Retractable access ladders

What happened?

An operator was fatally injured when he became entangled between the movable part of an excavator’s access ladder and the wall of the engine room. (See Figure 1)

How did it happen?

Injuries were sustained as a result of entanglement in handrails, following activation of the access ladder emergency release valve.

Recommendations

Inform users of retractable ladders about the contents of this safety alert.
Although procedure (an administrative control) required the access ladder to be lowered through a safe process and location, it was physically possible to access the emergency ladder release valve. An engineering control would have been more effective in keeping persons away from this location e.g. by positioning the valve in a place that is not accessible or by covering it.
The design of the access ladder, where the rotating handrails pass the stationary handrails in a scissor action, should be reviewed.
Refer to Komatsu ‘Parts & Service News subject: “Hydraulically operated access”; Emergency release function, No AH19881; 18 July 2019’.

Investigations are ongoing and further information may be published as it becomes available. The information in this publication is what is known at the time of writing.

We issue Safety Notices to draw attention to the occurrence of a serious incident, raise awareness of risks, and prompt assessment of your existing controls.

Why did it happen?

While the Mines Inspectorate’s investigation is ongoing, it appears the operator somehow became caught within handrail cell A2 shown in Figure 2.

When the ladder was lowered, following activation of the emergency ladder release valve, which is located behind the stationary handrails, the operator sustained injuries from the moving handrails. (See Figure 3).

The requirements of the OEM are that the emergency release valve is intended to be operated by a pull cable, positioned in a safe location. The investigation has identified that this valve can be activated without the use of the pull cable, which was found to be difficult to operate.

For routine operation, the access ladder is lowered using a set of controls, positioned in a non- hazardous area. These controls were verified as being functional.

Authorised by Shaun Dobson - A/g Chief Inspector of Coal

Contact: Theo Kahl, Inspector of Mines , +61 7 4936 0127 annemarie.todd@dnrme.qld.gov.au

Issued by Queensland Department of Natural Resources, Mines and Energy

Placement: Place this announcement on noticeboards and ensure all relevant people in your organisation receive a copy.

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