This document analyzes fire incident data on mobile plant from July 2014 to March 2019. It shows trends in fires by month, quarter, sector, and potential heat and fuel sources. Investigation findings identify failures to identify risks, implement safe work systems, properly supervise work, provide adequate training, and use fit-for-purpose equipment. Recommendations focus on risk assessment, supervision, training, equipment design, and procedures to prevent fires during refueling. Specific case studies on refueling truck and grader fires provide additional investigation findings and recommendations.

1. Ross Stutchbury
September 2019
Fires on Mobile Plant
RE-FUELLING

2. NSW Fires on Mobile Plant - Trend
Jul2014 Aug2014 Sep2014 Oct2014 Nov2014 Dec2014 Jan2015 Feb2015 Mar2015 Apr2015 May2015 Jun2015 Jul2015 Aug2015 Sep2015 Oct2015 Nov2015 Dec2015 Jan2016 Feb2016 Mar2016 Apr2016 May2016 Jun2016 Jul2016 Aug2016 Sep2016 Oct2016 Nov2016 Dec2016 Jan2017 Feb2017 Mar2017 Apr2017 May2017 Jun2017 Jul2017 Aug2017 Sep2017 Oct2017 Nov2017 Dec2017 Jan2018 Feb2018 Mar2018 Apr2018 May2018 Jun2018 Jul2018 Aug2018 Sep2018 Oct2018 Nov2018 Dec2018 Jan2019 Feb2019 Mar2019
0
2
4
6
8
10
12
14
16
18
17
16
8
77
77
7
9
9
9
9
11
66 6 66
141414
1010
1010
2
5
5
5
5
55
13 13 13 13
11
11
3333
3
4
4
4
4
4
4
44
1212
12
12
12
Fire on mobile plant incident notifications by month - July 2014 to March 2019

3. NSW Fires on Mobile Plant – Trend by Quarter
FY 2015 Q1 FY 2015 Q2 FY 2015 Q3 FY 2015 Q4 FY 2016 Q1 FY 2016 Q2 FY 2016 Q3 FY 2016 Q4 FY 2017 Q1 FY 2017 Q2 FY 2017 Q3 FY 2017 Q4 FY 2018 Q1 FY 2018 Q2 FY 2018 Q3 FY 2018 Q4 FY 2019 Q1 FY 2019 Q2 FY 2019
0
5
10
15
20
25
30
35
40
45
23
43
22
25 27
19
28
18
9
10
36
3131
11
15
1212
34
33
Fire on mobile plant incident notifications by quarter - July 2014 to March 2019

4. NSW Fires on Mobile Plant – Sector
Segmentation
Jul2014 Aug2014 Sep2014 Oct2014 Nov2014 Dec2014 Jan2015 Feb2015 Mar2015 Apr2015 May2015 Jun2015 Jul2015 Aug2015 Sep2015 Oct2015 Nov2015 Dec2015 Jan2016 Feb2016 Mar2016 Apr2016 May2016 Jun2016 Jul2016 Aug2016 Sep2016 Oct2016 Nov2016 Dec2016 Jan2017 Feb2017 Mar2017 Apr2017 May2017 Jun2017 Jul2017 Aug2017 Sep2017 Oct2017 Nov2017 Dec2017 Jan2018 Feb2018 Mar2018 Apr2018 May2018 Jun2018 Jul2018 Aug2018 Sep2018 Oct2018 Nov2018 Dec2018 Jan2019 Feb2019 Mar2019
0
2
4
6
8
10
12
14
16
18
5
4
9
5
13
7
7
1
4
3
3
4
7
3
5
4
3
4
4
4
1
3
5
4
5
12
2
11
11
12
10
10
16
8
14
6
6
12
13
6
10
6
13
9
9
7
10
6
9
13
5
17
12
14
14
7
12
Fire on mobile plant incident notifications by sector and month - July 2014 to March 2019
Exploration sites (excluding Petroleum and Geothermal)
Small mines – Metalliferous, Quarries and Other Gemstones
Large mines – Metalliferous and Quarries
Coal mines

5. Jan
2019
Feb
2019
Mar
2019
Apr
2019
May
2019
Jun
2019
Grand
Total
Coal mines Underground
Surface
Total
Metalliferous mines Underground
Surface
Total
Extractives mines Surface
Total
Grand Total
43
39
4
7
7
9
7
2
5
5
9
8
1
4
4
9
8
1
19
2
17
2
2
4
1
3
4
1
3
2
2
3
3
4
4
3
3
1
1
1
1
1
1
659131012714
NSW Fires on Mobile Plant 2019 – Sector
Segmentation

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 contractor’s tyre handlers.
workers accessing the refuelling facility without authorisation
and/or training
the 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 contractor’s
tyre handlers at the mine.
Failure to communicate expectations
Delays in the supply of diesel to the contractor’s tyre handlers
Lack of awareness of obligation of service cart operators to provide
fuel
Low priority given to contractor’s 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.
The refuelling facility was not supervised to ensure compliance with
site induction processes
The contractor worked within the external boundary fences
The masts of the contractor’s tyre handlers were too tall to fit under
the roof of the mine’s 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 contractor’s
workers were authorised to use
the refuelling facility
the ad hoc instruction that was provided to the contractor’s workers
by a number of the operator’s service cart operators was incomplete
Confusion about the order of actions when fuelling
The 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 contractor’s tyre
handlers
It has not been precisely determined who introduced the adapter to the mine site.
Given the adapter was kept at the mine for such a long time demonstrates that
there was a deficiency in the operator’s inspection regime for the refuelling facility
the 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
 Contractor management - The mine operator’s contractor management system failed to identify
that the contractor’s workers were undertaking risky refuelling practices.
 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
 Training sufficiency - The mine operator and contractor each failed to provide workers with enough
training to competently identify the risks associated with refuelling.
 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 contractor’s mobile
plant.
 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:
review their fuel delivery systems to ensure that only competent and authorised workers
have access to refuelling facilities
conduct an audit of refuelling facilities and service equipment to ensure that all refuelling
equipment is fit for purpose
review safety management systems (including contractor management systems) to ensure
that adequate risk assessments are conducted for the full range of work activities
ensure that adequate supervision is provided to workers undertaking refuelling activities
train workers about the correct use of refuelling equipment
prohibit 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:
fuel 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
the design arrangements of the ball float and breather vent settings on fuel service trucks
to ensure that they meet OEM specifications
controls to manage the hazard of fuel venting through breathers during fuelling and roll-
over event are effective
the operating gradients of fuel service trucks are within OEM design specifications
maintenance practices of ball float and breather vent settings on fuel service trucks to
ensure life cycle inspections and maintenance programs are effectively performed
change 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:
The refuelling systems were all quick-fill – dry break type.
The refuelling system relied on a pressure build-up in the tank to trigger the refuelling
system to stop.
The fuel filling system, tank, or associated fittings or alternate fill points failed to contain
the pressurised fuel.
The close proximity of the fill points to exposed hot engine components facilitated the
ignition of the fuel when it escaped the pressurised system.
People were in the vicinity during refuelling.
Most installations were user-specified, site specific alterations to the plant.
The 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:
 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
 carrying out a failure modes effects analysis (FMEA), or similar analysis, on the final design to
identify lifecycle inspection and maintenance requirements
 using refuelling systems that do not rely on fuel tank pressurisation to stop fuel flow when the tanks
are full
 locating fuel fill points and air vents away from hot engine components as far as possible
 ensuring fuel dispensing flow rate and air vent capacity of fuel tanks is correctly matched
 ensuring refuelling nozzles and fuel tank receivers are a matched set
 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:
installing decals on or near the fill points with max designed flow rates nominated
for the mobile plant
verifying the quick fill system design is compatible with the refuelling farm or
tanker delivery capacities
an engineering means or alternative cap to prevent regular “splash” fill points from
being left open and preventing pressurisation of the fuel tank during refuelling
using 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:
 review refuelling procedures with consideration to:
 the potential for the regular fuel cap to be inadvertently left open during quick refuelling
 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
 ensuring an attendant remains at the fuel quick fill point during refuelling and does not leave the mobile plant
unattended
 no people being on the refuelled plant during the refuelling process.
 ensure inspection and maintenance activities consider lifecycle degradation of the refuelling system,
the mine environment and the manufacturer’s recommendations.
 provide refresher training to workers who refuel mobile plant.
 check an engineered “break link” 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 – 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.