Mine Truck Operator Crushed in Rollover off Bridge Date of Incident: March 3, 2008 Type of Incident: Fatality

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1 Mine Truck Operator Crushed in Rollover off Bridge Date of Incident: March 3, 2008 Type of Incident: Fatality

2 File: F TABLE OF CONTENTS SECTION TITLE PAGE NUMBER 1.0 DATE AND TIME OF INCIDENT NAME& ADDRESS OF PRINCIPAL PARTIES 3 Owner 3 Prime Contractor 3 Contractor 3 Employer 3 Worker 4 Other Truck Operators DESCRIPTION OF PRINCIPAL PARTIES LOCATION OF INCIDENT EQUIPMENT, MATERIAL AND OBSERVATIONS NARRATIVE DESCRIPTION OF INCIDENT ANALYSIS 11 Engineering/Mechanical Assessments Findings FOLLOW-UP/ ACTION TAKEN SIGNATURES ATTACHMENTS 16 2

3 File: F SECTION 1.0 DATE AND TIME OF INCIDENT 1.1 The incident occurred at approximately 8:30 p.m. on March 3, SECTION 2.0 NAME AND ADDRESS OF PRINCIPAL PARTIES 2.1 Owner Grande Cache Coal Corporation P.O. Box 8000 Grande Cache, Alberta T0E 0Y0 2.2 Prime Contractor Grande Cache Coal Corporation P.O. Box 8000 Grande Cache, Alberta T0E 0Y0 2.3 Employer (of the Grande Cache Coal Corporation s mine workers) Grande Cache Coal Corporation P.O. Box 8000 Grande Cache, Alberta T0E 0Y0 2.4 Contractor Grande Cache Coal Corporation P.O. Box 8000 Grande Cache, Alberta T0E 0Y0 2.5 Contractor Crater Enterprises Ltd St. Box 1020 Grande Cache, Alberta. T0E 0Y0 3

4 File: F Employer (of the fatally injured worker) Crater Enterprises Ltd St. Box 1020 Grande Cache, Alberta. T0E 0Y0 2.7 Worker (Unit C-87 Truck Operator, also referred to as Driver A) Truck Operator 2.8 Other Truck Operators for Crater Enterprises Ltd Driver A (Operator who became fatally injured) Driver B Driver C Driver D (Crater Enterprises Ltd s Shift Leader) Driver E Driver F Heavy Equipment Operator (Grande Cache Coal Corporation worker being used as a Truck Operator Trainer) SECTION 3.0 DESCRIPTIONS OF PRINCIPAL PARTIES 3.1 Grande Cache Coal Corporation was formed in the year Grande Cache Coal Corporation's coal leases cover over 22,000 hectares of the Smoky River Coalfield located in west-central Alberta. The Grande Cache Coal Mine operations include large open pit and underground mining facilities. The various mine areas have haul roads in a mountain range to a central processing facility located approximately 19 km north of the Town of Grande Cache. Grande Cache is 146 km north of Hinton, Alberta. 3.2 Crater Enterprises Ltd. began operations in Alberta in 1982 in the logging and log haul industry. Grande Cache Coal Corporation entered into a contract with Crater Enterprises Ltd. on April 1, 2005 to provide coal haulage and coal haul road maintenance services at the Grande Cache Coal Mine site. Crater Enterprises Ltd. presently has a fleet of 21 haul trucks and support equipment. 3.3 The Truck Operator started employment with Crater Enterprises Ltd. on January 22, Prior to this he had eleven years of truck operator experience in Newfoundland. His experience was mainly operating highway tractor semi-trailer transports in his home province. 4

5 File: F SECTION 4.0 LOCATION OF INCIDENT 4.1 The incident occurred on the mine haul road from the #12 Coal Mine at the northwest entrance to the Sheep Creek Bridge. The Sheep Creek Bridge is located on Grande Cache Coal Corporation s property approximately 12 km from the Grande Cache Coal Corporation s Coal Processing Plant. (The Sheep Creek Bridge was marked by a km 12 sign on the haul road at the southeast entrance) The Grande Cache Coal Corporation s Processing Plant is located approximately 19 km north of Grande Cache on Highway # 40. (Attachment A, Map)(Attachment B, Photograph 1) SECTION 5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS 5.1 Equipment and Material Coal Haul Truck - Unit C-87(owned by Crater Enterprises Ltd.) Western Star Conventional Model 4964 Coal Hauler 50 Ton capacity Year of manufacture: 2005 Serial Number: 5KKPALAV75PU91509 License Plate Number: 91J243 (Attachment B, Photograph 2) 5.2 Sheep Creek Bridge The Sheep Creek Bridge was originally constructed in The north side of the bridge joined a roadway directed to the # 9 Coal Mine site. The Bridge consists of two 27.1 m modified FC type precast, prestressed concrete channel girders which have been post tensioned transversally. Each span has six FC type channel girders. The Sheep Creek Bridge has eight spaced lamp posts on each side of the bridge deck. The Sheep Creek Bridge is 10.5 m wide and is used only for single lane travel by the coal haul trucks and light duty vehicles. (Attachment C, Engineered Bridge Drawing) 5.3 Observations The Coal Haul Truck involved in the incident was among the fleet of Crater Enterprises Ltd s trucks used to haul coal from the coal mine to the processing plant. On this type of Coal Haul Truck the weight of the load averages between 30 and 33 5

6 File: F tons. Each loaded truck on its way to the Coal Processing Plant passes through a scale for a weigh ticket. The scale is maintained and operated by Grande Cache Coal Corporation. The Coal Haul Truck involved in the incident had not reached the scale at the processing plant and had spilled its load during the incident. The weight of the load could not be determined Grande Cache Coal Corporation is producing on an average daily basis during full production, approximately 135 truck loads of coal from both the surface and the underground mines. The Coal Haul Trucks operate 24 hours per day with drivers working 12 hour shifts from 7:00 a.m. to 7:00 p.m. A round-trip from the dump (at the Coal Processing Plant site), to the # 12 Coal Mine, including loading and unloading time takes approximately two hours. During the round trip the various truck operators would call out specific km marker signs to alert other truck operators in the vicinity, of their location According to contractual agreement, the coal mine road maintenance and the maintenance of existing road signs is the responsibility of Crater Enterprises Ltd. Grande Cache Coal Corporation is responsible for the placement of new road signs. Grande Cache Coal Corporation is responsible for the Sheep Creek Bridge maintenance An engineering assessment of the Sheep Creek Bridge was done in November 2005 by UMA Engineering Ltd. utilizing an Alberta Infrastructure and Transportation s Bridge Inspection and Maintenance format. The assessment report rated the Sheep Creek Bridge guardrail as adequate at that time. The Sheep Creek Bridge guardrail was not designed structurally to keep light traffic within the confines of the bridge deck area if the guardrailing was struck by a vehicle UMA engineering documents from 1997 indicate that the Sheep Creek Bridge deck had been modified since original construction with the addition of 6 mm steel grating surfaced with concrete which cantilevers past the exterior of the girders by over 300 mm. These cantilevers were to act as gutters along the bridge edges. This modification was completed prior to Grande Cache Coal Corporation s start-up of the coal mining in the area. Note: This modification would not allow for weight bearing along the edge of the bridge structure. A curb was not installed along the Sheep Creek Bridge edges at this time. A hazard assessment was not completed to determine if the cantilever on the bridge could pose a collapsing hazard if the tires of a Coal Haul Truck drove onto it. Bridge warning lighting was modified at this time. (Attachment D, Engineered Bridge Edge Detail) 6

7 File: F Before Grande Cache Coal Corporation took control of the mine, the bridge lighting system was operational. The power supply was removed when the mine was decommissioned by the previous owner. The mine was not in use between the years 2000 to When the mine was re-opened by Grande Cache Coal Corporation, power supply to the Sheep Creek Bridge lighting system was not re-activated Just prior to the incident a snow squall had developed at the location of the coal haul route from the # 12 Coal Mine with high wind gusts limiting visibility. The berm on the edge of the haul road caused the snow to swirl at the Truck Operator s line of vision. Workplace Health and Safety Compliance Investigator interviews with workers revealed that at approximately 8:00 p.m. the snow started and substantially increased by 8:30 p.m. The snow varied along with the geography, limiting the visibility intermittently. It was later estimated that a maximum of 4 to 5 cm of snow fell at the Sheep Creek Bridge location The anti-lock braking system is a safety system on motor vehicles which prevents the wheels from locking and sliding while braking. An anti-lock braking system allows the driver to maintain steering control under heavy braking, by preventing a skid. The anti-lock braking system allows the wheel to continue a forward roll and create lateral control, as directed by driver steering inputs. Disadvantages of the anti-lock braking system include increased braking distances under some limited circumstances including ice, snow, gravel and soft surfaces. According to the manufacturer of the Anti-Locking Braking System on Coal Haul Truck Unit C-87, during the malfunction of the Anti-Lock Braking System the Electronic Control Unit will disable all or only a portion of the Anti-Lock Braking System and return the affected wheels to normal braking. SECTION 6.0 NARRATIVE DESCRIPTION OF THE INCIDENT 6.1 On March 3, 2008 at approximately 5:00 p.m. Coal Haul Truck Unit C-87 was offloaded by the day shift operator and parked near the Coal Processing Plant. Unit C- 87 was left idling for the next operator. Work had been stopped early for the dayshift operators to allow them to vote in the Provincial election. 6.2 At approximately 7:00 p.m. the, Truck Operator Driver A for Unit C-87 took the Coal Haul Truck and drove it empty to #12 Coal Mine to receive his first load. 7

8 File: F At approximately 7:53 p.m., Truck Operator Driver A operating Unit C-87, was loaded at the Coal Mine and started his return journey to the Coal Processing Plant from #12 Coal Mine. A snow squall had developed, the road was becoming covered with snow and wind gusts were swirling the snow. 6.4 At approximately 8:00 p.m. Driver B operating Unit C-90 was loaded and proceeded to travel towards the Coal Processing Plant from #12 Coal Mine. Driver B was traveling behind Unit C-87. At some time prior to 8:30 p.m., Driver B heard the Truck Operator Driver A call the km 13 sign which is 750 m before the Sheep Creek Bridge during his trip to the Coal Processing Plant from #12 Coal Mine. 6.5 At approximately 8:30 p.m., the Crater Enterprises Ltd s Coal Haul Truck, Unit C-87 was approaching the northeast entry of the Sheep Creek Bridge with a full load. The Coal Haul Truck, Unit C-87 operated by Driver A failed to negotiate the right-hand turn onto the Sheep Creek Bridge. The Truck Operator s Driver A left front tire of Unit C-87 drove onto the cantilever section of the bridge deck, which gave way, and the Coal Haul Truck Operator s side started to roll against the guardrailing. 5.2 m of the Sheep Creek Bridge guardrailing broke away. The Coal Haul Truck Unit C-87 continued to roll off the Sheep Creek Bridge deck and came to rest upside-down 13.7 m below, along the bank of, and partially in the Sheep Creek. 6.6 At the time of the incident s occurrence, Coal Haul Truck C-88 was approximately 4 minutes in front of the Unit C-87 and Units C-90, C-94, and C-93 were immediately following Unit C-87. Coal Haul Truck Unit C-85 was 5 minutes behind all the other Coal Haul Trucks. As time passed after the incident, the four loaded Coal Haul Trucks going towards the Coal Processing Plant and two empty Coal Haul Trucks returning from the Coal Processing Plant (Units C-81 and C-88) had passed over the Sheep Creek Bridge without realizing that an incident had occurred. Driver B the operator of Coal Haul Truck C-90 had noticed the missing guardrailing, but believed it had occurred the previous evening. 6.7 At approximately 9:00 p.m: Driver B dumped his load at the Coal Processing Plant. At this time Driver B called Driver C on the two-way radio to determine if the Sheep Creek Bridge guardrailing had been missing the night before. It was at this time that Driver B realized that the Truck Operator of Unit C-87, Driver A, was missing. 6.8 At approximately 9:10 p.m. Driver D, Shift Leader decided to shut down coal hauling from the #12 Coal Mine, and made the announcement to all the Coal Haul Truck Operators. Driver D, Shift Leader then proceeded to drive about 1 km away from the Coal Processing Plant to a Coal Haul Truck pull-out, and started some documentation. After off-loading his Coal Haul Truck, Driver B proceeded to the same Coal Haul Truck pull-out. 8

9 File: F At approximately 9:15 p.m. Driver D, Shift Leader realized that while he had been completing his Coal Haul Truck load count documentation he had not heard from Truck Operator Driver A. He tried to reach him by two-way radio approximately four times with no response At approximately 9:15 p.m. Driver E had been on his return trip to #12 Coal Mine to pick up another load. He heard on the two-way radio that coal hauling had been stopped, so he had pulled over at km 25.5 and stopped at a truck pullout. Driver F had already received a load at Coal Mine #12 and was returning to the Coal Processing Plant. Driver F drove his loaded truck down to km 25, and parked his Coal Haul Truck at a Coal Haul Truck pull-out. Driver F had picked up a Crew Bus along with Driver E and then proceeded to drive towards the Coal Processing Plant and pick up any Coal Haul Truck Operators that had parked their trucks along the haul route. Driver E heard on the Crew Bus two-way radio that Driver D, Shift Leader had been trying to reach Driver A. Driver E radioed back that he was at km 13 near the Sheep Creek Bridge At approximately 9:15 p.m. Heavy Equipment Operator had left the # 12 Coal Mine to travel back to the Coal Processing Plant to pick up a fellow co-worker and bring him back to the #12 Coal Mine. On her approach to the Sheep Creek Bridge she had noticed that a length of guardrailing was missing. The Heavy Equipment Operator called the Crater Enterprises Ltd. Crew Bus behind her and asked if they were aware of a report of an incident at the Bridge because there was missing guardrailing. She stated that she had also heard the Crater Enterprises Ltd s Shift Leader radioing for Driver A and there had been no response. The Crater Enterprises Ltd s Bus Driver called back to ask if there was a problem. She replied that she didn t know but stated she would stop and take a look At approximately 9:20 p.m. the Heavy Equipment Operator positioned her truck about 17 m from the Sheep Creek Bridge and shone her headlights in the direction of the missing guardrailing. She had not seen any tire tracks or skid marks since the snow had been gathering. She walked over to the edge of the bridge deck and noticed what looked like taillights, but there was no noise. She immediately ran back to the truck and radioed the following to Security: This is I m travelling loaded at 12 Bridge. I noticed a missing railing on the bridge and there is a Crater Enterprises Ltd. Haul Truck over the Bridge and upside down in the river. The Heavy Equipment Operator then grabbed her flashlight, ran back to the deck of the bridge, called down to the Truck Operator, but received no response At approximately 9:20 p.m. Driver D, Shift Leader, had heard the Heavy Equipment Operator call on the radio that there was possibly an accident at km 12 Sheep Creek Bridge. He proceeded to drive to the Sheep Creek Bridge along with another Driver B who had parked his truck at the same location as Driver D, Shift Leader. 9

10 File: F At approximately 9:22 p.m. the Crater Enterprises Ltd. Crew Bus with Driver D and Driver F arrived at the Sheep Creek Bridge. They observed no indication of tire tracks or a truck sliding out of control. They proceeded down to the truck and observed that the headlights on the truck were out and that there was no visual indication that would alert any passers-by that an incident had occurred.they noticed Driver A in the crushed cab of the Coal Haul Truck Unit C-87. They called his name and reached into the wreckage and gave him a little push. There was no response The Grande Cache Coal Corporation s Security, Rescue Personnel, Emergency Rescue Team members and Fire Department were notified to respond At approximately 9:39 p.m. the Grande Cache Coal Corporation s Security personnel called the Town of Grande Cache Ambulance to respond to the scene At approximately 9:40 p.m. the Grande Cache Coal Corporation s Emergency Response Vehicle arrived at the scene. The ambulance staff could elicit no response from Driver A, Truck Operator. He could not be extracted from the crushed cab of the Coal Haul Truck At approximately 9:55 p.m. the Grande Cache Coal Corporation s Security called 911 to dispatch Town of Grande Cache s Fire Department for vehicle roll-over rescue assistance. The 911 Dispatcher also contacted the local RCMP At approximately 10:30 p.m. the Town of Grande Cache Ambulance, Rescue Personnel, and RCMP arrived at the scene Driver A, Truck Operator was found deceased and extracted from the overturned Coal Haul Truck and taken to the Grande Cache Hospital for assessment. SECTION 7.0 ANALYSIS 7.1 Direct Cause The Truck Operator was fatally injured when he drove his Coal Haul Truck, Unit C- 87 off the Sheep Creek Bridge landing upside down, 13.7 m below, crushing the cab of his truck. 10

11 File: F Contributing Factors The coal haul route from the #12 Coal Mine did not have signage indicating a right hand turn prior to the turn onto the Sheep Creek Bridge. There was no signage indicating that there was a T-intersection and that a sharp turn must be made. The speed limit that was signed for crossing the Sheep Creek Bridge was not posted far enough in advance and before the turn onto the bridge. Other signs prior to the entry to the Sheep Creek Bridge were not easily visible due to brush and stones on the berm beside the coal haul route. The Truck Operator had called the km 13 sign 750 m prior to the Sheep Creek Bridge entry. (Attachment B, Photographs 3-6) The Truck Operator involved in the incident was familiar with the Coal Haul route as he had traveled it many times. Timesheets indicated he had hauled approximately 144 loads on the route from the #12 Coal Mine. The Truck Operator was on a schedule of ten days on, and four days off. Each workday was 12 hours. He had worked six days and was on his first night shift. This was his first load of the night The Sheep Creek Bridge had 8 light standards with lamps on either side of the bridge to illuminate the roadway on the bridge. The lights were not functioning and had not been made operable since the reopening of the Coal Mine. (Attachment B, Photograph 5 and Attachment C, Engineered Bridge Drawing) A snow squall had erupted and had decreased visibility for the Truck Operator as he approached the Sheep Creek Bridge. The berm on the passenger side of the road caused the snow to swirl in the Truck Operator s line of vision with the wind gusts that were reported. According to witness statements the haul roads were not overly slippery as none of the Coal Truck Operators had indicated to Driver D, Shift Leader, that the roads were becoming dangerous. Truck Operators were allowed to stop hauling on their own if the road conditions were deemed to be too dangerous The Workplace Health and Safety Compliance Investigators were not able to determine if any skidding had taken place just prior to the incident occurring as the Crater Enterprises Ltd. road maintenance crew had graded the road up to the edge of the Sheep Creek Bridge shortly after the incident occurred. Emergency Vehicles attending to the scene destroyed any remaining evidence. (Attachment B, Photograph 7, taken by the RCMP and Photograph 8 taken the day after the incident by the Workplace Health and Safety Compliance Investigators) The Royal Canadian Mounted Police Report indicated weather conditions at 10:30 p.m. at the location of the incident as being extremely poor. Heavy snowing, snow covered roads with slush and ice, and poor visibility. 11

12 File: F The cantilever on either side of the Sheep Creek Bridge was not designed to carry the weight of Coal Haul Truck wheels. When the Coal Haul Truck Unit C-87 drove onto this cantilever it gave way and started the roll-over of the truck. There was no curb on the east side of the Sheep Creek Bridge to guide a wheel away from the edge of the bridge. (Attachment B, Photographs 8-11)(Attachment D, Engineered Bridge Edge Detail) The Sheep Creek Bridge guardrailing was poorly welded and easily broke loose when the Coal Haul Truck s body pushed against it, allowing a roll-over off the bridge deck. The Sheep Creek Bridge guardrailing was not designed to contain any type of vehicles on the bridge deck. (Attachment B, Photographs 11-13) The Coal Haul Truck Unit C-87 had air ride suspension which made the truck lean away from the direction of the turn and changed the center of gravity making the truck prone to tipping in that direction. This tipping action became more pronounced with an increase in the forward speed of the Coal Haul Truck The Coal Haul Truck was modified with an extra-high box to carry a greater quantity of coal to the Coal Processing Plant. This added height would make the truck more top heavy and prone to tip-over The Truck Operator had received a cautionary warning from another Coal Haul Truck Operator the week previous, to slow down as he felt he was over-speeding and may be putting himself in danger. The Crater Enterprises Safety Coordinator reported that speeding was a problem with a few drivers and that she tried to monitor this with a speed gun that was used during the day shift. She stated that she had not noted any speeding problems with the Driver A, Truck Operator.. There were two items of note on the Driver A, Truck Operator s Driver s Abstract. On October 19, 2006 the Driver A, Truck Operator was sited for traveling at 31 kph over the posted speed limit (in his home province) and on January 9, 2007 a citation was received for not using a head protection helmet while operating an All Terrain Vehicle (in his home province). It is not known at what speed Driver A, the Truck Operator was traveling at the time of the incident. The Unit C-87 s vehicle information module was removed and read by the manufacturer s service depot staff but no speed or other relevant information had been recorded The Anti-Lock Brakes on Coal Haul Truck Unit C-87 and many of the other Coal Haulage Truck were not functional. (see explanation of Anti-Lock Brake System in 5.3.8) Lack of the Anti-Lock Brake function would have had an effect on the ability of Driver A, the Truck Operator to steer and brake at the same time in slippery conditions when he was negotiating a sharp turn onto the Sheep Creek Bridge. (Attachment E, Mechanical Report) 12

13 File: F Grande Cache Coal Corporation s staff had not conducted a formal hazard assessment for heavy equipment using the haul route from #12 Coal Mine to the Coal Processing Plant including the Sheep Creek Bridge Grande Cache Coal Corporation s staff and Crater Enterprises Ltd s staff had not conducted a formal hazard assessment of the Sheep Creek Bridge for use by a different type of Coal Haulage vehicle to those used by the previous owners of the Mine. The previous owners of the Coal Mine had larger vehicles specifically designed for heavy hauling with much larger tires. 7.3 Engineering/Mechanical Assessments and Findings Mechanical Inspection revealed that the steering components on this truck were in good condition and appeared to work as designed. Some deficiencies were found in the brake system, the auto slack adjusters required some manual adjusting. The left front brake slack adjuster was out of adjustment far enough to allow the wheel to turn freely with the spring brake (emergency brake) on, but would lock up under the service brake (normal braking with the foot pedal). It was also noted that the Anti- Lock Braking system on the Unit C-87 was not functional. Both front brakes were in good condition, the friction material was well above the minimum required and the service brakes functioned as designed. Even at the worst case scenario of two wheels having no braking effort at all the unit should have approximately 70% braking capacity. (Attachment E, Mechanical Report) SECTION 9.0 FOLLOW-UP/ ACTION TAKEN 9.1 Employment and Immigration; Workplace Health and Safety Compliance A Workplace Health and Safety Compliance Investigator along with the Workplace Health and Safety Acting Director of Mines attended to the scene of the incident on March 4, 2008 and investigated the incident The Workplace Health and Safety Compliance Investigators initiated a mechanical inspection of the Coal Haul Truck Unit C-87. The mechanical inspection was overseen by a Professional Mechanical Engineer/Heavy Duty Mechanic from Associated Geosciences Ltd. and assisted by three heavy duty mechanics; one from Finning Ltd., one from Crater Enterprises Ltd., and one from Grande Cache Coal Corporation. 13

14 File: F Workplace Health and Safety Compliance issued a stop work order to Grande Cache Coal Corporation for travel across the Sheep Creek Bridge until an engineering evaluation of the structure was completed. A hazard assessment was required for the Sheep Creek Bridge structure due to a long crack in the main support beam (discovered by the Workplace Health and Safety Compliance Investigators during the investigative process) directly below the site of the missing guardrailing. Grande Cache Coal Corporation was required to ensure hazard assessments were completed and hazards were controlled or eliminated on the coal haulage routes to #12 Coal Mine and to #7 Coal Mine after it was determined the signage was inadequate on the #12 Coal Haul route. Grande Cache Coal Corporation was issued an order to evaluate whether the electrical power supply to the Sheep Creek Bridge Light Standards could be re-activated. Grande Cache Coal Corporation was ordered to review their responsibilities as a Contractor relating to ensuring that Crater Enterprises Ltd. complied with the Occupational Health and Safety Act and associated Regulations and Code. Grande Cache Coal Corporation was required to evaluate the response of the Emergency Team from the Coal Mine and determine if any improvements could be made. A safe work plan was required for removal of the Coal Haulage Unit C-87 from the Sheep Creek. Grande Cache Coal Corporation was informed about their obligations to maintain coal haulage roads according to the requirements of Section 539 of the Occupational Health and Safety Code. Grande Cache Coal Corporation complied with all the orders written Based on the findings of the Associated Geosciences Ltd s mechanical inspection of Coal Haulage Truck Unit C-87, Workplace Health and Safety Compliance ordered Crater Enterprises Ltd., to stop hauling with their other Coal Haul Trucks and have each unit receive a mechanical inspection. An additional order was written to have the Anti-Lock Braking Systems made functional in all the Coal Haulage Trucks where this system was not operational. Crater Enterprises Ltd. was also written an order to participate in the hazard assessments for haul routes to # 12 and #7 Coal Mines and ensure elimination or control of the hazards found. Crater Enterprises Ltd. complied with all the orders written. 9.2 Industry Grande Cache Coal Corporation and Crater Enterprises Ltd. collaborated to produce an investigation report outlining the incident and corrective measures for preventing a similar occurrence in future Grande Cache Coal Corporation complied with all of the orders written by Workplace Health and Safety Compliance Investigators. 14

15 File: F Grande Cache Coal Corporation and Crater Enterprises Ltd. Enterprises Ltd. collaborated and performed the hazard assessment on the mine haul roads. Necessary steps were taken to address the identified hazards, including speed limit signage upgrade, an additional turn sign, ordering of flashing warning signs, installation of temporary power for bridge lighting and installation of temporary curbing on both sides of the Sheep Creek Bridge. (Attachment B, Photographs 14-18) Grande Cache Coal Corporation has had an engineering review of the haul route signage surrounding the Sheep Creek Bridge for comparison with the requirements of the Alberta Traffic Accommodations Guidelines for signage Grande Cache Coal Corporation retained the services of third party engineers to perform an assessment on the Sheep Creek Bridge. Grande Cache Coal Corporation performed temporary repairs and established a protocol for crossing the Sheep Creek Bridge as per the instructions in the engineering assessment report. Grande Cache Coal has plans processed to modify the Sheep Creek Bridge guardrailing system and complete other repairs to ensure the long term integrity of the bridge Grande Cache Coal Corporation reviewed and updated their Emergency Response plan Grande Cache Coal Corporation reviewed and updated their Contractor Services Agreement and included clauses related to contractor obligations to ensure the health and safety of workers with references to the Occupational Health and Safety Legislation Crater Enterprises Ltd. complied with all the orders that were received from Workplace Health and Safety Compliance Crater Enterprises Ltd. completed a third party inspection on their entire fleet of Coal Haul Trucks to examine for and address any mechanical deficiencies. All anti-lock braking systems were made functional. 9.3 Additional Measures No additional measures were required. 15

16 File: F SECTION 10.0 SIGNATURES Original Report Signed Lead Investigator Date Original Report Signed Investigator, Director of Mines Date Original Report Signed Manager Date Original Report Signed Regional Senior Manager, North Date SECTION 11.0 Attachment A Attachment B Attachment C Attachment D Attachment E ATTACHMENTS: Map Photographs Engineered Bridge Drawing Engineered Bridge Edge Detail Mechanical Report (Copy on file) 16

17 File: F

18 File: F Attachment B Page 1 of 18 Guardrailing that was broken off the Sheep Creek Bridge on the northeast side Coal Haul Truck Unit C-87 Sheep Creek Photograph #1 Shows the Sheep Creek Bridge looking northwest during the morning after the incident. The Coal Haul Truck Unit C-87 had gone through the guardrailing on the north end of the Sheep Creek Bridge and is resting on the lower bank of the Sheep Creek. 18

19 File: F Attachment B Page 2 of 18 Photograph #2 Shows a closer view of Unit C-87 overturned in the Sheep Creek. The Truck Operator s compartment is crushed. 19

20 File: F Attachment B Page 3 of 18 Photograph #3 Shows the limited visibility of the 3 signs during daylight hours. The signs are indicated by the yellow arrows. None of the signs indicate a turn in the road, posted speed limit, a T-intersection, or a bridge ahead. The signs are mounted on the berm (where the wind and snow were blowing during the snow squall described in the Incident Investigation Report). Follow the curvature of the road ahead in the next two photographs. 20

21 File: F Attachment B Page 4 of 18 Some of the Lamp Posts See photos 5 and 6 Berm Photograph # 4 Shows the area where the haul road enters a sharp turn going downhill to the north entry of the Sheep Creek Bridge. The Bridge is not visible from this location even during daylight hours due to the height of the berm on the right. The top sections of the lamp posts are visible. There is no turn indicator or an indicator that there is a T-intersection. 21

22 File: F Attachment B Page 5 of 18 This is the location of a sign with a posted speed of 8 km per hour Photograph #5 Shows a progression into the downhill curve that approaches the Sheep Creek Bridge. The Bridge is visible at this point during daylight hours but would not be visible during hours of darkness as the vehicle lights would not illuminate the entry point. 22

23 File: F Attachment B Page 6 of 18 Photograph #6 Shows the location where the Coal Haul Truck hit the guardrailing, broke it off, and rolled over the side of the Sheep Creek Bridge. 23

24 File: F Attachment B Page 7 of 18 Photograph #7 Shows the rate of snowfall and the amount of snow that had fallen as taken by the RCMP the night of the incident. 24

25 File: F Attachment B Page 8 of 18 Shows a broken section of the cantilever. See photographs 9, 10, and 11 Track from the Coal Haul Truck Photograph #8 Shows a track made in the mud at the edge of the Sheep Creek Bridge. The track is nearly parallel with the edge where the guardrailing was located before the incident. The track is entering the location of the Bridge cantilever. 25

26 File: F Attachment B Page 9 of 18 Shows the cantilever protruding over the edge of the Bridge deck on the east side. See Photograph 10 for a closer view of where the Coal Haul Truck broke through. Broken Guardrailing anchors Photograph #9 Shows how the Sheep Creek Bridge appears from under the northeast side of the bridge deck. The guardrailing has been broken away and the orange arrows show the stripped bolts that held the guardrailing in place. 26

27 File: F Attachment B Page 10 of 18 Photograph #10 Shows a closer view of where the Bridge deck cantilever has bent down from excess weight. 27

28 File: F Attachment B Page 11 of 18 Section of broken away Guardrailing. See Photograph 12 for a perspective from the opposite side of the creek. Section of Broken away Cantilever Photograph #11 Shows an area of the Bridge deck cantilever that has broken away. The guardrailing section is lying on the ground. The rear wheels of the overturned Coal Haul Truck are visible as is the front axle assembly that was separated from the Coal Haul Truck. 28

29 File: F Attachment B Page 12 of 18 Photograph #12 Shows the north end approach to the Sheep Creek Bridge and where the guardrailing broke away from the Bridge and fell onto the embankment as seen from the opposite (south) side of the Sheep Creek. 29

30 File: F Attachment B Page 13 of 18 Photograph #13 Shows that the welding holding the top guardrailing steel I-beam was welded poorly and very little of it was holding the splice in the beam together. This would have allowed the top I-beam to separate very easily. The section between the arrows was the only section that exhibited fresh weld separation. 30

31 File: F Attachment B Page 14 of 18 Photograph #14 Shows the installation of a temporary guardailing at the edge of the Sheep Creek Bridge and concrete Jersey Barriers along the east side of the bridge. Wooden curbing has been added to the west side of the bridge. 31

32 File: F Attachment B Page 15 of 18 Photograph #15 Shows the addition of signage on the Mine Haul Road at the north end of the Sheep Creek Bridge. One sign indicates new signage and the further sign is a km 12 distance marking. More new signs are shown in the following photographs. 32

33 File: F Attachment B Page 16 of 18 Photograph #16 Shows the signs behind the km 12 marker. One sign states Proceed with Caution. The other sign requires the trucks to stop and proceed at 5 km per hour. The lowest sign states Narrow Bridge. 33

34 File: F Attachment B Page 17 of 18 Photograph #17 Shows a new curve sign located just before the sharp turn onto the Sheep Creek Bridge. 34

35 File: F Attachment B Page 18 of 18 Power Generator for the lights on the Sheep Creek Bridge Painted over sign (temporary speed limit until Bridge repairs are completed) Photograph #18 Shows the power generator that has been installed to operate the Sheep Creek Bridge lights during hours of darkness. Also shows the original 8 km per hour speed limit sign that has been painted over with a large 5. 35

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