25th annual Mechanical Engineering Safety Seminar 2015

1. NSW Mine Safety
Investigations Update
25th Mechanical Engineering
Safety Seminar
9-10 September 2015
NSW Mine Safety Investigations Update – Tony Smith – Senior Investigator – 10 September 2015

2. 2
NSW Mine Safety- industry report
 12 month period from 1 July 2014 to 30 June 2015
(excludes petroleum)
2,097 notified incidents to NSW Mine Safety
• Serious injuries 34 (coal) and 14 (metals & other)
• 2 fatal incidents at surface extractives mines

3. 3
The incident triangle for 2014-15
48 serious injuries
 31 fractures
 7 amputations
 1 injection of fluid
 9 other types of injuries
308 reported outcomes of injuries
 71 hospital admissions
 29 medical treatment
 7 lost consciousness
2,097 reported incidents
 1,491 underground
 606 surface
2 fatal incidents
 Excavator roll over at a quarry - 9 September 2014
 Electric shock in a residence - 27 August 2014
All incidents notified to NSW Mine Safety for 2014-15

4. 4
Fatal electric shock in a residence
27 August 2014
 A person was found
deceased in a house
near a quarry at Cudal
(Orange), NSW. The
house was supplied
with electricity from
the quarry’s electrical
supply system.
 Industry information release
http://www.resourcesandenergy.nsw.gov.au/__dat
a/assets/pdf_file/0009/542475/IIR15-01-Fatality-at-
house-near-quarry.pdf

5. 5
Fatal crush in an excavator tip over
9 September 2014
 An excavator operator
was using a track-type
excavator above a
quarry bench near
Karuah, NSW. The
excavator was on
uneven ground with a
cross-gradient. The
excavator tipped over.
 Industry information release
http://www.resourcesandenergy.nsw.gov.au/__dat
a/assets/pdf_file/0009/534069/IIR1406-
Investigation-Information-Release-Karuah.pdf

6. 6
Conference theme
Evolution of Mechanical Safety
 Investigation case study
 Mobile elevated work platform
 Incident review
 High pressure energy release during maintenance
 Mobile equipment interaction
 Maintaining plant explosion protection systems

7. 7
Conference theme
Evolution of Mechanical Safety
 Investigation observations
 Primary reliance placed on lower order
hierarchy of risk controls - the easier option
o training, administrative controls, PPE
 Risk assessments are not effectively
identifying and implementing higher order
mechanical engineered risk controls – the
harder option
o Hard mechanical barriers to isolate
uncontrolled energy
 ‘Reasonably practicable’ mechanical
engineering risk controls are not being
implemented

8. 8
Case study- Mobile elevated work platform
Fatal incident – 21 May 2014 at a mine construction site
Risk controls relied upon:
 Plant unintended activation design
 Plant supplier risk assessment
 Operator held RTO training
qualifications for the specific MEWP
 NSW Workcover high risk licence held
 Site verification of operator
competency on the specific MEWP
 Plant pre-start checks
 Generic task/plant risk assessments
 Generic safe work procedures
 Working at heights permit
 Spotter present near the MEWP base
The Incident:
MEWP operator (Rigger) received a fatal head and neck crush injury in a
pinch point between the platform console frame and the underside of a steel
beam.

9. 9
Investigation report findings
Ultimately the lower order risk
controls relied upon failed to
prevent the crush injury.
Whilst the specific causation cannot
be identified the most likely cause of
the platform to rise:
- A person located on the walkway adjacent to
the platform gave the operator a verbal
warning about the platform moving upwards
under the beam just prior to incident
- Operator, stopped the platform, then:
- likely he leant forward over the controls
and his body contacted a switch
- or he incorrectly operated a control
device
- Engineered controls on the platform to
reduce unintentional operation:
- Operator active decision to engage the
covered footswitch
- Timed seven second console activation
window then no movement is possible
- Raised molded guard against each
console switch

10. 10
Damaged rubber cover on joystick control and corrosion found
on electrical board
A damaged rubber cover
(boot) on the lift swing
joystick control device had
not been identified by any
pre start or maintenance
inspection.
Corrosion was found on the
hall-effect electrical control
board of the joy stick.
Investigation testing
conducted to Australian
Standards could not prove
that the less than optimal
condition of the lift swing
joystick electrical control
board caused an unintended
upwards movement of the
platform.

11. 11
Secondary guarding devices use in Australian access industry
Secondary Guarding Device
A device in addition to primary guarding to
reduce the risk of entrapment.
• Physical barriers
• Pressure sensing devices
February 2013 OEM advertised to
Australian industry a Secondary Guarding
Device was available
July 2013 European standards EN280:2013
MEWP required secondary guarding options
and allowed an 18 month transition to Jan 2015
14 May 2014 OEM sought Australian Design
Registration (ADR) for the secondary guarding
device
21 May 2014 Fatal incident at the mine
10 June 2014 ADR awarded by Worksafe
WA for the device
The OEM had provided quotes to Australian
access industry to supply the secondary guarding
device but no orders had been received.

12. 12
Mobile elevated work platform
Recommended practice for industry – in proximity to fixed structure
1. MEWP access in proximity of fixed structures – hierarchy of control
• Are there safer alternate access methods – scaffolding
• Selection of MEWP – don’t rely entirely on generic risk assessments
• Use secondary guarding devices on MEWP
2. Work Permit System - Pathway of MEWP moving in proximity to fixed structures
• Specific task assessment with the MEWP operator and spotter doing the task - similar process to a
crane lift (AS2550.10 MEWP safe use) - supervisor sign off
• Identify the access pathway – plan complex three dimensional movements of platform sequence
• Establish ‘No Go Zones’ with visual marking devices – flagging tape, electronic warning systems
• Determine acceptable clearances for the task
• Do operators crouch down or lean over the platform controls in a tight location?
• What is an acceptable proximity distance to the platform or boom?
3. Plant - fit for purpose checks
• Pre-start checks to include inspection for damaged joystick rubber covers.
4. Training and competency of operator
• MEWP operators to be challenged with complex move sequences to prove ‘Verification of
Competency’. Does every operator ‘pass’ VOC. Prepare a competency ‘failure’ re-training process
5. Industry information
• Update training guidelines by access industry groups and regulators
• Australian Standards should be reviewed with European Standards

13. 13
Safety Bulletin and Investigation Report published
May 2015 August 2015

14. 14
Incident review –
High pressure energy release during maintenance.
Comparison of Mechanical vs Electrical energy incidents for 2014/15
Electrical: 16 contacts with high voltage energy
Mechanical: 147 escapes of high pressure fluid
 HP energy isolation, guarding and pressure
removal systems during maintenance are available
 Issues with operator competence with the HP system
 Several incidents with Apprentices placed at risk
in the energy release
Data range 1 January 2013 to 12 May 2015

15. 15
High pressure energy release during maintenance.
Reported issues
 Maintenance people struck by hydraulic fluids, air and water
 Staples still a problem - falling out and intentional removal, engineered
alternatives to staples are available
 Residual energy isolation system failures during maintenance
 Failure to ensure HP guarding systems in place for maintenance
Data range 1 January 2013 to 12 May 2015

16. 16
High pressure energy release during maintenance
Are your maintenance people required to remove staples ?
- Do they use hard barriers to isolate any energy release ?
- Have they dissipated and confirmed release of stored energy ?
Fatal incident on a
longwall pump station
on 26 July 2006.
Removed a staple
with a shifter on a
energised hydraulic
line at 300 bar
Safety Alerts SA06-16
SA06-18, SA14-03,
SB13-01, SB12-03

17. 17
Incident review –
Mobile equipment interactions 2014/15
 Collisions 82 events
 Underground = 28
 Surface = 54
 Unplanned movement or unintended
activation 202 events
 Underground = 109
 Surface = 93
WHSMR14 commenced 1 February 2015
Surface includes open cuts, processing plants and exploration
Investigation Report published
Consider higher order engineering design risk controls:
- Light vehicle (LV) to heavy vehicle (HV) roadway segregation
- Road and intersection design – sight lines at intersections
- Improve HV truck tub visibility at night time for the LV driver
consider the headboard and sides of tub
- Proximity detection systems

18. 18
Incident review –
Maintaining plant explosion protection systems 2014/15
 Gas trips/detections for underground coal 369 events
 Failure of Ex. protection systems for underground coal 309 events
Maintaining the integrity of
higher order engineered risk controls
for explosion protection systems:
General issues:
- Water scrubber tank test failures
- Incorrect bolt types found in Ex. Plant
- Non compliance of Ex. with plant serviced
by registered workshops returning to site
- Refer to Safety Bulletin SB12-01

19. 19
Conference theme
Evolution of Mechanical Safety
In summary
 Review your site risk assessments for over reliance placed
on lower order hierarchy of risk controls – taking the easier
option
 Question why site risk assessments are not effectively
identifying and implementing higher order mechanical
engineered risk controls – the hard isolation barrier option
 Encourage a ‘paradigm shift’ in risk assessment outcomes to
move towards higher order hierarchy of risk controls at your
mine site.