In Search Of The Facts - Accident Investigations In Metal And Non-Metal Mining (1976)

this is an open-pit mine in the West it's big thousands of tonnes of ore are mined loaded hauled processed and hauled again daily it takes a lot of equipment to do this [Music] [Music] [Music] big equipment and Hardy men and women to operate it its vast productive and can be dangerous [Music] the doctor and the ambulance had been called for Bill Johnson a front-end loader operator so people gathered around him are his co-workers to kill me they - why heavy equipment operators pretty bad their concern right now is for their friend who has been fatally injured the concern of others who will soon be involved is the accident itself and the events leading to it if the factor is contributing to the accident can be determined steps may be taken to see that the same kind of accident never happens again some accidents such as this turned over front-end loader involved fatalities and some disabling injuries in almost all cases however the cause of the accident is not the cause of the injury in any case company officials should be notified and an accident investigation begun as soon as possible [Music] to a five four seven four nothing more can be done for the fatally injured man and he can do nothing to explain what happened it's obvious that the front-end loader turned over but there are a lot of questions to be answered the first company officials who arrived on the scene begins to gather information who witnessed the accident what happened how did it happen why did it happen necessary safety measures are taken a firetruck has been sent due to the possibility of fire or explosion from spilled fuel every possible precaution should be taken for the safety and protection of everyone conducting the investigation clues such as tire tracks which may be valuable in determining the causes of the accident are protected by dangering off the area and the accident investigation is set into motion I saw these guys and I yelled for some help okay I think we better get this whole area sectioned off don't any of you touch anything please we'll get close get these plastic pylons and cover this whole perimeter hey I'm at the accident site the ambulance is on the way to town have released the firetruck there's no possibility of any safety hazards up here at this time we should start an investigation right away I'll have Hal call me so and we'll get the investigating team together and each episode company officials shall notify Mesa immediately upon learning of a fatal accident or one causing serious injury hello this is Pete I've just talked to Don doe Johnson was fatally injured in the field will you please call me sir I'll meet you up aside metal and nonmetal health and safety Vern Gomez speaking hello Vernon this is Hell Adams we've just had an accident only one person involved a front-end loader overturned and injured the operator fatally when did this happen how about 20 minutes ago how'd you go ahead and start your investigation and we'll be out there as soon as possible we'll be seeing you plans for handling an accident investigation should be developed prior to an emergency those assigned should be capable of going into action immediately upon being notified they should be representative of a broad cross-section of all interest involved and should be trained in investigative techniques making up the team for this investigation will be the safety director a union safety committee was thrown out and the mine superintendent dr. as soon as possible the entire investigating team should interview eyewitnesses at the accident site interviews should be conducted while memories are fresh and they should be conducted separately in that way the testimony of one witness cannot influence the testimony of another the observations of witnesses often give new inputs that must be digested sorted and logically evaluated by all members of the investigation team a good interviewer never puts words in the witness's mouth but allows a witness to tell the story without interruptions what did you see Tom well we were coming down the haul road he was about 50 or 60 yards in front of me and he started picking up speed and I don't know whether he hit an optic in the road but seemed like the front end of the loader bounced and I thought he was gonna be able to hold it all right we went down a few more yards and just went over the edge Tom at the beginning of the shift had you and Kelly both travel this particular ramp to get to the 42 them yes did you notice anything in the other order or the way to travel up this run well it was pretty rough we'd had that rain and there were there was some pretty good bridges in the road did he ever complain to you during the shift before you came back down though his machine was faulty I didn't get any indication from him and he was having any problems at all Pete when he equipment he was going very fast going down the hill was he pulling away from you as you were both oh well he was he was he was pulling away from do you think it was intentional or you just think he was losing control I don't have any idea he I think he was must have been losing control from what happened yeah jumped or do you think he was wrong are you sure he didn't have a seatbelt on it doesn't look to me like he did because when I came up he was he had been thrown out of the cab of the loader and the belts were intact me we're just dangling loose and it looked at me like he just didn't even have long when interviewing a witness make it clear at the outset your purpose in asking questions is fact-finding and not to fix blame what the witness of ease phrase questions and statements simply never give the witness the third degree the investigation is primarily for getting the facts that will keep the same thing from happening again it is not unusual to discover the statements of one contradict the statements of another if the victim is alive he should be interviewed as soon as first aid treatment or treatment by a doctor permits unfortunately Bill's death made it impossible for investigators to get his first-hand account of what happened bill could neither deny nor corroborate the data being gathered a good interviewer only ask questions to fill in the gaps or to check or clarify his understanding of events to discover evidence that may have some bearing on the cause of the accident an important point to remember in any investigation is don't jump to conclusions just gather as much data as you possibly can as they conduct their search for facts the investigation team will unearth sufficient information to enable them not only to pinpoint the cause but also to prepare constructive recommendations to prevent similar accidents from happening again the procedures and techniques used to investigate an accident in the mining industry are basically the same whether the accident occurs on the surface or underground however because bill Johnson's accident was fatal the procedure and people involved in this investigation may differ slightly from those for a non fatal accident nevertheless the objective will be the same the search for facts to determine the real cause of the accident properly conducted an accident investigation is the best way for a company to establish the causes both direct and indirect that produced the accident it is one of the most effective tools available to prevent similar accidents from happening again both individually and collectively the team systematically investigates and observes all conditions that might have some bearing on the accident no fact regardless of how small it appears will be overlooked although many will be discarded eventually as having no bearing on the cause of the accident many seemingly insignificant facts will help determine the cause you know this Heath Bell was hanging down here also we were for the bucket isn't the whole position just like it was intact from the evidence this investigation team uncovers the real factors that caused bill Johnson's fatal accident will be determined nothing is overlooked nothing taken for granted every bit of data obtained is carefully recorded the measurement of grade the absence of berm in the area of the accident size of potholes and debris on the haul road the obvious clues even things that seem irrelevant are noted written down rather than left to memory notes are taken by everyone the Mesa team should be brought up to date as soon as possible after their arrival usually a two-man Mesa team will be assigned and additional support is available if needed where state laws require it state investigators must be notified if they so desire they can work concurrently with the company's team or they can work independently until all the facts are gathered the investigation reveals the road was not adequately maintained or properly graded a pile of material large enough to deflect the front-end loader is found on the haulage road near the accident site and tracks indicate that the loader had run over this pile it is decided that the pills found at the site of the accident would be analyzed and the findings would be presented at a later meeting along with the rest of the data photographs are taken of everything pictures will help refresh memories and assist team members later in the preparation of the final accident report once the technical investigation at the site is completed team members are assigned other specific areas of responsibility in addition to eyewitnesses people with knowledge of conditions prior to the accident should be interviewed I understand that you who Phil Johnson pretty well all right yes do you know of any problems that he's been having re part of the road conditions bad I was told the grader was in the shop would you report that to Keith to my former workers on the previous shifts may be able to add something specialists are called in if necessary in this case surveyors were brought in to accurately measure the slope of the berm and the grade of the road 47.8 the safety director may be able to add some information thank you he missed one however it was during the training period and ironically it was concerning rollover fellows only had one week's experience as an operator prior to that he was a maintenance worker a check made of the repair shops records reveals the front-end loader had been brought in for brake repair during the investigation members of the team are assigned to check contact and entry reports to see if there have been similar accidents before such information is usually on file in the Safety Department or personnel office other pertinent data relating to the accident is checked the status of mechanical equipment the workers performance records company records disclose some interesting bits of information that reinforce data collected from witnesses during interviews when all the facts have been gathered the investigation team should meet as soon as possible to evaluate the data collected everything gleaned from the investigation interview contact or entry records shop records and work reports are carefully analyzed by the accident investigation team the detailed sketch to be included in the final report is checked for accuracy photographs taken are reviewed and used as referenced in discussing the various factors that could or could not have contributed to the accident while you're up there you just started to say something about that or what's that one by one each member of the team reports on his area of responsibility every clue every shred of evidence that might have even the slightest bearing on the case is reviewed evaluated accepted or discarded as irrelevant okay each of us report our findings and we can all fill in the blank spots I'll start it off and let you know what I found out learned that the real grater was in the shop and wasn't available and it wouldn't be available for a couple of days bill would you have anything you'd like to add to that no but I checked for the shop foreman of the master mechanic the brakes on the loader were repaired but this machine was never road tested the reason the burn was inadequate up there was due to the heavy rain and he kept washing out that section of the road how did you check with the foreman to see what had taken so long to get around to replacing that berm yes but since it had only washed away last evening he hadn't gotten around to replacing it with the grater down and no other front-end loader operator available bill was on his way to replace a broom when the accident happened I have a lot of report here and the lab tests showed that the pills we found were a type of decongestant and the check would bills doctor confirmed that he had described them to join up the sinuses and there will be no side effects that's a drowsiness I interviewed two witnesses and both of them stated the bill was not using his seatbelt after all the findings of the investigation have been presented by the various members and all the facts concerning the accident have been evaluated the team will meet again to reach conclusions and to prepare their final report let's assemble it and see what we have here and see if we can't reach a decision as to how this accident happened findings indicate this this accident was caused by faulty brakes road conditions and Bill's lack of training and experience contributing factors were the lack of Burns and bill failure to wear a seatbelt failure to wear that seatbelt probably cost bill his life it seems clear safety procedures have not been carried out the rain the greater being is no excuse for us not having the proper safeguards enforce the intent of this investigation has been accomplished we've determined the causes and the factors which resulted in this accident we will make specific recommendations to prevent similar accidents in the future the conclusion reached was that bills accident and death were caused by a series of factors the final report for this and any accident should include a description of the accident a list of the factors that caused the accident and specific recommendations to see that the factors that caused the accident never recur the data contained in the team's final report is used in filling out all required accident report forms such as the injury and illness report the employers quarterly data report and Mase's fatal accident report this information may help prevent others from making the same mistake it may prevent the same factors from ever combining to cause a similar accident in the future the recommendations were implemented immediately new drivers were given more comprehensive on-the-job training older drivers were given refresher training to keep them constantly aware of the relationship between good driver practices and increased safety the importance of seatbelts to hold drivers in place in case equipment turns over was stressed the notion that rollover protection alone without the use of seatbelts could protect the driver was debunked turnover even though you have rolled made immediately effective was a rule stating that no equipment could be released from the shop unless repaired inspected and Road tested by shop personnel all roads had to be properly graded adequate berm or guardrails were to be provided and maintained on all elevated haulage roads and debris removed at all times regardless of weather conditions and speed limits said on grades [Music] drivers on medication were required to advise their supervisors before accepting an assignment to drive mine equipment follow-up inspections were recommended requiring the company Safety Committee to make periodic inspections of all equipment the data contained in the final report is entered on tabulating cards for used nationwide and industry-wide for accident data analysis the recommendations made on bill Johnson's accident report were made available to help other safety departments upgrade their safety procedures and equipment they will be used by other mining companies Union and state agencies and Mesa district offices aside from the immediate corrective actions that result from a properly conducted accident investigation there is the cumulative value of the information gathered the information from this accident along with information from a number of other accidents calls attention to problem areas which ordinarily might not be spotted if there is a lesson to be learned from tragedy it is for all of us to realize that everything possible must be done to see that the factors that caused the accident never happen again [Music] and one of the most important tools available to us to prevent tragedy is a thorough accident investigation the neverending search for facts [Music]