Drill ICAM Prelim Notification

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    Drill ICAM-preliminary information

    For information purposes only. Managers & Supervisors shouldevaluate this information to determine if it can be applied to their own

    situations and practices.

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    Drillingterms

    Feed Cylinder

    Hydraulic hosefitting

    Drill stringdown

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    WHAT HAPPENED:

    Time: Between 11h04 -11h17

    Fitter had completed daily checks on Drill and was undertaking the repair to an oil leak on the lefthe drill. Mechanic was observing Fitter as, Mechanic, was being coached on the workings & mathe drill. Fitter had requested the drill operator to raise the drill string [for] better access the leakwork on. Fitter took up a kneeling position with their right leg over the drill platform hole throughpasses during drilling operations.

    Fitter loosened the hydraulic hose fitting which connected to the feed cylinder. This resulted in tstored energy within the cylinder, resulting in the release of the drill string which plunged down athrough the platform drill hole it resulted in the amputation of the right leg below the knee.

    Mechanic had taken up a position on the right side of Fitter with back to the [drill] operators cabiprobably holding on to the steel rope, which passes under a sheave wheel for the control of the uof the drill string, with their right hand. When the pressure was released from the feed cylinder thdrill string moved downwards as did the steel rope [and the] Mechanics right hand was pulled thwheel resulting in the amputation of four fingers & thumb.

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    Fitters leg position prior to the accident simulatedwith a mannequin

    Simulatedposition of

    the Fitter withhis right legover the drillhole

    Drill string ina raisedposition (drill

    bit seen here)

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    Hydraulic hose fitting on feed cylinder

    Hydraulic hose fitting thatwas loosened resulting inthe release of storedenergy

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    WHAT CAUSED IT:

    Root causes

    Loosening the hydraulic hose fitting connecting the hose to a hydraulic feed cylinder, and inan uncontrolled release of oil pressure from the cylinder causing the drill string to fall.Stored energy not released prior to commencing activities.

    Key contributing factors

    Did not take the time to plan and reflect on the risks of the task at hand. No formal risk assessment performed prior to the task. Insufficient understanding of the hydraulic system on the drill. Insufficient knowledge on the concept of stored energy. No guarding in place covering the moving sheave wheel.

    Key learning's

    Awareness campaigns not enough to embed understanding of sources and consequence There is no substitute for taking time out to perform proper planning and understanding th

    to commencing any task.

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    To address this incident, this Asset is consideringthe following:

    Launch a communication campaign in regard to stored energy in simple and clear terms

    Review, Verify, Sign off Risk Assessments that all stored energy risks are captured and high risk areas are covered by

    Guards to be fitted on all bottoms of sheave wheels on drills. Formally review guarding to ensure all moving parts are guarded

    Supervision verification through quality PTOs and CTOs. The one up line manager must verify the quality of a sample

    Assess the capability of Supervisors in key critical areas to ensure they are competent to execute their responsibilities

    Include stored energy in the COP for isolation, lock, test and tag.

    Update procedures to ensure that unplanned work (subsequent work) is properly planned and executed.

    Supervisors are notified of, pre-approve, and adequately mitigate risk in Remote work.

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