FATAL REVIEW. Sibongiseni Sihle Majozi Matla Coal Mine 2: Back-Bye Engineering Mechanical 1 March 2017

Transcription

1 FATAL REVIEW Sibongiseni Sihle Majozi Matla Coal Mine 2: Back-Bye Engineering Mechanical 1 March 2017

2 Details of Deceased 1 Name of the deceased Occupation : Sibongiseni Sihle Majozi : Artisan Aide ID No / Coy No : / Address : Vumanhlamvu Area, PO Box 2090 Nkandla 3855 Employee/Contractor : Employee Date of incident : 01 March 2017 Time of incident Type of incident Total length of service : 01H25 : Vehicle Safety : 7 Years 10 months Experience in current position : 1 Year 5 months (1 September 2015) Age Marital Status & Dependants : 28 year : Married with 2 dependents

3 Accident Details 2 A team of three employees were moving a belt drive utilising an LHD. It is alleged that the belt drive got stuck against another stationary belt drive. The employees then attempted to dislodge and reposition the belt drive. In the process the now deceased was caught between the LHD and the belt drive.

4 In-loco Investigation 3 On the 01 March 2017, after the fatal incident at Mine 2 Back Bye area, a team made up of the Inspectors and Mine Officials visited Underground for an In-loco investigation. Area Visited DMR Inspectors Mine Officials Mine 2, Back bye, split 7 A.B.Nkosi T.Matanga B. van Stelten S.Badenhorst M.Geduldt T.Nkwe T.Sehloho G.Mathebula J.Beukes V.Simelane J.Janse van Rensburg S Sindane L Dzondzi

5 Section 54 Instruction 4

6 Findings of the Inspector 5 The following findings were observed and the accompanying instructions were issued by the Inspectors: Area Deviation Order Matla Coal The SOP to ensure the safe towing of machinery/equipment applicable to Matla Coal does not address the folowing: 1. Dealing with any obstruction on the travelling road. 2. Communication method between the employees involved in towing, coupling or de-coupling. 3. Clearance between the machine and persons during towing, coupling or de-coupling the equipment. The Employer is hereby instructed to stop all towing, coupling and de-coupling of machinery and equipment using LHD.

7 Immediate Actions 6 Stop all towing, coupling and de-coupling utilising the LHD. Communicate the Section 54 instruction with all employees at the safety mass meetings. Meeting with the H&S committee and Union representatives to be held to inform the committee of the Section 54 instruction and actions to be taken by a task team..

8 Instruction to be Actioned 7 (Jointly with members of H&S committee) 1 Conduct a comprehensive systems audit on towing, coupling and de-coupling for: All LHD towing activities at Matla Coal focusing on: Travelling road obstructions Communication between the LHD operators and the employees The clearance distance between the equipment and the employees performing the towing activities 2 Investigate root causes and areas of improvement 3 Institute an action plan to prevent further re ocurrences.

9 Further communication from the BU manager s desk 8

10 Implementation Plan process flow diagram Section 54 issued by the DMR Stop all towing, coupling and decoupling utilising the LHD and other equipment. Meeting with the H&S committee and Union representatives to be held to inform the committee of the Sec 54 instruction. Conduct an audit with regards to all towing, coupling and uncoupling activities on the mine Appoint of task team to remedial the section 54 instruction Review and update risk assessments accordingly No Does the SOP cover the activity in detail update as informed by the risk assessment Yes All relevant employees to be informed, trained and deemed competent on the updated procedure

11 Implementation plan (Risk Based) Production / Engineer HoM and M O Foreman or S/boss Artisan(s) or miners Man carriers U/G LDV Continuous miners C/M Shuttle car S/C LHD Tractor Matla coal has existing risk assessments(ra) and procedures, however while the review of those RA s and procedures are underway the towing, coupling and de-coupling will ony be done under supervision of the senior official based on the perceived risk Surface LDV Surface shuttle Bus Pool car Trailer Skids lowbed Continuous miners C/M Shuttle car S/C LHD Tractor Trailer Skids lowbed Man carriers U/G LDV Surface LDV Surface shuttle Bus Pool car 7-14 March End April End May End June 10

12 Prioritasation of the Fleet By Risk 11 INDEX SIGNIFICANT PRIORITY Risk Rating Tolerability Tolerability Definition Extreme (21-25) INTOLERABLE - Significant & urgent actions required ALARP - Reduce risk to As Low As Reasonably Practicable Very high risk - immediate preventive action required to reduce risk or consider discontinue Preventive action request EXTREME HIGH (13-20) High risk implement preventive action where practical and monitor action HIGH MODERATE (6- Substantial risk - implement preventive action 12) where practical and monitor action MODERATE LOW (1-5) TOLERABLE Acceptable risk - Monitor and manage risk LOW SEVERITY (BI/MD) Business (R/S/C) (S/H) (EI) Interruption / (L&R) Impact on Harm to People Environmental Material Damage & Legal & Regulatory Reputation / Social (Safety / Health) Impact Other / Community Consequential Losses Multiple fatalities / Impact on health ultimately fatal Single fatality or loss of quality of life / Irreversible impact on health Lost time injury / Reversible impact on health Medical treatment case / Exposure to major health risk First aid case / Exposure to minor health risk Extreme environmental harm - L3 incident irreversible Major environmental harm - L2 incident remediable post LOM Serious environmental harm - L2 incident remediable within LOM Material environmental harm - L2 incident remediable short term Minimal environmental harm - L1 incident Substantial or total loss of operation / > R Partial loss of operation R to R Partial shutdown / R to R Brief description to operation / R to R No disruption to operation R to R Very considerable penalties & prosecutions. Multiple Law Suits & jail terms Major breach of the law; considerable prosecution and penalties Serious breach of the law; investigation report to authority, prosecution and or moderate penalty possible Minor legal issue; non compliance and breaches of the law Low level legal issue International impact - international public attention National impact national public concern Considerable impact - regional public concern Limited impact - local public concern Slight impact - public awareness may exist but no public concern Rare - The unwanted event has never been known to occur in the business; or it is highly unlikely that it will occur within 20 years Unlikely - The unwanted event has happened in the business at some time; or could happen within 20 years FREQUENCY / PROBABILITY Possible - The unwanted event has happened in the business at some time; or could happen within 10 years Likely - The unwanted event has occurred infrequently; occurs in order of less than once per year & is likely to reoccur within 5 years Almost certain - The unwanted event has occurred frequently; occurs in order of one or more times per year & is likely to reoccur within 1 year Moderate (11) High (16) High (20) Extreme (23) Extreme (25) Man carriers U/G LDV 4 Moderate (7) Moderate (12) High (17) Extreme (21) Extreme (24) 3 Low (4) Moderate (8) High (13) High (18) Extreme (22) 2 Low (2) Low (5) Moderate (9) High (14) High (19) Surface LDV Surface shuttle Bus Pool car Continuous miners C/M Shuttle car S/C LHD Tractor 1 Low (1) Low (3) Moderate (6) Moderate (10) High (15) Trailer Skids lowbed

13 Training schedule for the LHD 12 LHD OPERATOR TRAINING - COUPLING - TOWING - UNCOUPLING OF MACHINERY AND EQUIPMENT DATE DAY SESSION 1 Session 2 SESSION 3 Mine 2 Number of Learners Mine 3 Number of Learners Timothy 20 July Mar-17 Friday 06H30 to 09H30 10H30 to 13H30 14H30 to 17H30 Jabu 20 Daniel/Max Mar-17 Monday 06H30 to 09H30 10H30 to 13H30 14H30 to 17H30 14-Mar-17 Tuesday 06H30 to 09H30 10H30 to 13H30 14H30 to 17H30 Timothy 20 July 20 Jabu 20 Daniel/Max 20 Timothy 20 July 20 Jabu 20 Daniel/Max 20 Please take note that only as and when employees have been trained and deemed competent will they be allowed to commence with working on towing, coupling and de- coupling LHD activities