Incident - Queensland, 2006

Incidents Queensland, 2006

Project Cranes The Outcome Key Learning

Queensland Mine Site

Iveco Acco 2350G truck • Near miss • Limitations to brake design • Ensure park brake works whether ignition is on or off • Driver’s understanding of the braking system was inadequate – drivers must be aware of design weaknesses

An unattended partly loaded bulk explosives truck was parked with its engine running. The driver had applied the parking brake before disembarking and was walking away from the truck when he noticed it moving. While the truck was rolling away, he climbed back in the cab and stopped the truck by applying the foot brake. The truck had travelled about 20 metres and ended up with its front wheels suspended over the edge of a 2.5m drop. The truck’s ‘brake not applied’

The park brake lever did not lock into position when applied. When the driver closed the door as he left the cabin, the vibration jolted the lever into the release position.

The Department of Natural Resources, Mines and Energy identified several learnings in their mine’s safety alert (no. The park brake lever is designed to be locked into position by a detent (a spring-activated pin that automatically drops into a catch hole). Tests showed that the parking brake could be ‘applied’ while the pin remained unlocked. A slight jolt to the lever was all it took to release the brake.

150) outlining the incident, including: alarm is activated by a sensor that monitors the position of the lever rather than the status of the detent.

Post-incident testing revealed that the alarm worked only when the ignition was on.

The driver’s understanding of the truck’s braking system was inadequate.

Climbing into the cabin of a runaway vehicle is dangerous and can result in serious injuries, or worse.

The designated area in which the truck was parked was not suitably designed to prevent vehicles rolling away in the event of a park brake failure.

A slight jolt to the lever was all it took to release the brake.

Recommendations

Truck operators should ensure:

Drivers of trucks with similar park brake levers are aware of the design weakness and that they doublecheck the lever is locked in position when parking

The ‘brake not applied’ alarm works regardless of the ignition position

Risk controls—including parking procedures and the design of designated parking areas—adequately reduce the risk of vehicles or mobile equipment rolling away

Manufacturers and suppliers of trucks with similar park brake levers should:

Review the design of the lever’s locking mechanism to reduce the risk of similar failures, and

Improve the alarm systems so that they can detect whether the levers are locked in position.

Smithbridge Guam experienced an incident of this nature several years ago when a vehicle began uncontrollably rolling due to mechanical failure. An operator was driving a forklift up the steep access road out of a quarry, and lost power when the engine stalled. The driver had been trained on what to do in this situation and followed his training in the moment. He was wearing his seat belt and simply held the steering wheel, attempting to turn toward the bank as the machine began rolling backwards down the slope. When the rear wheels contacted the safety berm on the road side, the forklift tipped over toward the operator’s cab. When the vehicle had come to a complete rest, the operator unbuckled his seat belt and safely exited the cab uninjured.

This incident is proof that training on good procedure can save lives. Smithbridge Guam had implemented comprehensive training on uncontrolled rolling and roll overs, and what to do in these situations.

There is sadly a long list of fatalities from similar incidents around Guam and internationally where operators were not belted in and tried to jump off rolling machinery only to be pinned to death by the equipment they were operating. Reviewing those events always makes an impression.

The rule is: sit down, buckle in, and hold on with both hands. If rolling down a slope, turn the vehicle toward the bank. Those who follow this guideline live!

Russ Prokos,

Operations Manager, Smithbridge Guam