6. Heat Sources
0 1 2 3 4 5 6 7 8 9 10 11
Exhaust system
Electrical component
Not recorded
Turbo
Friction e.g. breaks
Engine
Hot work (welding or grinding)
10
6
5
5
3
2
1
Fires on mobile plant heat sources - January 2019 to March 2019
7. Fuel Sources
0 1 2 3 4 5 6 7 8 9 10
Hydraulic oil
Null
Other
Diesel or petrol
Electrical wiring
Engine oil
Grease
Lubricating gear oil
Rags, cartons or other debris
9
5
5
4
3
3
1
1
1
Fires on mobile plant fuel sources - January 2019 to March 2019
8. Failed Component
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Hose
Not recorded
Any electrical cable or wiring
Fitting
Seal
Any other part of the engine
Any part of the braking system
Any part of the starter motor
N/A
Other
Transmission or drive chain
13
5
4
2
2
1
1
1
1
1
1
Fires on mobile plant failed component - January 2019 to March 2019
9. Actions that can reduce the likelihood of fire
incidents
SURFACE TEMPERATURE
⢠Reduce surface temperature
⢠Double skin
⢠Water jacket
⢠If lagged, cover completely and
securely
⢠Survey for electrical hot joints
FUEL SOURCE
⢠Prevent escape of fluids
⢠Careful supervised maintenance
⢠Security of fittings and joints
⢠Hose clamping and routing
⢠Eliminate rubbing and chafing
⢠Segregation from hot surfaces
⢠Fire walls
⢠Guards
⢠Minimise non-metallic materials
⢠Consider fire resistant fluids
10. FOCUS RE-FUELLING
⢠https://youtu.be/fiSr4r8uqhM
The injured worker ran in an easterly direction.
He knew that the sleeve of his shirt was on fire
and took the shirt off as he ran. He knew that
there was an emergency shower at the
refuelling facility but considered it to be too
close to the fire to stop and safely use it. After
he took his shirt off, he realised that his hair
was on fire. He continued to run to a drain at
the eastern end of the refuelling facility. He
put his head into mud that was in the drain
and extinguished the fire in his hair.
11. Investigation Findings - Failing to identify and
assess the risks
⢠Failure by Operator and
Contractor to identify all risks
associated with the operation
of the refuelling facility and
the contractorâs tyre handlers.
ďworkers accessing the refuelling facility without authorisation
and/or training
ďthe introduction and use of non-fit for purpose equipment at the
refuelling facility.
12. Investigation Findings - Failure to implement
safe systems of work
⢠The mine operator and
contractor each failed to
establish safe systems of work
for refuelling the contractorâs
tyre handlers at the mine.
ďFailure to communicate expectations
ďDelays in the supply of diesel to the contractorâs tyre handlers
ďLack of awareness of obligation of service cart operators to provide
fuel
ďLow priority given to contractorâs requests for fuel
13. Investigation Findings - Failing to properly
supervise
⢠The mine operator stated that it
used three controls to prevent
unauthorised access to the
refuelling facility. None of the
controls were effective.
ďThe refuelling facility was not supervised to ensure compliance with
site induction processes
ďThe contractor worked within the external boundary fences
ďThe masts of the contractorâs tyre handlers were too tall to fit under
the roof of the mineâs light vehicle refuelling facility.
14. Investigation Findings - Failing to provide
information and training
⢠contributed to the belief by a
number of service cart
operators that the contractorâs
workers were authorised to use
the refuelling facility
ďthe ad hoc instruction that was provided to the contractorâs workers
by a number of the operatorâs service cart operators was incomplete
ďConfusion about the order of actions when fuelling
ďThe contractor did not provide any training to its workers at the mine
in relation to the use of the refuelling facility
15. Investigation Findings - Provision of
equipment that was not fit for purpose
⢠the adapter was not fit for purpose for
refuelling the contractorâs tyre
handlers
ďIt has not been precisely determined who introduced the adapter to the mine site.
ďGiven the adapter was kept at the mine for such a long time demonstrates that
there was a deficiency in the operatorâs inspection regime for the refuelling facility
ďthe contractor did not know that the adapter was being used. This was a result of
its failure to undertake risk assessments and supervise its workers
16. Investigation Findings - Human and
organisational factors
⢠Performance shaping factors
ď Contractor management - The mine operatorâs contractor management system failed to identify
that the contractorâs workers were undertaking risky refuelling practices.
ď Supervision leader expectations - The mine operator and contractor failed to communicate with
each other about the difficulties that the contractor was experiencing with respect to refuelling
ď Training sufficiency - The mine operator and contractor each failed to provide workers with enough
training to competently identify the risks associated with refuelling.
ď Risk management practices - Effective risk management practices were not applied by the
contractor, nor enforced by the mine operator, in relation to the fuelling of the contractorâs mobile
plant.
ď Checking, inspection and monitoring - The mine operator did not supervise activity at its
refuelling facility to a sufficient standard to enable it to identify that unauthorised use was occurring.
17. Investigation Findings - Recommendations
⢠Operators and Contractors:
ďreview their fuel delivery systems to ensure that only competent and authorised workers
have access to refuelling facilities
ďconduct an audit of refuelling facilities and service equipment to ensure that all refuelling
equipment is fit for purpose
ďreview safety management systems (including contractor management systems) to ensure
that adequate risk assessments are conducted for the full range of work activities
ďensure that adequate supervision is provided to workers undertaking refuelling activities
ďtrain workers about the correct use of refuelling equipment
ďprohibit the use of free flow fuel adapters that defeat inbuilt safety functions of refuelling
systems
18. FOCUS RE-FUELLING
A fuel service truck caught fire at an open cut
coal mine. Diesel fuel from a breather
assembly on top of the fuel tank flowed
directly onto hot engine surfaces. The onboard
fire suppression systems on the truck were
unable to extinguish the fire.
19. Investigation Findings - Recommendations
⢠Operators and Contractors to review:
ďfuel service trucks to ensure control measures are effective to contain and redirect
flammable liquids spilled from the top of the tank away from hot surfaces
ďthe design arrangements of the ball float and breather vent settings on fuel service trucks
to ensure that they meet OEM specifications
ďcontrols to manage the hazard of fuel venting through breathers during fuelling and roll-
over event are effective
ďthe operating gradients of fuel service trucks are within OEM design specifications
ďmaintenance practices of ball float and breather vent settings on fuel service trucks to
ensure life cycle inspections and maintenance programs are effectively performed
ďchange management systems to ensure modifications of fuel storage and delivery
systems on fuel service trucks are appropriately assessed and include consultation with
OEM.
20. FOCUS RE-FUELLING
Fire occurred in the engine bay of a grader
whilst being refuelled.
The root cause of the incident was identified
as a blocked fuel cap breather element
allowing the designed pressurised fuel system
to release flammables onto adjacent hot
components.
21. Investigation Findings - Factors
⢠Contributing Factors:
ďThe refuelling systems were all quick-fill â dry break type.
ďThe refuelling system relied on a pressure build-up in the tank to trigger the refuelling
system to stop.
ďThe fuel filling system, tank, or associated fittings or alternate fill points failed to contain
the pressurised fuel.
ďThe close proximity of the fill points to exposed hot engine components facilitated the
ignition of the fuel when it escaped the pressurised system.
ďPeople were in the vicinity during refuelling.
ďMost installations were user-specified, site specific alterations to the plant.
ďThe source of diesel fuel was from the fuel tank manual fill cap dislodged o-ring seal
22. Investigation Findings - Recommendations
⢠When altering plant to fit quick fill refuelling
systems consideration should be given to:
ď identify all risk scenarios that may give rise to fuel spillage and/or fire during the refuelling process
and implement control measures in accordance with the hierarchy of risk controls
ď carrying out a failure modes effects analysis (FMEA), or similar analysis, on the final design to
identify lifecycle inspection and maintenance requirements
ď using refuelling systems that do not rely on fuel tank pressurisation to stop fuel flow when the tanks
are full
ď locating fuel fill points and air vents away from hot engine components as far as possible
ď ensuring fuel dispensing flow rate and air vent capacity of fuel tanks is correctly matched
ď ensuring refuelling nozzles and fuel tank receivers are a matched set
ď checking the designs of fuel tanks to ensure they are capable of accepting the high delivery flows
and pressure of the refuelling system on a cyclic basis without deformation of the fuel tank
23. Investigation Findings - Recommendations
⢠When altering plant to fit quick fill
refuelling systems consideration
should be given to:
ďinstalling decals on or near the fill points with max designed flow rates nominated
for the mobile plant
ďverifying the quick fill system design is compatible with the refuelling farm or
tanker delivery capacities
ďan engineering means or alternative cap to prevent regular âsplashâ fill points from
being left open and preventing pressurisation of the fuel tank during refuelling
ďusing hose(s) compatible with diesel fuel and capable of withstanding the
maximum refuelling pressure, even if used as a drain line.
24. Investigation Findings - Recommendations
⢠Mines that use quick fuel systems should:
ď review refuelling procedures with consideration to:
ď the potential for the regular fuel cap to be inadvertently left open during quick refuelling
ď the need to leave the refuelling vehicle running, the position and the distance between the vehicle being refuelled
and the refuelling vehicle so it can be moved away quickly in the event of an emergency
ď ensuring an attendant remains at the fuel quick fill point during refuelling and does not leave the mobile plant
unattended
ď no people being on the refuelled plant during the refuelling process.
ď ensure inspection and maintenance activities consider lifecycle degradation of the refuelling system,
the mine environment and the manufacturerâs recommendations.
ď provide refresher training to workers who refuel mobile plant.
ď check an engineered âbreak linkâ is fitted to the fuel filling line at the fuel supply end to stop flow of
fuel in an emergency and for a quick exit away from a potential fire.
25. Fires on Mobile Plant â Focus
⢠Fire risk assessments must be rigorous and identified controls must be
effectively implemented and regularly monitored
⢠It is considered reasonably practicable for mine engineers and equipment
manufacturers to work towards engineering solutions to control surface
temperature
⢠Stringent monitoring and quality control of maintenance and repair
activities must be undertaken on mine sites to prevent fires on mobile
plant
⢠OEMs, designers and suppliers need to develop solutions to address the
persistence of fires on mobile plant, to ensure they are meeting their
obligations under the Work Health and Safety legislation.