2002 Blackwater

12/04/2002 - Blackwater Mine - Crush Injury / Crane Operation

The Coroner Found: 

I find that on that day Mr Belfield had been operating a vehicle loading crane attached to a Mitsubishi flat tray truck and in the course of that operation-of that crane he was crushed between the passenger side controls and the jib of that vehicle loading crane . There were no direct witnesses to see exactly how that occurred and it really is a matter of conjecture as to how that did happen. 

This accident claimed the life of Chris Belfield


1 Risk assessments should be carried out on the operations of all vehicle loading cranes used in the industry and appropriate controls should be put in place to ensure the operator is not exposed to an unacceptable level of risk. Included in the risk assessment should be the:

a) Design features of the vehicle loading crane including:
" Guarding of the control levers;
" Location of the control levers;
" Slew of the crane within the area of the control levers;
" Direction of the control lever movements for each function

" Labelling of the functions;
" Ability to release hydraulic pressure in the case of an emergency

b) Configuration of the crane on the vehicle, with special attention given to:
" The use of the vehicle and vehicle loading crane;
" The location of the crane slew end points;
" The vision of the operator;
" The location of the operator when folding/unfolding the crane;
" The confinement of the operator's work area at the control levers .
c) Operational activities.

2 Training and Assessment packages for the operation of vehicle loading cranes within the industry should be reviewed to ensure the hazafds of operation are identified and addressed.

As part of the review, particular reference should be made to the General Requirements of the Australian Standard AS 2550.1 Cranes - Safe Use, which addresses the operational hazards associated with this accident. Critical aspects to be considered should be :
" The implementation of 'no-go' zones around the operator's control panel where the crane should not be operated or slewed into;
" The description of these 'no-go' areas including the use of drawings, photographs and videos;
" The importance of watching the crane hook when operating crane;
" The importance of not working under the boom of the crane ;
" Recording of the inspections and any defects found, in a Log book.

3 Manufacturers that supply vehicle loading cranes to the industry should be informed of this accident and the outcomes of the investigation so that engineering design changes can be made to ensure:

" That a crane cannot be slewed into the operator's working area at the controls;
" That the operations of the control levers for similar functions are the same ;
" That to lower the boom or jib should require the control lever to be moved upwards;
" That the location of the control levers allows a person to operate the crane in safety with clear vision of the operations;
" That the control levers are guarded or shrouded to prevent accidental operation ;
" That the geometry and configuration of the jib ram or hydraulic circuit to this function is modified to remove the acceleration of the
jib when it passes the centre of the pivot between the jib and boom .
" That deadman controls are incorporated that will stop all operations in the event of an accident or absence of the operator from the controls.

4. Instruction manuals and training material should not display drawings and practices that encourage unwanted practices and risk to the operator. 

5. Contractors and suppliers to the industry who operate vehicle loading cranes on mine sites should be made awsare of this accident and the outcomes of the investigation so that the equipment and operation of the equipment meet the standard required by the industry. 

6. Workplace Health and Safey should be informed of the accident and the recommendations so that they can make similar actions with other industries. 

7. THe Chief Inspector should convene a Review Committee as allowed for in the Compliance Policy to determine the appropriate action to determine the appropriate action to be initiated in response to the legislative non-compliance issues detailed in Section 6.5 of this report.