On the morning of 30 August 2016, Mr Ian Hansen was fatally injured by a falling deck plate that he and three other workers were in the process of removing. Despite immediate and persistent first aid by first responders, an Emergency Response Team and the Queensland Ambulance Service, Mr Hansen was pronounced deceased at the scene.
The incident occurred at a chain feeder at the Newlands Mine Coal Handling and Preparation Plant (CHPP) which was undergoing work as part of a general maintenance shutdown. Glencore, the operator of the Newlands Mine CHPP, had contracted UGL to undertake the maintenance work.
The investigation concluded that Mr Hansen was in a known danger area when the deck plate swung in an arc into him.
There were a range of failures surrounding the incident including that safe work method statements and risks assessments required under the Umbrella Contract were not made, a known method for removing the deck plates was not obtained, the risk assessment for the task was not comprehensive and supervision was lax.
As the work on the chain feeder progressed there was little formal communication between the shifts or among supervisors, procedures to update the JSA reflecting changes to the task were not followed and the supervisor was not always close at hand. The factors that contributed to the incident can be grouped into planning, supervision and communication.
There was a lack of detailed planning to guide the chain feeder work. The process for removing the plates appears to have relied on the workers’ knowledge of similar structures and estimating possible outcomes. This lead to unnecessary risks in undertaking the work. The lack of planning to clearly outline the equipment to be used and the standards to be followed also lead to the use of substandard engineering practices.
More rigorous supervision of the process - from ensuring the Umbrella Contract was properly made to signing off on amendments to the process of removing the plates – would have provided greater opportunities to identify and mitigate risks on site. There was an evident lack of formal communication channels and practices. Between supervisors, between work groups and within work groups, poor communication is evident. At the time of the incident there was a misunderstood communication, as the bolts were removed prior to clearing the area under the deck plates.
Some of the oversights surrounding the incident occurred due to a less than rigorous enforcement of existing safety and risk assessment procedures while some appear to have arisen due to gaps in the safety and risk assessment regimen. Accordingly, the Mines Inspectorate (coal) has made a number of recommendations.
• Newlands Mine SSE:
o audit the application of risk management procedures as they are practised on a day to day basis. Based on results of the audit initiate necessary changes to ensure risk assessments meet the requirements and standards in the site SOPs.
o Implement internal audit processes to review and check on an ongoing basis the quality of the risk management assessments being undertaken at the site and to implement the necessary corrective actions to ensure site established standards are maintained.
o review supervision arrangements, in particular supervision arrangements for shutdown work. The review should consider roles, responsibilities, qualifications, span of control, shift to shift communication expectations and specific tasks and behaviours supervisors must demonstrate each shift when supervising coal mine workers.
o review and establish minimum requirements for the level of planning of works to be completed prior to actual work being undertaken. The review should consider the degree of work planning required prior to shutdowns, work method statement development, risk assessment, quality checks and approval to proceed processes.
o review the site SHMS and corporate contracts and resolve inconsistencies between corporate and site requirements.
o implement training/familiarisation processes to ensure relevant supervisors are familiar with the terms and conditions of contracts.
o review the site "Introduction of equipment to site" processes to ensure all equipment used by contractors is fit for purpose.
o be requested to present at industry forums learnings from the incident.
• UGL:
o review the set-up and management of work groups. The review and actions should consider who is in charge of the work group, work group expectations, rapid assembly of teams, teamwork and communication processes within work groups. UGL should provide training in teamwork and communications between work group members with an aim of minimising teamwork failures.
o implement processes to ensure equipment is used in accordance with recognised standards and manufacturers recommendations. This should include documented records of inspections of equipment prior to use.
• FLSmith ABON should provide updated operations and maintenance manuals to the mine for the chain feeder that include a risk-based methodology for foreseeable tasks as far as reasonably practicable.
• The DNRM communicate to industry circumstances and learnings from the incident.