MECHANIC RUN OVER by HEAVY HAUL TRUCK Type of Incident: Fatality Date of Incident: July 8, 2008
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MECHANIC RUN OVER BY HEAVY HAUL TRUCK Type of Incident: Fatality Date of Incident: July 8, 2008 File:F-671981 TABLE OF CONTENTS SECTION TITLE PAGE NUMBER 1.0 DATE AND TIME OF INCIDENT 3 2.0 NAME & ADDRESS OF PRINCIPAL PARTIES 3 2.1 Owners 3 2.2 Prime Contractor 3 2.3 Employer of Injured Worker 3 2.4 Employer of Other Workers 3 2.5 Worker 3 3.0 DESCRIPTION OF PRINCIPAL PARTIES 4 3.1 Owner of the Heavy Haul Truck 4 3.2 Owner of the Site 4 3.3 Prime Contractor 4 3.4 Employer 4 4.0 LOCATION OF INCIDENT 4 5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS 5 5.1 Equipment and Material 5 5.2 Observations 6 6.0 NARRATIVE DESCRIPTION OF INCIDENT 7 7.0 ANALYSIS 11 7.1 Direct Cause 11 7.2 Contributing Factors 11 8.0 FOLLOW-UP/ ACTION TAKEN 16 8.1 Occupational Health and Safety 16 8.2 Industry 17 8.3 Additional Measures 17 9.0 SIGNATURES 17 10.0 ATTACHMENTS 17 2 July 9, 2009 Alberta Employment and Immigration, Occupational Health and Safety File:F-671981 SECTION 1.0 DATE AND TIME OF INCIDENT 1.1 The incident occurred on July 8, 2008 at approximately 11:30 a.m. SECTION 2.0 NAME AND ADDRESS OF PRINCIPAL PARTIES 2.1 Owner(s) 2.1.1 Site owner Suncor Energy Inc. P.O. Box 4001 Fort McMurray, Alberta T9H 3E3 2.1.2 Owner of the 797F heavy haul truck Caterpillar Canada Corporation 10243-178 Street Edmonton, Alberta T5S 1M3 2.2 Prime Contractor 2.2.1 Suncor Energy Inc. P.O. Box 4001 Fort McMurray, Alberta T9H 3E3 2.3 Employer of Injured Worker 2.3.1 Finning (Canada) 118 MacDonald Crescent Fort McMurray, Alberta T9H 4B2 2.4 Employer of Other Workers Present 2.4.1 Suncor Energy Inc. P.O. Box 4001 Fort McMurray, Alberta T9H 3E3 3 July 9, 2009 Alberta Employment and Immigration, Occupational Health and Safety File:F-671981 SECTION 5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS 5.1 Equipment and Material 5.1.1 Caterpillar 797F Heavy Hauler Truck 5.1.1.1 The Caterpillar 797F truck was a 400 ton capacity heavy haul truck. The Caterpillar 797F truck was an experimental model developed by Caterpillar. It was being tested by Caterpillar for reliability and performance under field conditions at the Suncor Energy Inc. mine site. The 797F heavy haul truck was leased to Suncor Energy Inc. by Caterpillar Canada Inc. and given the designation Unit 190. Suncor Energy Inc. operated the 797F heavy haul truck while Finning (Canada) monitored and serviced the truck. (Attachment A – Photographs #1, #2, #3, #12). 5.1.2 Auxiliary Power Unit 5.1.2.1 The Auxiliary Power Unit (referred to as the tow module) was manufactured by Norcan Fluid Power Ltd. and was owned and serviced by Suncor Energy Inc. The tow module consisted of a diesel engine, hydraulic pump and air compressor. The primary use of the tow module was to provide hydraulic pumping and pressure to the steering and braking functions of equipment while being towed. The tow module was attached to the back of the 797F heavy haul truck to provide hydraulic pumping and pressure to the steering and braking functions. (Attachment A – Photographs #11, #12). 5.1.3 Front End Loader 5.1.3.1 The Komatsu WA 800, unit #6601, front end loader was owned and operated by Suncor Energy Inc. The front end loader was used in the mine to primarily load material into smaller heavy haul trucks. The front end loader was also utilized to tow heavy haul trucks. (Attachment A – Photographs #1, #2, #3). 5.1.4 Tow Cable 5.1.4.1 The tow cable consisted of two 6.5 m long by 3.8 mm diameter wire cable slings connected by a 35T Crosby shackle. One end of the tow cable was attached to the heavy hauler truck tie-down eye with a 35T Crosby shackle and the other end of the cable sling was attached to the Komatsu tow pin system. (Attachment A – Photographs #4, #5, #6). 5 July 9, 2009 Alberta Employment and Immigration, Occupational Health and Safety File:F-671981 5.1.5 Portable Two-Way Radios 5.1.6.1 The portable two-way radios used by the Finning (Canada) mechanics and the Suncor Energy Inc. operators were Motorola model HT1000, Handie-Talkie Fm Radio model #H01KDC9AA3DN. The portable two-way radios were owned and serviced by Suncor Energy Inc. 5.2 Observations When the Workplace Health and Safety Compliance investigators arrived at the incident site, the following observations were made: 5.2.1 The 797F Unit #190 heavy haul truck was lodged into the berm of the centre ramp with wheel chocks on both the left front and left rear wheels. (Attachment A – Photographs #1, #2, #12). 5.2.2 The Norcan Fluid Power Ltd. auxiliary power unit was hitched onto the back of the 797F heavy haul truck with the hydraulic lines attached to the service brake, steering and emergency brake tanks on the truck. The auxiliary power unit was towed behind the heavy haul truck. The auxiliary power unit was shut down. (Attachment A- Photographs # 11, #12). 5.2.3 The Komatsu WA 800, unit #6601, front end loader was parked on the centre ramp roadway with the tow cables attached to the tow pin assembly at the back of the loader. (Attachment A-Photographs #1, #2, #3, #4). 5.2.4 The tie-down eye that had broken away from the 797F heavy haul truck was on the floor inside the cab of the Komatsu WA 800. The Equipment operator had recovered the broken tie down eye from the centre ramp roadway and placed it inside the cab of the Komatsu. (Attachment A-Photographs #8, #9). 5.2.5 The centre ramp had a large puddle of hydraulic fluid where the 797F heavy haul truck had stopped when the tow cable broke away. (Attachment A-Photograph #2). 5.2.6 There were two Finning (Canada) field mechanic trucks parked at the top of the centre ramp. The trucks’ cabs were both locked. One of the mechanic trucks was assigned to the Finning (Canada) Journeyman Heavy Duty Mechanic and the other truck was assigned to the Finning (Canada) 3 year Apprentice Heavy Duty Mechanic . (Attachment A-Photograph #7). 5.2.7 The incident site on the centre ramp was covered with tarpaulins. (Attachment A- Photographs #1, #2). 5.2.8 June 25, 2008 was a clear, sunny day. The ambient temperature was 13 C and the centre ramp roadway was dry. 6 July 9, 2009 Alberta Employment and Immigration, Occupational Health and Safety File:F-671981 SECTION 6.0 NARRATIVE DESCRIPTION OF THE INCIDENT 6.1 On June 25, 2008 the 797F Caterpillar heavy haul truck was hauling material to the mud dump at the end of the MD8 haul road when the motor became disabled. The oil filter housing assembly broke off from the truck resulting in the loss of engine oil and seizing up of the heavy haul truck’s motor. 6.2 The loaded 797F heavy haul truck was left disabled on the side of the MD8 haul road while a new motor was ordered and a service bay became available at the Suncor Energy Inc. Steepbank truck shop. Suncor Energy Inc. built a berm around the 797F heavy haul truck to protect it from other heavy haul truck traffic. 6.3 On July 7, 2008 Suncor Energy Inc. started to tow the 797F heavy haul truck from the MD8 haul road to the Suncor Energy Inc. Steepbank truck shop. Suncor Energy Inc. heavy duty mechanics towed the Norcan Fluid Power Ltd. auxiliary power unit to the 797F heavy haul truck and positioned it along side the berm near the back of the 797F heavy haul truck. The Suncor Energy Inc. heavy duty mechanics did not hook up the hydraulic lines of the Norcan auxiliary power unit to the 797F heavy haul truck because they were advised the field follow contract stated only Finning (Canada) mechanics could work on the 797F heavy haul truck. The Suncor Energy Inc. heavy duty mechanics transported two 6.2 m long by 3.8 mm diameter wire cable tow slings with two 35T shackles to the 797F heavy haul truck. 6.4 On July 7, 2008 two Finning (Canada) journeyman heavy duty field mechanics, Mechanic #1 and Mechanic #2 were dispatched by Suncor Energy Inc. to hook up the Norcan auxiliary power unit hydraulic lines to the 797F heavy haul truck to allow Suncor Energy inc. to tow the 797F heavy haul truck to the Suncor Energy Inc. Steepbank truck shop. 6.5 The two Finning (Canada) journeyman heavy duty field mechanics, Mechanic #1 and Mechanic #2 attached the hydraulic lines from the Norcan auxiliary power unit to the 797F heavy haul truck and manually dumped the 797F load onto the side of the MD8 haul road. They arranged for a Suncor Energy Inc. dozer to remove the birm from around the front of the heavy haul truck so it could be towed ahead to hitch the Norcan auxiliary power unit onto the back of the 797F heavy haul truck. Mechanic #1 attached the tow cable shackle onto the tie-down eye located under the right side of the front bumper of the 797F heavy haul truck. However, they were unable to arrange to have the 797F heavy haul truck towed forward to hook up the Norcan auxiliary power unit and Suncor Energy Inc.