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Analysis of Fairfield Quarry Fatality - Coggle Diagram
Analysis of Fairfield Quarry Fatality
People
Worker's safety concerns were not addressed
Personnal did not report all hazards
Poor supervision
Claimed to have read site procedures
No record of this
Claimed to have checked pre-start inspection and checked equipment
No record of this
Claimed to have records of Mr Milne's capabilities
No record of this
Technology
Pull wire switch
Over- extended in activated position
Reset buttons used cable ties
Infrastructure
Perished rubber skirting on conveyor belt
Missing impact roller
Idler missing under transfer chute
Missing clips to secure idler to cradle frame
Bolt holding guard in place was not applied correctly
Broken lug
Missing guards
Processes
Differing Safety Management Systems
simultaneously in use
Lack of action plan to record hazards and control risks
Lack of hazard reporting system
Site induction was not performed with Mr Milne
Professional plant operation training unavailable
Absent documented procedure of rock spillage removal
Practice to clear rocks without guard or complete PPE and while the machine is still operational.
Cleaning plough not in the near vicinity of conveyor
Missing responsibility outlines
Supervisor
Safety Coordinator
Maintenance coordinator
Missing ongoing training and performance audits
Goals
Focus on high productivity
Conveyor still operational whilest being cleared
Does not focus on worker's safety
Culture
Assumed Mr Milne knew what he was doing based on his previous experience.
Isolation procedures ignored
High supervisor turnover