December 24, 2011

High Potential Risk Incident

Compressed Air-Face / Eye Injury

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The Incident

• On Dec 24th, 2011 two worker’s were assigned to pull back the compressed air and water services from an existing heading, in order to start a new drift.

• This resulted in a face / eyes injury from the uncontrolled release of air energy to one of the workers.

• Injured has 3 years mining experience• 2 ½ years in ore flow• 6 months in rehab

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Mine LayoutInjury Site

6200 LevelGrey Wacky Lens

Location of worker’s pulling back the mine services in order to slash the corner and proceed to drive the drift –nobody worked in this location for approx. 1 year

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Services Orientation-Actual

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Incident Details

• Both workers went to the work area; one worker operating the tractor with a basket to elevate his partner to the main line header valves to lock out the 4” main air and water lines.

• The air line valve had a missing handle so the worker closed the 4” valve with his adjustable wrench.

• He then placed a chain around the two service pipes and put his personal hold tag and lock on the chain.

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Incident Details

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Main Header Valve Lockout-Actual

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Incident Details

• The tractor operator lowered his partner.

• The worker in the tractor basket got out of the basket and proceeded approx. 16’ to the end of the air service line to bleed off any residual air.

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Contributing Factor

• There was a 1” bull hose attached to the 1” valve at the end of the air service line 100’ long. The worker opened and bled off residual air while attached to the bull hose.

• The worker then decided to remove the bull hose from the 1” valve.

• While trying to remove the hose fitting he struggled to wrench off the 1” bull hose due to the valve handle in the open position. So he decided to close the 1” valve, to ease the removal of the bull hose.

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1” Air Valve1” Bull HoseOrientation

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Incident Worker Position

• The worker then inadvertently proceeded back to the tractor basket without reopening the 1” valve.

• The tractor operator

elevated him up to disconnect the 4”X 2” reducer Victaulic clamp to start pulling back the services.

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Incident Details

• There were approx. 12-15 minutes that elapsed from when the worker reclosed the 1” valve, removed the bull hose and positioned himself at the 2” reducer and began removing the Victaulic clamp.

• The injured had one bolt removed from the clamp and began loosening the second bolt when the 2” Victaulic clamp and down pipe blew off the reducer.

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Injury Scene

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Incident Details

550 lbs of energy force when the Victaulic clamp became a projectile

7-9 lbs of energy force to break a human bone

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Mechanism of Injury

• The worker received a blast of compressed air that had built up from the 4” line to the end of the 1” line, where he had reclosed the valve to remove the 1”bull hose.

• The result was residual metal rust fragments from the inside of the pipe embedded in his face and both eyes.

• The Victaulic clamp or rubber gasket did not hit him in the face.

• The injured was brought up to surface immediately and transported to the district hospital.

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Incident Details

• The scene was frozen and we awaited results from the hospital on the extent of the injury.

• Upon assessment at the hospital it was decided to air ambulance him to North Bay to have a specialist remove any particulate from his eyes and face.

• On Dec 25th an update from OH was sent; the worker returned home from North Bay and he was not going to loose any of his sight. The injured was on a modified work assignment and returned to full underground duties on January 16th.

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Investigation

Root Causes:Deficiencies in the site lock out tag out test

systems.

Contributing Causes:• 4” valve on main air line not sealing at 100%

(Direct Cause / immediate)

• Ventilation fan noise in the heading would have stopped any leaking air from being heard (Direct Cause / immediate)

• Operator didn’t follow procedure (Basic Cause / personal factor)

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Corrective Actions

• Contact supplier and other mine operations to review options for improved locking 4” service valves.

• Review lock out tag out Procedure to determine if zero energy at all times is adequately covered. Audit the training materials to ensure that the zero energy sources are properly reinforced in the curriculum

• Job Task Observations on lock out tag out will be scheduled for the month of January at Kidd Operations. Supervisors to complete spot observations in January with relevant crew members and log it in their supervisor log book.

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New Valve Standard

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Corrective Actions

• Improve the mine site work permit system for Lock Out Tag Out Test process

• Refresher training on lock out tag out test will be scheduled for the workforce-with revised training material

• Review site HHACP and CHMP to ensure the site training materials includes the critical controls in the training curriculum.

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Lessons Learned

Controls need to be continuously improvedStates of mind can create critical errors

Rushing Mind not on task Fatigue Line-of-fire Complacency Eyes not on task Frustration Balance traction or

grip

Safe Start-Larry Wilson

States of Mind

Critical Errors

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The End

Questions