Coal Inspectorate |
V 1 |
04 April 2023
Overburden drill rollover – Investigation summary
During a night shift on 14 September 2021, two Coal Mine Workers (CMWs) (maintainers) arrived at an overburden drill rig to inspect and repair a reported oil leak. In preparation for the repair, the machine was washed and jacked to near full height with the mast raised. The two maintainers were standing on the deck of the machine and the operator was in the cab when the drill began to slowly topple, coming to rest on the drill cab side, and making contact with an adjacent light vehicle (refer Figures 1 & 2).
The operator and one maintainer exited the drill safely. The other maintainer was trapped between the deck handrail and the light vehicle parked beside the drill. An emergency was initiated, and the Emergency Response Team (ERT) assisted with the safe recovery of the trapped maintainer.
How did it happen?
Events leading up to the incident
- The operator completed drilling a hole as per design when machine sensors detected low hydraulic oil level. The mast of the drill was in a raised position at around 25 degrees off vertical.
- Two drill maintainers arrived at the overburden drill to inspect and repair a reported oil leak.
- In preparation for the repair the drill was washed, lowered off its three hydraulic levelling jacks, refuelled and the hydraulic tank refilled.
- Using the drill levelling jacks, the operator commenced to raise the drill to a height that would enable a maintainer to walk under the machine, inspect and trace the the hydraulic hosing.
- The drill operator was unable to get the left-hand cab side jack to full height as the jack stopped lifting.
- The maintainers decided to isolate the rig when it began to slowly tip to the left side of the cab, coming to rest on the ground, having made significant contact with an adjacent light vehicle (refer Figure 2).
- The operator was able to extract himself from a cab side door and one maintainer was able to jump off the walkway onto the ground away from the machine.
- The other maintainer was unable to jump off the rig and was caught between the deck handrail and the light vehicle parked beside the drill.
- An emergency was initiated and ERT assisted with the safe recovery of the trapped CMW.
- The drill was manufactured around 2009. Since then, modifications had been made to the drill including the addition of larger water tanks, walkways and stairs. The investigation found no evidence that change management processes had been followed or operator manuals updated.
- No operational risk assessment for the use of the drill was identified.
- There was no working visible manual level bubble fitted.
- The drill had been involved in a rollover five years prior. Following this incident grade alarms were fitted to the drill. These alarms function when the drill is sitting on its tracks, but are not designed to function when the machine is on levelling jacks.
- Site compliance checks of the three-leg overburden drill had been completed in December 2020.
- The drill pad had been prepared in accordance with mine standards. To meet design requirements bunds were repositioned and unconsolidated fill added to the area where the drill was operating.
The investigation identified that the toppling of the drill while on levelling jacks was caused when the maximum lateral stable angle of the drill was exceeded. Contributing factors were:
- Unlevel ground at the drill location.
- Ground fill and degree of consolidation.
- The jacked height of the drill.
- Hydraulic cylinder creep or failure, or other form of movement.
- Lack of clear definition, knowledge and monitoring of operating limits on jacks.
The investigation identified that the cab side hydraulic levelling jack cylinder piston and rod seals were severely worn, failed to carry the load and were unlikely to support the drill. Testing of the cylinder showed the hydraulic system operating pressure and cylinder relief pressures were well below what is required according to the operating manual.
Survey data coupled with the jack extension measurements taken after the incident, indicate that the drill was outside safe working limit design parameters for roll/tilting.
Stability alarms installed at the time of the previous incident did not alert the operator when the drill was positioned outside the equipment design parameters, when supported on levelling jacks.
Drill training requirements did not include information related to the safe operation of jacks including risks associated with imbalance between jacks.
The maintainers intended to inspect and be underneath the drill whilst it was raised and only supported by the hydraulic levelling jacks.
All Site Senior Executives should:
- Review and update as required, site processes and standards for the introduction of equipment to:
Update site standards, related documentation and training requirements, and communicate this to all affected CMWs.Ensure CMWs are aware of the risks associated with working under suspended loads unless appropriate jack stands are in place.Implement and monitor systems which validate that CMWs are following the requirements of the documents held in the Safety and Health Management System to maintain an acceptable level of risk.
- ensure that third party suppliers of equipment provide up to date safety files including maintenance and operations manuals, and evidence of risk assessments covering major changes or additional items added post Original Equipment Manufacturer (OEM) build.
- require OEM / third party providers of drilling equipment to provide equipment that has alarms fitted that alert the operator of unstable conditions during travelling and drilling operations. Further, that the alarms are installed and set in accordance with designated safe operating limits and ground conditions.
- ensure operational risk assessments are conducted for the introduction and use of plant. The potential for rollover to be considered in all operating conditions. Risk assessments should include suitably qualified and competent CMWs including OEM, drilling contractors and subject matter experts.
- review operational risk assessments, including ground condition checks and grades when relocating to a new site.
OEMs and third-party suppliers:
- Suppliers of drilling equipment should develop guidance notes on safe jacking limits and include this within drill operator training material and operating procedures.
- Identify stability limits (inclusive of a safety factor) when plant is moving on tracks or raising or lowering on levelling jacks and configure stability alarms on drills to incorporate these.
- Consider implementation of interlock and auto levelling systems where this is practicable to do so.
- Ensure design risk assessments for equipment are reviewed when additional items are being added to the machine that were not originally supplied by the OEM. Appropriate expertise should be involved to ensure no additional hazards have been added.
Chief Inspector – Coal
Senior Inspector of Mines
0477 373 213
Issued by Resources Safety & Health Queensland
Safety: This information is issued to promote safety through experience. It is not to be taken as a statement of law and must not be construed to waive or modify any legal obligation.
Placement: Place this announcement on noticeboards and ensure all relevant people in your organisation receive a copy, understand the content, findings and recommendations as applicable to their operation. SSEs should validate that recommendations have been implemented.
All information on this page (Overburden drill rollover – Investigation summary - https://www.rshq.qld.gov.au/safety-notices/mines/overburden-drill-rollover-investigation-summary) is correct as of time of printing (31 May 2023 9:07 pm).