Home > Risk management failures to blame for Cobar mine death

Risk management failures to blame for Cobar mine death

Editorial
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Ineffective risk management controls have been found to have contributed to the death of a worker at Glencore’s CSA Copper mine.

Jeremy Junk, 41, was working as the shift supervisor as part of a four-man crew on a shaft extension project at the mine in western NSW for contracting firm MacMahon Mining Services.

On March 16, 2013,he suffered a fatal head injury after being struck by the underside of an operating platform.

In a report into the incident, prepared by New South Wales Trade and Investment, it stated that the shaft crew were in the process of lowering a kerb ring using chain blocks in preparation for the installation of hanging rods when the incident occurred.

During the works the shaft crew used the stage signalling system to communicate with the winder driver to lower the kibble into the shaft. The winder driver lowered the kibble into the shaft and through the stage’s kibble well to the lower platform of the stage where Junk climbed into the kibble.

Workers reported that Junk intended to be raised in the kibble to the 9240 brace level to obtain hanging rods (threaded steel rods used to secure the kerb ring in place).

Workers reported that Junk signalled the winder driver to raise the kibble by ringing three bells from the communication system inside the kibble.

While the kibble was being raised through the stage’s kibble well, workers reported seeing Junk extend his head over the side of the kibble to communicate with a shaft worker on the stage.

As the kibble approached the stage’s upper platform workers reported seeing Junk’s head impact between the kibble and the upper platform of the stage.

After attempts to communicate with Junk failed, emergency response procedures were activated and an unconscious Junk was transported to the surface and taken to Cobar Hospital where he was pronounced dead.

The report stated the accident was foreseeable; stating ineffective risk management procedures, inadequate training, and fatigue may have contributed to the accident.

It said the signalling system in effect at the time of the accident did not encompass a specific signal identifying when people were riding in the kibble.

The report stated the “Man Riding in Kibble Procedure” documented procedures to exclusively control the risks associated with riding in the kibble and the hazardous pinch points in the kibble well of  the stage.

The document stated “Caution: Keep body parts inside the confines of the kibble”.

But this statement was not given any emphasis in the procedure, the report said.

Further, the report found the procedure did not link this behaviour to personal safety, but rather to equipment or property damage.

Additionally, the one-page assessment task attached to the procedure did not specifically test workers’ knowledge on the importance of keeping body parts inside the confines of the kibble.

The procedure also documented a situation where it was necessary for personnel in the kibble to look over the edge of the kibble to ensure the stage or shaft bench was clear before lowering the kibble.

“These practical differences made the procedure ambiguous,” the report said.

“Administrative controls such as this are considered to be ‘soft controls’ and are not as effective as other hierarchical risk management controls. It is undesirable to have an administrative control as an exclusive risk management strategy.

“This procedure was ineffective in this and other instances, and failed to prevent Mr Junk from being exposed to a risk to his health and safety.”

The report also stated the design of the shaft sinking stage created pinch points and did not incorporate psychical barriers to prevent people riding a kibble from exposing their body parts to these pinch points.

It was also found the unique dual platform stage design had not been previously used by Macmahon personnel for shaft sinking projects.

Training records indicate that no training was provided to workers about the use of the stage or the stage design prior to the incident occurring.

Fatigue was also highlighted, with the report stating that Junk, a FIFO employee, had worked extremely long hours during the shifts preceding the incident. His working hours exceeded the 12 hour shift times on six of the preceding eight shifts.

“This incident highlights the importance of an effective risk management program in relation to shaft sinking activities,” the report concluded.

Recommendations made as part of the investigation include the use of man riding cages in lieu of a kibble as a form of shaft conveyance, adequate training, the alteration of shaft sinking stage designs to eliminate pinch points and specific signalling systems.

It said Macmahon had implemented a number of safety procedure since Junk’s death, including significant amendments to the e ‘Man Riding in Kibble Procedure’ and related training.

A physical barrier in the form of webbing material has also been attached to the kibble to prevent people from extending their body parts outside of it.

Macmahon reported that the mesh barrier was a temporary measure until specialised man riding kibbles were designed and implemented.

Macmahon’s contract at the mine was terminated three months after the accident occurred and is the subject of a civil action case as the contractor pursues claims for unpaid work in relation to the project, and claims for damages arising from the “sudden” termination.

A former Macmahon employee told Australian Mining that in his opinion the company lost the project because of safety issues, not just because the mining sector was contracting.

“I was gobsmacked that they don’t have things like cages, mechanical and physical barriers around the shaft sinking process to keep people from sticking their heads over the edge having a look at what’s happening down below.

“That’s a third world country thing in a first world country.”

A full report into Jeremy Junk’s death can be viewed here.

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