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Fairfield Quarry Fatal Accident - 15th November 2018. Worker trapped in…
Fairfield Quarry Fatal Accident - 15th November 2018. Worker trapped in conveyor.
Infrastructure
Safety Systems
Whilst not directly mentioned, a lack of additional Personal Protective Equipment may have contributed to the
Lack of Tagout / Lockout for the machine. This failure enabled the machine to operate while they handled the rocks.
Inadequate facilities for emergency response
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Inadequate communication systems which delay safety information and emergency response
Maintenance and operations
Equipment was poorly maintained and outdated without guarding
Poor safety signage to indicate the hazards such as crushing pinch points
Equipment was old
Poor maintenance schedule due to worn skirting rubbers, which contributed to the rocks spilling out.
No standard operating procedure to clear rocks for the equipment
Physical infrastructure
Poor maintenance of the conveyor skirting rubber and impact roller resulting in rocks to move onto the tail pulley area
Prone to surging rocks near pinch points
No guarding was a direct failing of the physical infrastructure and resulted in an unguarded pinch point
Site practice was to remove the rocks by hand, without guarding and whilst the machine was operating.
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Infrastructure failed to enable a tagout or lockout system, which would have isolated the machine before accessing it.
Design of the conveyor enabled easy access to hazardous areas.
No designated safety area
Missing impact roller and inadequate skirting rubber
Culture
Quarry failed to learn from past accidents
Quarry failed to enforce safety procedures and policies
Poor incident reporting culture
Mangement lacked avenue for empowering workers regarding safety issues
Poor leadership commitment to safety
Quarry failed to install safety values
Quarry neglect to comply with safety regulations
Quarry was an environment of complacency which normalised unsafe actions and hazards
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Quarry failed to foster a safe work environment
People
Safety Representatives
Poor safety oversight
Failed to raise safety concerns of workers
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Poor training or resources to advocate for worker safety
Lack of safety committee
Trainers
Worker lacked proper site induction
Worker lacked training in equipment and machines
Unqualified trainer resulting in inadequate instructions
Lack of training to identify hazards and report them
No training records were available to show competency in the equipment
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Workers
Workers lacked formal training
Inexperienced workers and unfamiliar with machines
Failed to report hazards
Worker complacency
Poor hazard identification training
Workers experiencing fatigue and heat stress under the sun
Poor peer accountability regarding safety
Workers relied on manual labour to remove rocks
Workers were fearful of production delays
Workers did not have full understanding of safety procedures and policies
Workers confused by multiple versions of Safety Management Systems
Workers poor involvement in safety procedures
Workers had poor awareness into safety hazards and risks
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Worker had only working at the new position for 2 weeks
Allowed poor maintenance of the conveyor
Allowed workers to remove guarding without Permit to remove guarding or Permit to isolate
External Stakeholders
External safety consultants were not engaged to look at ongoing hazards at the quarry
Regulatory authorities failure to ensure quarry were compliant as evidence by the missing guards and misuse of equipment
Supervisors
Workers had minimal or no supervision
Supervisors failed to properly communicate work procedures
Supervisors lacked required training in proper training practices
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Supervisors failed to monitor safety practices and procedures, and report hazards to management
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Failed to ensure plant is safe to operate.
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Failed to encourage hazard and incident reporting
Other Departments
Poor communication between departments of safety and plant to address machine hazards
Poor problem solving between departments
Mangaement
Management assumed workers familiarity with machine and safety procedures due to past experience (lack of Verification of Competency)
Allowed multiple safety documents found within the system
Failure to enforce safety procedures including lock out and tag out procedures
Management failed to prioritise safety
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Poor management accountability in regards to safety accidents
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Failed to complete site inductions
Goal
Failure to improve on safety procedures and processes
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Lack of regular audits for safety hazards and improvements
Failure to promote safety culture
Lack of accountability
Lack of cohesion between safety goals and production goals
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Failure to promote hazard reporting
Failed to identify measurable safety performances and indicators
Poor alignment between quarry performance goals and safety
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Quarry focus on production over workers safety
Process
Poor process for hazard reporting and identification, including following up on hazards
Inadequate process for safety inspections and audits
No formal process for accident review
Lack of process to remove rocks from the fully area of the conveyor tail
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Failure to establish a feedback system for workers to identify hazards
Quarry did not contain consistent hazard identification procedures
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Workers failed to follow isolation procedures
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Failure to enforce safety procedures
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Quarry lacked documented safety procedure to remove rocks from the conveyor
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Informal training process
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Lacked safety drills at the quarry
Failed compliance with regulations
Unsure if the Conveyor had a Plant Risk Assessment which could have identified any hazards
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Failed onboarding process as well as Verification of Competency and training procedures
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Technology
Detection technology
Lack of Tagout/Lockout technology to isolate machine
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Lack of technology to automate isolation of the conveyor
Lack of automated rock removal system
Lacked safety alarms to notify and report spillage
Maintenance technology
Lack of maintenance technology/software to track repairs and maintenance of the conveyor
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Lack of predictive technology to monitor condition of the machine and prevent rock spillage
Machine lacked safety features/technology
Whilst not stated, a emergency stop close to hazardous areas is better able to stop a machine in the event of an emergency
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Lack of safety interlock to automatically stop when a guard is removed
Outdated technology
Machine lacked automation
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Lack of fail-safe technologies to shut down in unsafe environments