2 TitleDescriptionsi)Incident Descriptionii)Profile of Victimiii)Immediate actioniv)RCA- Team- Chain of Event- Sequence of Action- Relevant Photos- Root Cause Analysis (RCA)- Main causes of the Incident- System and Management Related Causesv)Corrective and Preventive Actionvi)Key Learning Lesson
3 Incident DescriptionDate and Time of Incident : 12th May 2010, 10:15 a.m.Person involved : (51 years)for the past 10 years as a dump truck operatorCompany :Type of injury sustained : Crack of two ribs (Injured worker is stable as reported after medical check at Gangneung Asan Hospital)Incident Description : At 10:15 am, Dump truck(No.1222) was overturned at the limestone stock pile because the crest of stock pile was collapsed.Based on the interview, dump truck reached crest of stock pile to dump the limestone as backward.The dump truck was slid and overturned when the operator was about to dump limestone at the crest of stock pile.
4 Profile of Victim Victim Work Location Work Activities Type of Injury Name : ************Position : Dump Truck OperatorAge : 51 years oldFamily Situation : Married and 2 childrenYear of Experience at ******* : 10 YearsDriving License Category: 1st grade certificate for heavy truckWork LocationQuarry 2 CentreWork ActivitiesTransporting limestone to stock pilesType of InjuryThe injured worker had crack of 2 ribs after medical check up and came back to his work now.
5 Immediate Actions by Plant Team No.Corrective ActionsAction PartyTime line1- Stop all stock pile workIndustrial Director&Plant Management Team12thMay2- Sharing accident information to all teams3- Inspection of the condition of 9 stock piles locatedin quarry site and improved stockpiling method: “Preferred” Stockpiling : 2 → 7“Secondary” Stockpiling : 3 → 2(Discussed with ATC : we have determined whatis the status and possible action for theremaining 2 stockpiles where "secondarydumping method" is applied)“Prohibited” Stockpiling : 4 → 04- Conference call with regional safety coordinatorand ATC: Further investigation by technical point of view,develop communication material for the other BUto avoid any recurrence
6 Root Cause Analysis RCA Team No. Name Designation 1 JongGoo Moon Industrial Director2SungRae ChungPlant Operations Manager3SeYong LeeProduction Manager4WeonGyoo KimMining Team Leader5KwanKyo ChungMining Team Engineer6JunYong Pyun7YongIn WooContractor - Joongang Co.8DongGun ParkContractor (foreman) - Joongang Co.9WonWai KimContractor - YeGun Co.10SangWoong LeeContractor - DaeLim Co11TaeHun KimContractor - SooKwang Co.12SooChang KimPlant Health & Safety Coordinator
7 Chain of Event (Before the Incident) TimeActivity08:10 amThe injured worker conducted visual inspection of dump truck before operating08:30 amThe injured worker drove first load to the stock pile from bench(B-0) at quarry 2 central10:14 amDump truck reached the stock pile to dump 8th limestone transporting10:15 amDump truck reached the crest of stock pile as backward and was about to dumpDump truck was slid and overturned at the crest of stock pile when the operator was about to dump limestone due to collapse of the crest(Stockpile height : 10m)10:15-11:20 amThe accident was witnessed by inspector (Mining manager) and the driver rescued by contractor’s foreman (DongGeun Park). Then transferred to the hospital by 119 (Emergency Ambulance) at 10:40 a.m. The truck driver arrived at the hospital at 11:20 a.m.- Mining manager and Foreman : First Aid trained- 119 : Korean rescue staffs by government (Branch office is located inOkke)
8 Sequence of Action Before Accident - Sketch Dump truck was OverturnedAlong the Hauling RoadB-0 Working placeThe material has been taken at the bottom on May 11th .The operator reached the crest of stock pile as backward and was about to dump limestone but the crest of stock pile was collapsed and dump tuck was overturned.Transporting limestoneLimestone loading by excavator
9 PhotosBerming10MSliding and overturnedSafety bermbackward
12 PhotosSafety Berm gave awaytruck moving backward
13 Accident Figure at Limestone Stock Yard Sliding and overturnedSafety Berm
14 Root Cause Analysis< Vehicle Inspection and operator’s condition >The daily inspection of the dump truck was conducted by operator before starting the work including breaking system and there was no defects found.The regular preventive and specific inspection was conducted by maintenance workshop in quarry.The dump truck has safety facilities like rear camera, frontal mirror, reversing alarm and seat belt.The condition of operator was in normal.The operator was fasten seat belt.
16 Main cause of the Incident (Based on the RCA) Root Cause AnalysisMain cause of the Incident (Based on the RCA)Misunderstanding of working method : Main cause of the incident is misunderstanding of "where " with "when"According to stock pile advisory,“Secondary” Method of Stockpiling involves dumping a load directly over the crest of the pile. For this method to be performed safely, adequate berms must be maintained ~ ….It is critical to ensure that material is not removed from the toe of the pile when dumping is taking place at the top of the pile. → Applied“Prohibited” Method of Stockpiling involves ~ …. ~where material has been removed from the toe is prohibited. → Not applied
17 System and Management Related Causes Root Cause AnalysisSystem and Management Related CausesLack of risk assessment : Risk assessment of dumping work did not make complex working condition which clearly identifies all potential & practical risks (for example, multiple visible inspection for stable repose angle from the pile upside and downside)Lack of real time inspection system : Real time inspection needs to check the risks of working condition and unsafe behavior depending on the working environment and weather conditionInadequate SOP : SOP of dumping work is in place but there is inaccurate application for dumping work due to misunderstanding of stock pile advisoryInsufficient communication : Lack of communication between inspector and dump truck operators about the risks observed by inspector
18 Behavior related causes Root Cause AnalysisBehavior related causesMistranslation of the Advisory : Stock piling methods are not correctly translated to cause incorrect application of stock piling method.Insufficient training of risk management : Workers are not skillful of risk recognition and assessment because of insufficient training of risk management including refresher training.Not fully understanding of the Advisory : Especially stock piling method is not fully understood by workers even though repetitive training due to the mistranslation.
19 Root Cause Analysis Good/ Positive Risks / Issues Experienced 10 years Safety training – MEA, Stock & Surge pile, Standard & Advisory, etc.Emergency Evacuation : quickProtection canopy of the truckSeat beltCamera installed in the rearVehicle – good conditionInspection, shift checkNo alcohol, Day worker, Looked okayNo overloading (35 ton)Reconsider the remaining 2 stock piles method – under reviewNeed front-end loaders – if we want preferred stock piles methodLocation of truck at crest & toe (2m – 10m)Flexible movement of the dump point & Stock pile & crest (3 or 4 times within 6 months/ m)Rain-wet material impacted compactIncorrect method used prohibited – understanding (how come for years happening?)Risk assessment – awareness on changing environment & situation / supervision & real timecommunication – joint assessment of risk
20 Other risks in Quarry Risks Safety Measures Fog/Snow/Rain _ situation changeFrequent monitoring by supervisor in real time and sharing information of working conditionFloating rocksManagers conduct specific inspection of bench face considering climate change more frequently while raining or snowing (install buffer zone or isolate the risky area)Flying rocksChanging current blasting direction to safety area where no risk zone from blasting when drilling workCommunication processEstablish robust communication system to share all risk situation in real time using radio.Road condition (Gradient/Width)Gradually improve the gradient and width of the roadsFalling risk of equipment _ side bermInstall strong side berm
21 Corrective and Preventive Action (Immediate) NoCorrective ActionBy WhomBy WhenStatus1Stop all stock piling workPlant Mgr.ImmediateDone2Sharing accident information to all teams and Regional H&S director and Relation director.Industrial Director3Inspection of stock pile condition (stopped 4 activities on prohibited stock piling and changed 1 activity from secondary methods to preferred stock piling).According to the inspection of all berms for road side, condition was good.Industrial Dir.WG Kim4Conference call with regional safety director & relation director. Technical support was coordinated by ATC geo-mining manager.5Removed unstable steep slope of the accident stock pile.YongIn Woo6Training of the revised Stock Piling method was conducted to all workers in quarry.Contractors7Safety inspection of all working areas in quarry and immediate actions for improvement were taken until May 14th, such as ;· Installation of buffer zone at Q2T· Expanded entrance road at Q2T development area· Removed floating rocks at Q2C· Expanded transporting road at Q2C
22 Corrective and Preventive Action (For Improvement) NoCorrective ActionBy WhomBy WhenStatus1Develop risk assessment of dumping work which clearly identifies all potential & practical risks under support of ATC geo-mining manager.ContractorsJY PyunOn-going2Effective inspection system should be established with a series of visits at suitably frequent intervals to ensure that work activities are monitored and that any unsafe acts and conditions are observed and correctedDone3Improve communication between inspector and dump truck operator about risks observed in real timeKK Chung4Revise standard & FHRA of dumping work and training (revision of SOP)- Material should be pushed by loader or dozer to the crest of stock pile where material is removed from the toe.- If dozer or loader can’t operate, prohibit the dumping directly. Otherwise dumping work should be done at the toe of stock pileWG Kim5Training of risk management skills and stock pile advisory in detail to make sure all contractors fully understanding
23 Key Lessons LearnedWorkers should clearly understand Standard and Advisory (e.g.If you take materials at the toe of the pile direct dumping is strictly prohibited)In order to set up a SOP, it should be based on the Group Safety Standard & Advisory fully understood by workers.The risk management system including inspection, risk assessment and communication system should be working effectively on-site to control not only formal & visible risk but all potential & practical risks in real time and regular monitoring should be followed to make sure the system is workingAll employees and non-employees that operate or ride in any mobile equipment or vehicle shall fasten seat belts at all times.