MECHANIC RUN OVER BY HEAVY HAUL TRUCK Type of Incident: Fatality Date of Incident: July 8, 2008

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2 July 9, 2009 Alberta Employment and Immigration, Occupational Health and Safety

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

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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

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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).

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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.

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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. decided to tow the 797F heavy haul truck the next day.

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7.2.2 The Finning (Canada) journeyman heavy duty field Mechanic #1 was not trained in the front bumper tow pin configuration of the 797F Caterpillar heavy haul truck and attached the tow cable shackle to the right front bumper tie-down eye. The tie-down eye was engineered for holding truck parts in transportation to prevent damage and for use in the assembly of the truck. The 797F truck tie-down eyes were not engineered by Caterpillar as tow pins. (Attachment A-Photographs #8, #9, #10, #15, #17).

7.2.3 The two Finning (Canada) field mechanics

were not trained in the operation of the Norcan auxiliary power unit and did not realize that there would be a resulting loss of hydraulic pressure in the 797F truck steering and service brake accumulators within a few minutes of shutting off the Norcan auxiliary power unit.

7.2.4 The Finning (Canada) field mechanics were

not trained in the front bumper tow pin configuration of the 797F and were attempting to attach the tow cable shackle to the left front bumper tie down eye. The tie down eye was not engineered for towing the 797F truck. (Attachment A-Photographs #15, #17).

7.2.5 The Finning (Canada) field mechanics were

not trained in the Suncor Energy Inc. heavy hauler truck towing procedures. This was the first heavy haul truck towing job for the two Finning (Canada) field mechanics

. 7.2.6 The 797B heavy haul Truck Operator was not trained in the

operation of the 797F heavy haul truck. 7.2.7 This was the first time the 797B heavy haul Truck Operator operated

the 797F heavy haul truck. 7.2.8 The 797B heavy haul Truck Operator was not trained in the Suncor

Energy Inc. heavy haul truck towing procedure. 7.2.9 The 797B heavy haul Truck Operator was not trained to operate a

heavy haul truck that was being towed. 7.2.10 This was the first time for the 797B heavy haul Truck Operator to

operate a heavy haul truck that was being towed with the Norcan Auxiliary power unit. (Attachment A-Photograph #11).

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7.2.16 As the 797F was towed around the right hand turn of the centre ramp and began to go down the access ramp hill, the tow cable became slack. The 797F heavy haul Truck Operator applied the service brake to avoid running over the tow cable and take up the cable slack. There was no radio communication between the 797F Truck Operator and the Equipment Operator to coordinate the activity. The Equipment Operator was pulling on the tow cable with the front end loader to take up the slack when the tow cable broke free of the 797F heavy haul truck and snapped back striking the back railing of the Komatsu front end loader. The 797F truck stopped on the downhill grade of the centre ramp.

7.2.17 Although the Equipment Operator radioed that the tow cable had

broken away from the 797F truck, the Suncor Energy Inc. Mine Operation Supervisor did not direct the tow crew to follow Suncor Energy Inc. mine policy

to secure the 797F truck from movement by setting the park brake, the Truck Operator to exit the haul truck and chocking the heavy haul truck wheels before approaching the 797F heavy haul truck.

7.2.18 The Suncor Energy Inc. Mine Operations Supervisor did not direct

the tow crew to conduct a new hazard assessment of the tow procedure when the conditions had changed due to the tow cable breaking away from the 797F heavy haul truck.

7.2.19 As the 797F heavy haul truck braked on the ramp hill with the Norcan auxiliary

power unit shut off and no longer providing hydraulic pressure to the 797F truck, the hydraulic pressure drained from both the steering and service brake accumulators and dropped below the minimum 900 psi operating pressure. The 797F truck service brakes and steering suddenly failed, without warning, due to a loss of hydraulic pressure after approximately 4 minutes and 20 seconds. The 797F heavy haul truck began to move forward and accelerate down the hill towards the two Finning (Canada) mechanics.

7.2.20 The heavy haul Truck Operator attempted to alert the two Finning

(Canada) mechanics on the roadway in front of the 797F truck by sounding the horn using the left foot floor horn button that he was familiar with using; however, while a floor horn bracket was installed in the 797F heavy haul truck, the floor horn itself had not been installed. The horn did not work to alert the mechanics. (Attachment A-Photograph #13).

7.2.21 The 797F Truck Operator applied the retarder brake and the service

brake; however, the 797F truck had lost hydraulic pressure in the service braking system and the truck continued to roll downhill towards the two Finning (Canada) mechanics. (Refer to Attachment A-Photographs #13, #14).

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7.2.29 The Caterpillar 797F draft operator manual did not identify the tie-down eyes on the front bumper of the 797F truck as tie-down eyes and not to be used for towing the heavy haul truck. (Attachment A-Photographs #8, #14).

7.2.30 Caterpillar Canada Inc. did not train the Finning (Canada) field follow mechanics on

the towing procedures to be used for towing the 797F heavy haul truck. Caterpillar Canada Inc. did not advise the Finning (Canada) field follow mechanics that the two pins under the front bumper of the 797F truck were the engineered tow pins to be used to tow the 797F truck forward. Caterpillar Canada Inc. did not advise the Finning (Canada) field follow mechanics that the tie-down eyes located underneath the 797F truck front bumper was not to be used for towing. (Attachment A-Photographs #8, #9, #15, #17).

SECTION 8.0 FOLLOW-UP/ ACTION TAKEN 8.1 Employment and Immigration; Occupational Health and Safety 8.1.2 Occupational Health and Safety issued Stop Work Orders to Suncor Energy Inc. for

the 797F heavy haul truck, the Komatsu WA 800 front end loader and the Norcan auxiliary power unit for mechanical inspections.

8.1.3 Occupational Health and Safety issued a Stop Work Order to Suncor Energy Inc. on

towing heavy haul trucks in the Suncor Energy Inc. mine and to develop an engineered heavy haul truck towing procedure and training of the Suncor Energy Inc. mine operations towing crew on the procedure.

8.1.4 Occupational Health and Safety issued orders to Suncor Energy Inc. for training

records, equipment maintenance records, towing procedures, radio dispatch records, survey maps and readings, manufacturers and operators manuals for the Norcan auxiliary power unit and 797F truck, mine health and safety policy and procedures and for an investigation report.

8.1.5 Occupational Health and Safety issued orders to Finning (Canada) for training

records, 797F truck maintenance records as well as the 797F truck and 797B truck manufacturer’s and operator’s manuals.

8.1.6 Occupational Health and Safety issued orders to Caterpillar Canada Inc. for the 797F

truck front bumper tie-down eyes and tow pins specifications.

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8.2 Industry 8.2.1 Suncor Energy Inc. completed the mechanical inspections on the 797F truck, the

Komatsu WA 800 front end loader and the Norcan auxiliary power unit. They developed an engineered heavy haul truck towing procedure. They provided the training records, maintenance records, dispatch records, weather reports, health and safety manual and an incident investigation report.

8.2.2 Finning (Canada) provided the requested training records, 797B truck and 797F truck

operators manual and assisted in testing the 797F truck hydraulic system. 8.2.3 Caterpillar Canada Inc. provided the specifications for the 797F truck front bumper

tie-down eyes and tow pins specifications. 8.2.4 An industry alert on towing heavy haul trucks was released by Suncor Energy Inc. 8.3 Additional Measures 8.3.1 No additional measures are required. SECTION 9.0 SIGNATURES ____________________________ _____________________ Lead Investigator Date ____________________________ _____________________ Investigator Date ____________________________ _____________________ Compliance Manager Date ____________________________ _____________________ Regional Senior Manager, North Date SECTION 10.0 ATTACHMENTS: Attachment A Photographs Attachment B Map

File:F-671981 Attachment “A”

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Alberta Employment and Immigration, Occupational Health and Safety

Photograph #5 Shows a close-up photo of the tow cable attached to the Komatsu tow pin at the back of the Komatsu WA 800 front end loader. The tow cable was used to tow the 797F heavy haul truck. Photo taken by Lead Investigator, July 9, 2008