Ravensworth Mine on 30 th November 2013 Brief summary of the investigation report 31 st March 2015 At 1150 pm on Saturday 30 November 2013 38yearold Ingrid Forshaw a trainee plant operator employed by TESA Mining NSW Pty Ltd was fatally injured while working at the Ravensworth ID: 303740
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Slide1
Investigation into the fatal collision between a CAT 793 & LV at the
Ravensworth Mine on 30th November 2013
Brief summary of the investigation report
31
st
March 2015Slide2
At 11.50 pm on Saturday, 30 November 2013, 38-year-old Ingrid Forshaw, a trainee plant operator employed by TESA Mining (NSW) Pty Ltd, was fatally injured while working at the Ravensworth open cut mine, near Singleton
NSW.Ms Forshaw suffered fatal injuries when the Toyota Landcruiser she was driving collided with and was run over by the front right-hand side wheel of a haul dump truck (Caterpillar 793D), weighing approximately 351 tonnes (including 186 tonnes of coal).
Ms Forshaw had earlier parked the haul truck she was operating at
the ULM stockpile and collected a Landcruiser that was parked at the stockpile by another operator at the start of the shift. Ms Forshaw was driving to collect other workers and go to a crib break. The truck operator was hauling coal along the 9th haul road (a main haul road in the Narama area). As he approached the T-intersection with the stockpile ramp (8th ramp) he saw the Landcruiser travelling down the 8th ramp. As the truck operator approached the T-intersection he saw the Landcruiser enter the 9th haul road to his right and then he lost sight of it. At the time, vehicles approaching the T-intersection on the 8th ramp were required to give way to vehicles on the 9th haul road. The Landcruiser driver turned right onto the 9th haul road into the path of the truck. The truck and Landcruiser collided and Ms Forshaw was crushed inside the Landcruiser and died immediately from multiple injuries.
Incident overviewSlide3
Pictures of the 8th ramp & intersection
View looking down the 8
th
ramp towards the intersection with the 9th haul road
View looking across the 9
th haul road at the intersection & up the 8th rampSlide4
Picture from truck operators perspective
Truck left hand drive. Blind spot to right
Position of LV within right hand blind spot & path of LV denoted by red arrow
View up the 8
th
rampSlide5
The truck operator had on bumper lights & low beamThe bumper lights were heavily obscured by mud at the time of the incident
The right hand low beam light was recessed and difficult to see from the sideVisibility of the truckSlide6
No direct artificial lighting at intersection
The left hand windrow of the 8th ramp was 2m high (vs design of 1m) & only the top half of the truck was visible approaching the intersection. This part of the truck had no lights & minimal reflective tapeIn the background of the intersection were spot lights as well as light reflecting off water ponded at the intersection
that may have obscured
visibility of the truckWhat did the LV operator seeSlide7
Drivers experience:
Whilst the haul truck operator had nine+ months experience in CAT 789s this was his first shift operating a CAT 793 on his own.The LV operator had 9 months experience at the time of the accidentWA fatality statistics from 52 fatalities that occurred between 2000- 2012:
48% of fatalities occurred within the first 24 months of the job or role;
49% of fatalities occurred within the first year at the mine;44% of fatalities occurred under supervisors who were within their first year of supervision.Mine site experienceSlide8
Human factors
The truck operator observed the LV entering the intersection but assumed that the vehicle was pulling out to slip in behind the truck as it went byThis suggests that there was complacency in maintaining correct separation distance at the mine site
This assumption by the truck operator cost Ms Forshaw her life
All the critical controls identified were administrative controls (procedures) which in term place a high reliance on human factorsSlide9
Causal factors were in the safety statistics
From 289 hazards / improvements raised up to November 2013:Road related hazards were the top hazard (12% or 35 reports); andWindrows were equal second top hazard (8% or 23 reports).
Presentations on LV & HME interactions were given in November 2013 at safety talks due to these statistics:
Ms Forshaw had attended one of these safety talks 3 days prior to the incident but the truck operator had not yet attended a session.Slide10
Contributing factors from the investigationSlide11
Key observations
No distinction was drawn in risk assessments & controls measures concerning interaction of HME & LVs between night & day time operationThere was no recent risk assessment on the suitability of reflective devices on HME & LVs
There was no formal analysis conducted to determine the need to separate light & heavy vehicles on mine haul roads & access roadsSlide12
Recommendations from the investigation