural Resources, Mines and Energy 2019)
Mr Springer had mad several smaller cuts to remove the plates in smaller pieces. He made a horizontal cut across the right hand side of the left wear place and the plate has sprung up hitting Mr Springer. (Dep. of Natural Resources, Mines and Energy 2019)
Emergency Response team was called over the two way, where they conducted appropriate CPR until paramedics arrived. They transferred him to Townsville Base Hospital where he underwent surgery
)Dep. of Natural Resources, Mines and Energy 2019)
On 6 August Mr David Springer was pronounced clinically deceased. (Dep. of Natural Resources, Mines and Energy 2019)
Design Lifecycle
Concept
The concept of a bucket is to attach it to a hydraulic arm so it can relocate heavy amounts of dirt or ground material.
The bucket is easily detailed from front to back and where the external and internal designs are located.
Concept Design Failure
External wear plates regularly crack and get wear facets. This can affect time and cost management for companies
Design Failure
Decomissioning
Deconstructed down into scrap parts
Deccomission as per manufacturer's recommendations
Construction
Commisioning
Materials
Equipment/ tools
Manufactering
Necessary skills and requirements
Functionality
Design lifecycle
Quality
Usability of the machiney
Accessibility for maintenance
Commissioning System Failure
Workers can modify the design to financially benefit the company
Maintenance
As required/ specified by the original design manufacturer
Parts and equipment
Time
Necessary skills required to fix the bucket
Maintenance System failure
Trained workers may be limited
The design can be modified
Physical harm can occur
Operating
Functionality
Usability
Operator abilities and requirements
Controls
Hydraulic arm to attach bucket to
Goonyella Riverside Mine Maintenance workshop after the incident took place.
The excavator bucket up-close post incident
Department of Natural Resources, Mines and Energy 2019, Investigation Report: Report into a fatality at Goonyella Riverside Mine on 5 August 2017, viewed 26 Sep 2019,
https://www.dnrme.qld.gov.au/__data/assets/pdf_file/0007/1428703/goonyella-riverside-mine-investigation-report.pdf
Safe Work Australia 2019, Good work design, viewed 26 Sep 2019,
https://www.safeworkaustralia.gov.au/good-work-design
