Resources Limited Mining Facility North of Fort Mcmurray, Alberta (AB)

Investigation Report Worker Fatally Injured in Motor Vehicle Incident December 5, 2014

F-OHS-080865-389D3 February 2018 Page 1 of 12 F-OHS-080865-389D3 Alberta Final Report

The contents of this report This document reports the Occupational Health and Safety investigation of a reportable incident involving a worker who was fatally injured as a result of a two-vehicle collision in December 2014. It begins with a short summary of what happened. The remainder of the report reviews this same information in greater detail.

Incident summary The incident occurred at 8:20 a.m. on December 5, 2014, at a Canadian Natural Resources Limited mining facility north of Fort McMurray, Alberta (AB). While travelling along a mine haul road to pick up a load of ore, a heavy haul truck struck and ran over a light duty vehicle that was parked along the side of the mine haul road. The collision impact resulted in the death of the occupant in the light duty vehicle. The driver of the heavy haul truck was not injured.

Background information Employer Canadian Natural Resources Limited. (CNRL) is an independent crude oil and natural gas exploration, development and production company operating in Alberta, the North Sea and Africa. The company was founded in 1973, with the head office located in Calgary, AB. In 2014, the company employed over 7600 employees.

Worksite The CNRL Horizon mining site is located 75 kilometres (km) north of Fort McMurray, AB and has been operational since 2008. It includes a surface oil sands mine, a bitumen extraction plant, and a bitumen upgrading plant. Mining operations at Horizon site generate approximately 2000 heavy hauler loads (700 000 tonnes) of material daily. The Horizon facility produced approximately 128,000 barrels of synthetic light crude oil daily in 2014.

Worker 1 – Light Vehicle Driver Worker 1 was an ore shift team lead in the Operations process unit on ‘B crew’, within the mining business unit. Worker 1 was hired March 21, 2007, and had seven years of mining experience at CNRL Horizon site, with a cumulative 20+ years’ experience in the industry. Worker 1 was promoted to shift team lead on November 24, 2011, and had completed the required mine, safety and supervisory training modules as required by that position classification. Worker 1 possessed a valid Alberta Class 5 Operator’s License.

The role of worker 1 was ore shift team lead, responsible for all aspects of ore delivery to the processing plant and for a crew varying from 8 to 12 operators reporting directly to worker 1. Worker 1 utilized a light vehicle (a Ford F350), equipped with a two-way radio as well as a business cell phone; worker 1 could communicate while executing the tasks of supervising and monitoring the activities of mine shovels and heavy haul dump trucks.

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Worker 2 – Heavy Equipment Operator Worker 2 was a heavy equipment operator in the Operations process unit on ‘B crew’, within the mining business unit. Worker 2 was hired on May 13, 2009, and had six years’ experience on CNRL Horizon site, the last five of which were as a CNRL employee. Cumulatively worker 2 had ten years’ heavy equipment operating experience in the industry. Worker 2 had completed the required orientation and training for the position classification and possessed a valid Alberta Class 5 Operator’s License.

The role of worker 2 was heavy equipment operator, responsible for operating a heavy haul dump truck. Worker 2’s task at the time of incident was to operate a Caterpillar 797B heavy haul dump truck, to load/unload, and to haul material as directed.

Additional background information Worker 1 and worker 2 were on B crew hot change. Hot change shifts started at 5:45 a.m. and concluded at 6:30 p.m. The additional 45 minutes duration beyond the standard 12 hour shift was to enable hot change-out of operations personnel at equipment in the field, to ensure continuous operation of production equipment in the mine.

Employer policies prohibited use of personal or business cell phones while driving anywhere on site. There were highly prescriptive requirements which allowed for business cell phone use on business matters only, while a vehicle was not in motion.

At the time of the incident, the ore shift team lead and the heavy equipment operator were performing tasks in which they were experienced, which were within their regular job scopes, and for which they had received training from recognized training providers.

Equipment and materials The Mobile Equipment Vehicle 1–2015 Ford F350 Unit C657 – *********************** - (Major vehicle damage; no photograph attached). The Employer classified the Ford F350 as a light duty vehicle, with a weight of 3 tonnes or less.

Vehicle 2–2007 Caterpillar 797B Unit 2115 – *********************** – (Figure 1). The hour meter indicated 40 706 hours on last recorded entry on Dec 4, 2016.

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Figure 1. Perspective of Caterpillar 797B – Person on left for scale. (Photograph provided by Fort McMurray Royal Canadian Mounted Police (RCMP)).

The Caterpillar 797B Off-Highway Truck was described in International Standards Organization (ISO) 6165:2001, as an earthmoving machine and was classified as a dumper. This was a self- propelled wheeled machine with a rigid frame, wheel steering, and an open body that was intended for transporting and dumping loose material.

The Caterpillar 797B loaded weight (approximate gross vehicle weight (GVW)) was 626 686 kilograms (kg). The approximate empty vehicle weight (EVW) was 276 172 kg. The truck dimensions were 14.53 metres (m) in length x 9.48 m wide x 7.53 m high. Manufacturer’s specifications indicated the maximum attainable speed (loaded) of a 797B was 67.6 km per hour (kph).

The Mining Operation Overview Active mine areas were areas where heavy equipment was involved in the removal and transport of overburden and ore recovery. Mining operations involved heavy haul trucks being loaded with ore by electric or hydraulic shovels, and the trucks transported and then dumped the loads of ore into hoppers. The Mining business unit included the active mine pit and dike areas, the RT7 perimeter road, coke load-out area, coke dump, sand pit, and road to the north gravel pit.

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Ore was transported from the active mine pits to the hoppers at the Ore Preparation Hopper Pad, using heavy haul trucks via restricted-access mine haul roads. The ore hoppers fed the processing (extraction) plant, and at this point the process of extracting bitumen from the ore began. The quantity of ore hauled daily was approximately 300 000 tonnes.

Waste materials could be overburden clay or other non-productive materials. On the date of incident, this material was being disposed of at Dike 10, Road 3N, Drop Zones US1 and US2. The quantity of waste materials hauled daily was approximately 400 000 tonnes.

The Mine Haul Road

Figure 2. Perspective looking southwest, showing roadway, and road edges. (Photograph provided by Fort McMurray RCMP).

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Roadway Conditions at Time of Incident Environmental Conditions at Time of Incident Road Traffic Flow NE to SW Precipitation: Light snow, partly cloudy Road Class: Undivided two-way Temperature: -15 Celsius Road Type: Gravel Visibility: Unobstructed Road Condition: Loose gravel Light Conditions: Darkness Surface Condition Dry Sunrise: 08:44 a.m. (24 minutes after incident) Road Angle: Curved Road Gradient: Slight down-grade Due to recent snowfall, a 30.48 centimetre (cm) from NE to SW snow windrow was located on the north side of the road. The speed limit on mine haul roads was 70 kph. Manufacturer’s specifications indicated the maximum attainable speed (loaded) of a 797B was 67.6 kph. In the area where the incident occurred, speed was reduced to less than 30 kph due to a sharp right-hand turn in the mine haul road around the toe of the berm to the southwest towards Shovel 1202.

The road is 35.6 m wide where the F350 was parked. This is within the general standards for haul road construction practices of 2 to 2.5 times the width of the widest site haul truck.

Sequence of events At 5:45 a.m. on December 5, 2014, the B Crew hot change toolbox meeting started. Both worker 1 and worker 2 were in attendance. Worker 1 led the toolbox meeting.

After being loaded at Shovel 1003 Pit, haul truck 2115 had completed two loads, (haul cycles) of W03 (waste material) totaling 710 tonnes. The haul cycle was from Bench 3C to Dike 10, Road 3N, Drop Zones US 1 and US 2 respectively. The average haul distance was 9.908 km. Haul truck 2115 was then re-tasked by the computer control system to 1202 Pit.

At Shovel 1202 Pit, Bench 5 South, trucks were being loaded as normal from Shovel 1202. This shovel had been positioned at Bench 5 South for weeks prior to the incident. This was not a new area of the mine.

Prior to the incident, two loads (haul cycles) from Shovel 1202 were completed by haul truck 2115 from Bench 5 South in Pit 1202, to the Ore Preparation Hopper Pad. The average haul cycle distance was 3.142 km. The quantity of ore transported on each of the two haul cycles was 355 metric tonnes (MT).

The first haul cycle to Hopper 1 was completed in 33 minutes - 7:21 to 7:54. The second haul cycle to Hopper 2 was completed in 20 minutes - 7:54 to 8:14. The start time refers to empty at the hopper and proceeding towards the shovel.

Haul truck 2115 was travelling empty – returning back to Shovel 1202 to receive a third load of ore when the incident occurred.

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Immediately prior to the incident at 8:20 a.m., haul truck 2113 was being serviced on the road east of Shovel 1202, haul truck 2116 had just been loaded and was proceeding northeast, and haul truck 2130 was being loaded by Shovel 1202.

For at least ten minutes prior to the incident, worker 1 was in worker 1’s vehicle at 1202 Pit. Worker 1 had stopped and parked the F350 on the north side of the temporary mine haul road to the northeast of Shovel 1202 at Bench 5 South. The vehicle headlights were functional and activated.

The vehicle was parked diagonally to the road facing south, 70.6 m from the corner of the toe of the berm. Procedures stated there was no parking within 75 m of a corner or interchange. The driver’s door was facing towards the oncoming heavy hauler traffic. High-visibility reflective tape was affixed to the side of the cargo deck section of the F350, though not to the passenger section and engine compartment.

Worker 1 was speaking on the business cell phone to Mine Dispatch for approximately ten minutes prior to the incident. During the conversation, worker 1 did not state anything indicating awareness that a haul truck (2115) was approaching.

At 8:15 a.m., worker 2 started back from Hopper 2 towards Shovel 1202. Worker 2 indicated having experienced symptoms of a gastro-intestinal upset that required worker 2 to pull over urgently. Worker 2 stated observing “a wide open spot” to pull over to exit the haul truck.

Worker 2 indicated that while turning into “the wide open space”, worker 2 looked away “for a split second” to locate an item in the cab. Worker 2 did not see the F350 on the blind side of haul truck 2115, nor recalled hearing on the radio if worker 1 was in 1202 Pit.

At 8:19 a.m., the speed of haul truck 2115 was 11.3 kph (3.14 miles per second). This was approximately one minute before the incident occurred. Haul truck 2115 was travelling from northeast to southwest, towards Shovel 1202 along the north edge of the road, adjacent to the 30 cm snow windrow.

At 11.3 kph, (3.14miles per second), haul truck 2115 would have taken 22.5 seconds to travel the 70.6 m from the corner of the toe of the berm to the parked F350. The maximum braking distance for a 797B haul truck at that weight, speed and road condition is 2.66 m, and would average 2.02 m.

At 8:20 a.m., 24 minutes before sunrise (at 8:44 a.m.), the passenger side tires of haul truck 2115 struck and ran over the F350. The impact point was from the F350 driver’s side rear door to the passenger side front door. At 8:21a.m., worker 2 activated the haul truck 2115 emergency event alarm, which was displayed on the Mine Dispatch computer, at which time all mine operations were suspended.

At 8:23 a.m., mine rescue personnel were dispatched and arrived at scene at 8:25 a.m. They performed an initial survey to verify if the F350 was occupied, but they were unable to confirm Labour Occupational Health and Safety Page 7 of 12 F-OHS-080865-389D3 Alberta Final Report

occupancy due to extensive vehicle damage and a fire in the engine compartment. Utilities technicians used portable extinguishers to attack the fire until Plant Emergency Medical Services (EMS) arrived.

Plant EMS had been dispatched at 8:30 a.m. The engine compartment fire was extinguished at 8:44 a.m. A secondary survey to assess vehicle occupancy identified that worker 1 was an occupant in the vehicle, and worker 1 was confirmed deceased at that time. Plant EMS cut the seat belt that worker 1 had engaged, and extricated worker 1 from the vehicle.

Crash data retrieved from the F350 indicated: Accel/pedal % Full = 0; Brake: ON; Engine (rpm 518-528): IDLE; Transmission gear: DRIVE; Safety Belt status, driver: DRIVER BUCKLED. This data confirmed that worker 1 was in compliance with the cell phone policy and the seat belt policy.

Figure 3. Photo taken to simulate the collision. Heavy hauler positioned in an approximate location after completing the turn. Exemplar Ford F350 used in its pre-impact position. Note mining shovel in background. (Photograph provided by Fort McMurray RCMP).

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Collision Overview: The reportable incident occurred at 8:20 a.m. on December 5, 2014 Primary event: Right-angle Collision Type: Side-impact Contact F350 - from the driver’s side rear door to passenger side front door; as a Damage result of the contact, the light vehicle sustained major structural damage. Contact damage Truck 2115 - paint transfer on step ladder and hand rail; scuff and paint transfer on passenger side front and rear tires. Post-collision F350 - came to a stop facing south, wheels down; north side of road. Post-collision Truck 2115 - came to a controlled stop facing southeast; north side of the road.

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Diagram 1. Scale drawing of collision scene. Gouge marks lead off roadway and tire imprints returned to the road. (Diagram provided by Fort McMurray RCMP)

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F-OHS-080865-389D3 Alberta Final Report

Conclusions of the police report Being parked diagonally facing south, the F350 headlights/tail lights would not have been visible to southwest-bound haul truck traffic (worker 2 in haul truck 2115).

The F350 was positioned facing south, and worker 1 facing southwest towards Shovel 1202 would not have been able to see haul truck traffic approaching from the northeast.

Haul truck 2115 was travelling on the north side of the road, in preparation to turn off the normal path of heavy hauler traffic.

Due to lack of contrast, the white F350 may have blended with the white snow-covered terrain in pre-dawn conditions.

The lights of the shovel, dozer and heavy haulers to the southwest of the F350 may have naturally focused the eyes of worker 2 in haul truck 2115, and obscured visibility of the F350, which was closer.

The F350 was stopped and positioned in such a manner as to cause limited visibility at that location and time of day.

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F-OHS-080865-389D3 Alberta Final Report

Completion A review for enforcement action was completed on July 27, 2016, and it was determined that the file would be referred to Alberta Justice for review. The entire file was sent to Alberta Justice on October 12, 2016. Alberta Justice reviewed the file and determined the case did not support any charges under the Alberta Occupational Health and Safety Act, Regulation and Code.