worker fatally injured in haul truck collision in mine

WORKER FATALLY INJURED IN HAUL TRUCK COLLISION IN MINE Type of Incident: Fatality Date of Incident: November 23, 2009

File: F-74563

2 October 07, 2010 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 and ADDRESS OF PRINCIPAL PARTIES 3 2.1 Owner 3 2.2 Prime Contractor 3 2.3 Employer 3 2.4 Contractor 3 2.5 Supplier 3 2.6 Worker(s) 3 2.7 Others 3 3.0 DESCRIPTION OF PRINCIPAL PARTIES 4 3.1 Employer 4 3.2 Workers 4 4.0 LOCATION OF INCIDENT 4 5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS 4 5.1 Equipment and Material 4 5.2 Observations 5 6.0 NARRATIVE DESCRIPTION OF INCIDENT 6 7.0 ANALYSIS 9 7.1 Direct Cause 9 7.2 Contributing Factors 9 8.0 FOLLOW-UP/ ACTION TAKEN 11 8.1 Occupational Health and Safety 11 8.2 Industry 11 8.3 Additional Measures 12 9.0 SIGNATURES 12 10.0 ATTACHMENTS 13

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SECTION 3.0 DESCRIPTION OF PRINCIPAL PARTIES 3.1 Employer 3.1.1 Syncrude Canada Ltd. is a joint venture undertaking that mines and processes oil

sands in the Athabasca Oil Sands Region to produce synthetic crude oil. Syncrude Canada Ltd.’s Mildred Lake mine and processing facility are located 40 km north of Fort McMurray.

3.2 Workers 3.2.1 Operator #1 was employed as a Heavy Equipment Operator by

Syncrude Canada Ltd. since March 09, 2009. 3.2.2 Operator #2 was employed as a Heavy Equipment Operator by

Syncrude Canada Ltd. since June 02, 2008. SECTION 4.0 LOCATION OF INCIDENT 4.1 North Mine East Ramp #1 in the North Mine at the Syncrude Canada Ltd. Mildred

Lake site, approximately 40 km north of Fort McMurray, Alberta. (Refer to Attachment A – Map).

SECTION 5.0 EQUIPMENT, MATERIAL AND OBSERVATIONS 5.1 Equipment and Material 5.1.1 Caterpillar 793B Haul Truck (Unit 17-75) 5.1.1.1 The Caterpillar 793B is a 240 ton diesel powered haul truck used to move ore and

overburden in oil sands mining operations. (Attachment “C”- Photograph #1) 5.1.2 Liebherr T-282B Haul Truck (Unit 17-154) 5.1.2.1 The Liebherr T-282B Haul Truck is a 380 ton electric/diesel haul truck used to move

ore and overburden in oil sands mining operations. (Attachment “C”-Photograph #2) It is powered by electric wheel motors mounted in the axle box. The Liebherr T-282B is equipped with dry disc service brakes on each wheel, an electrical retarder system and a parking brake. The electrical retarder system is the primary speed control for the Liebherr T-282B. In the retarder mode, the wheel motors are transformed into generators and the retarding energy is dissipated through a grid of resistors mounted on the truck deck. Under normal operating conditions, the service brake is for stopping at speeds under 5 miles per hour and holding the unit while it is being loaded. The service brake is the emergency brake should the electrical retarder system fail. There are three separate

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pedals located on the operator’s cab floor for controlling the speed of the Liebherr T-282B: the throttle pedal, the electrical retarder pedal and the service brake pedal. (Attachment “C”- Photograph #3)

5.1.3 Caterpillar 797 Haul Truck (Unit 17-121) 5.1.3.1 The Caterpillar 797 is a 400 ton haul truck used to move ore and overburden in

oilsands mining operations. It is the largest haul truck in Syncrude Canada Ltd.’s fleet of mining haul trucks.

5.2 Observations 5.2.1 Occupational Health and Safety received notification of the incident from the

employer at 10:33 a.m. on November 23, 2009. Occupational Health and Safety arrived at the worksite at 12:08 p.m. on November 23, 2009. Representatives from the local R.C.M.P detachment were on scene at the time of arrival and had commenced their investigation into the incident.

5.2.2 When Occupational Health and Safety arrived at the incident site at 12:08 p.m., the

surface on North Mine East Ramp #1 was graded and well sanded. The temperature was -3 degrees Celsius, and the sky was clear. The scene had been secured by Syncrude Canada Ltd. by placing contracted security representatives at the top and bottom of the ramp to limit access to the incident scene.

5.2.3 Occupational Health and Safety attended the incident scene with the R.C.M.P. Traffic

Collision Reconstruction Specialist for the duration of his on-site activities. During this time, Occupational Health and Safety observed a significant amount of debris on the North Mine East Ramp #1 road (Attachment “C”, Photograph #4). There were a set of tire tracks consistent with the tread pattern of the Caterpillar 793 (Unit 17-75) observed leading to a cut on the west side of North Mine East Ramp #1. (Attachment “B”, Diagram)

5.24 A second set of tire tracks were observed on North Mine East Ramp #1, and were

consistent with the tread pattern on the Liebherr T-282B Haul Truck (Unit 17-154). These tire track marks were observed at the top of the ramp of North Mine East Ramp #1 at the edge of the east berm. These tracks from Unit 17-154 continued down North Mine East Ramp #1 and met with the tracks from the Caterpillar 793B Haul Truck (Unit 17-75) for a short distance. The tracks then led to a cut in the west berm of North Mine East Ramp #1, approximately 100 m beyond the cut where Unit 17-75 had left the road. There was a grader(Unit 14-42) pulled over and stopped on the right side of North Mine East Ramp #1 shortly past the cut where Unit 17-154 left the road. (Attachment “C”, Photograph #5)

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5.2.5 Unit 17-75 was observed further down the ramp over the side of the west berm and partially down the embankment. The right front side of Unit 17-75 was dug into the ground and there was a considerable amount of debris from Unit 17-75 on the ground surrounding the truck. (Attachment “C”, Photograph #6) The right front wheel was missing from Unit 17-75, and was observed approximately 40 m away in the ditch.

5.2.6 Unit 17-154 was observed over the edge of the west berm with its front end facing the

west berm. The rear wheel axle was completely ripped away and was resting in front of Unit 17-154. (Attachment “C”, Photograph #7) There was considerable damage to the front end and the operator’s cab of Unit 17-154. There was considerable debris from Unit 17-154 on the ground surrounding the truck, and a load of overburden was located to the right, behind Unit 17-154. There were footprints observed leading from the debris surrounding the truck to the edge of the berm.

5.2.7 The scene was released by the local R.C.M.P. Traffic Collision Reconstruction Specialist to Occupational Heath and Safety at 1:46 p.m. on November 25, 2009. Time and speed data for Unit 17-154 used for the reconstruction was obtained from GPS (Global Positioning System) tracking data for the unit.

SECTION 6.0 NARRATIVE DESCRIPTION OF THE INCIDENT 6.1 On November 23, 2009 at approximately 7:30 a.m. Operator #1

started her shift at the Syncrude Canada Ltd. Mildred Lake worksite. She was working an overtime shift as a Haul Truck operator in the North East Mine. Operator #1 reported to the Mine Operations building where she received her assigned duties for the shift. She was assigned to Unit 17-75.

6.2 Operator #1 started operating Unit 17-75 and followed the

instructions from the WENCO computerized communication system in the haul truck as to where to pick up and dump material in the mine.

6.3 At 10:02 a.m., Operator #1 left #45 Dump and was heading toward

Plant #79 to pick up her next scheduled load, as per the instructions on the WENCO system in Unit 17-75. (Refer to Attachment “B” Diagram while reading Sections 6.4-6.19)

6.4 Operator #1 continued in Unit 17-75 toward Plant #79, and

proceeded to descend North Mine East Ramp #1 in the empty Unit # 17-75.

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6.14 When the Team Leader saw Unit 17-154 go through the Stop sign without any signs of slowing or stopping, the Team Leader turned his light duty truck in the opposite direction, and proceeded to follow Unit 17-154 down North Mine East Ramp #1.

6.15 As Unit 17-154 continued down North Mine East Ramp #1, it continued gaining

speed. As Unit 17-154 approached the first corner of North Mine East Ramp #1 at a speed of 75.6 kph, an expeditor’s light duty truck was ascending North Mine East Ramp #1. At 10:08 a.m., Operator #2 steered Unit 17-154 to the right of the expeditor’s light-duty truck, losing some of its load as it avoided the expeditor’s light duty truck coming up the ramp.

6.16 At the same time, further down on North East Mine Ramp # 1, Grader Operator

was slowly descending the right side of the ramp in Grader Unit 14-42, while Operator #1 in Unit 17-75 was approaching Grader Unit 14-42 from behind. The Grader Operator flashed his signal lights to indicate to Operator #1 that it was alright to pass.

6.17 Operator #1 steered Unit 17-75 to pull out on the left side of North

Mine East Ramp #1 to pass Unit 14-42 grader. As Operator #1 was pulling out to pass the grader in Unit 17-75, Unit 17-154 was still gaining speed travelling down the North Mine East Ramp #1. As Operator #2 maneuvered Unit 17-154 around the second curve on North Mine East Ramp #1, he saw Unit 17-75 in the left lane and the grader Unit 14-42 on the right.

6.18 At 10:08 a.m., Operator #2 was traveling at a speed of 86.9 kph

when he attempted to drive Unit 17-154 between grader Unit 14-42 and Unit 17-75. The left front side of Unit 17-154 made contact with the right rear box of Unit 17-75. Unit 17-154 pushed Unit 17-75 for a short distance, and then Unit 17-75 was pushed into and over the west berm into the embankment on the west side of North Mine East Ramp #1. (Attachment “C”, Photograph #6)

6.19 When Unit 17-75 hit the west berm, Operator #1 was ejected

through the windshield of Unit 17-75 and thrown over the west berm. Unit 17-75 went over the west berm landing on and crushing Operator #1 . Operator #1 received fatal injuries as a result of the impact.

6.20 Unit 17-154 traveled a short distance and then also hit and went over the west berm

into the embankment on the west side of North Mine East Ramp #1. (Attachment “C”, Photograph #7). Operator #2 was ejected from Unit 17-154 and received minor injuries.

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7.2.2 The electrical retarder system did not respond when Operator #2 used the electrical retarder pedal to slow down Unit 17-154 when he was approaching the stop sign at the top of North Mine East Ramp #1. Data extracted from the Maintenance Decision Support Program (MDSP) computer module on Unit 17-154 indicated that the electrical retarder pedal had been applied, and the electrical retarding system was functioning immediately prior to the incident. However, after 10:07 a.m. there is no data available for the electrical retarder system. Syncrude Canada Ltd. conducted a thorough inspection on Unit 17-154 with representatives from Liebherr, the manufacturer of the T-282B. The inspection revealed that the electrical system, specifically the Traction Control Unit (TCU), had failed on the unit. When the TCU failed, the propel and retarder functions on the Liebherr T282B did not work.

Before the incident, Syncrude Canada Ltd. followed a comprehensive preventative maintenance program that included four pre-scheduled preventative maintenance procedures at designated intervals. These preventative maintenance procedures included all the recommended maintenance by the manufacturer, but an inspection of the TCU was not included in the recommended manufacturer’s preventative maintenance schedule for the Liebherr T-282B.

7.23 Operator #2 did not apply the service brake on Unit 17-154. The

Occupational Health and Safety Mechanical Consulting Engineer performed an inspection on the service braking system on Unit 17-154 at the time of the incident and determined that the service braking system was available for use, was in good operating condition, and that the service brakes had not been applied. The brake pads were within operating parameters and showed little sign of any use. The Occupational Health and Safety Mechanical Consulting Engineer indicated that had the service brakes been applied on Unit 17-154 at the top of East Mine Ramp #1, they would have been able to bring Unit 17-154 to a complete stop safely at the top of the North Mine East Ramp #1.

7.2.4 The electrical retarder system is the primary speed control for the Liebherr T-282B.

Operators are trained to use the electric retarder system as the primary way to control the speed of the Liebherr T-282B, and to use the service brake in emergency applications (each of the systems has a separate pedal located on the floor of the operator’s cab) (Attachment “C”, Photograph #3). When operating the Liebherr T-282B under normal conditions in the mine, an operator would be able to rely on the electrical retarder as the primary method for controlling the speed of the Liebherr T-282B, and would not have to use the service brake to slow or stop the truck. Operator #2 had received more than 118 hours of practical experience on the Liebherr T-282B trucks with a Syncrude Canada Ltd. trainer onboard before he started to operate the Liebherr T-282B by himself. He had more than 959 hours of experience operating Liebherr T-282B trucks at the Syncrude Canada Ltd. worksite prior to the incident, and according to Syncrude Canada Ltd records, had not applied

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the service brakes in any application over 5 mph. Operator #2 had received training on the emergency use and capabilities of the service brakes for the Liebherr T282B. However, as he was descending the North Mine East Ramp #1 and was rapidly gaining speed, he was focused on avoiding the trucks and equipment on the mine road and did not apply the service brakes.

SECTION 8.0 FOLLOW-UP/ ACTION TAKEN 8.1 Employment and Immigration; Occupational Health and Safety 8.1.1 Alberta Occupational Health and Safety attended the scene of the incident and

conducted an investigation into the incident.

8.1.2 Occupational Health and Safety issued a Stop Work order to Syncrude Canada Ltd. for the incident site so that Occupational Health and Safety could attend and conduct an investigation.

8.1.3 Occupational Health and Safety issued an order to Syncrude Canada Ltd. to conduct an investigation into the November 23, 2009 incident and to prepare a report of the circumstances surrounding the incident, the identified corrective actions to prevent a similar recurrence, and to make the report available to Occupational Health and Safety upon request.

8.1.4 Occupational Health and Safety issued orders to Syncrude Canada Ltd. for the following:

- to supply information requested by Occupational Health and Safety to support their investigative efforts.

- to conduct a hazard assessment for loss of the electrical retarder function on the Liebherr T-282B, and to demonstrate to Occupational Health and Safety that all affected workers are trained and know how to safely stop the Liebherr T-282B in the event of a loss of the dynamic retarder function.

8.1.5 Occupational Health and Safety issued orders to Syncrude Canada Ltd. to report all instances of the electrical retarder function failing on the Liebherr T-282B to Occupational Health and Safety.

8.2 Industry 8.2.1 Syncrude Canada Ltd. conducted an investigation into the incident, prepared a report

of their findings, and made the report available to Occupational Health and Safety for review.

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8.2.2 Syncrude Canada Ltd. provided re-training to all operators for the Liebherr T-282B to

ensure that they were trained and competent on the use of all braking systems on the Liebherr T-282B. Syncrude Canada Ltd’s training program includes a computer simulator portion for the practical component of training for new drivers at the worksite. The computer simulator has a mock T-282B cab to train new drivers on possible different scenarios they might encounter while operating the truck. Loss of retard function as a possible scenario is integrated into the training.

8.2.3 Syncrude Canada Ltd.’s Mine Management Team conducted meetings with all mine

operations staff to re-enforce their requirement for the mandatory use of safety restraints while operating equipment at their worksite.

8.2.5 Syncrude Canada Ltd. worked with the manufacturer, Liebherr, to develop a more

reliable TCU (Traction Control Unit) to prevent a recurrence. All of the Liebherr haulers at the Syncrude Canada Ltd. site have had the redesigned TCU upgrades installed to prevent a failure of the TCU in the future.

8.3 Additional Measures 8.3.1 No additional measures taken. SECTION 9.0 SIGNATURES ____________________________ _____________________ Lead Investigator Date ____________________________ _____________________ Investigator Date ____________________________ _____________________ Manager Date ____________________________ _____________________ Regional Director, North Date SECTION 10.0 ATTACHMENTS: Attachment A Map Attachment B Diagrams or Sketch Attachment C Photographs

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ORIGINAL REPORT SIGNED

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File: F-74563 Attachment “A” Map

Showing Incident Location

Alberta Employment and Immigration, Occupational Health and Safety

Incident Location

The incident occurred at Syncrude Canada Ltd.’s North Mine, approximately 40 km north of Fort McMurray, AB.

Incident Location

File: F-74563 Attachment “B” Diagram


= Location of equipment after incident

= Path of travel for Unit 17-154

= Speed & corresponding times for Unit 17-154 (GPS)

= Path of travel for Unit 17-75 = Path of travel for Unit 17-121

North Mine East

Ramp #1

(Not to scale)

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Attachment “C” Page 1 of 9


Photograph #1 Shows a Caterpillar 793B haul truck at the Syncrude Canada Ltd. worksite. This is the same model haul truck that Operator #1 was operating at the time of the incident.

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Photograph #2 Shows a Liebherr T-282B haul truck at the Syncrude Canada Ltd. worksite. This is the same model that Operator #2 was operating at the time of the incident.

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Photograph #3 Shows the floor of the operator’s cab in a Liebherr T-282B. These are the same controls that were in Unit 17-154 at the time of the incident.

Service Brake Pedal

Electrical Retarder Pedal

Throttle Pedal

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Photograph #4 Looking down North Mine East Ramp #1. The three inserts are close-ups of some of the debris from Unit 17-154 and Unit 17-75 found on the road when Occupational Health and Safety arrived. The top of Unit 14-42 Grader is highlighted in the photograph. (The other vehicles seen in this photograph were associated with recovery and investigative efforts after the incident, and were not present at the time of the incident.)

Unit 14-42 Grader

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Photograph #5 Shows position of equipment after the collision. The photo was taken after a snowfall; and the light duty truck and pylons seen in the photo were not present at the time of the incident. (This photo was provided by Syncrude Canada Ltd.)

Unit 14-42 Grader

Unit 17-154 Liebherr T-282B

Unit 17-75 Caterpillar 793

Location of fatally injured Operator #1

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Photograph #6 Shows Unit 17-75 positioning after the collision. The main photograph was taken from the west side berm on North Mine East Ramp #1. The inserts show different views of the truck. As shown in the top insert, the right front wheel was missing, and there was a significant amount of damage to the front right side of the truck.

Location of fatally injured Operator #1

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Photograph # 7 Shows Unit 17-154 positioning after the collision. The photograph was taken from the west side berm on North Mine East Ramp #1. The top right insert shows the driver’s side of Unit 17-154. As seen in the photograph, the operator’s cab for Unit 17-154 was crushed in and there was significant damage to the front end of the truck. The bottom right insert shows a close-up of the rear wheel axle of Unit 17-154. This was totally detached from the truck and sitting in front of the truck.

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Photograph #8 Shows footprints from Operator #2 observed coming from behind Unit 17-154 and leading to the berm on the west side of North Mine East Ramp #1.

Footprints from behind Unit 17-154 leading to the edge of the berm.

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Photograph #9 Shows Unit 17-75 from the right front of the truck. As highlighted in the photograph, the windshield for the operator’s cab of Unit 17-75 was missing. There was no visible damage to the frame or structure of the operator’s cab for Unit 17-75.

Windshield for Operator’s cab missing

worker fatally injured in haul truck collision in mine

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