Haul Truck Backs into T65 Dozer

Front view of Dozer

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Incident Overview  

• On Sunday, February 3rd, 2013 at approximately 11:30 am haul truck H09 was backing to the dozer at the end of the Hollinger Road to dump her load. The driver felt she wasn’t lined up properly. At which point she decided to reposition herself. She pulled ahead 15-20 feet turning to the right and away from the dozer. She then began to back up coming into contact with the left hand corner of T65 dozer. No injuries were sustained. This was deemed to be a high potential incident and a Root Cause Analysis ensued.

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Incident Causation

• Critical Factor: H09 stops and pulls ahead 15-20’ to the right and repositions herself and starts to back up. 

• Immediate Causes:

• 11. Improper placement. Operator of H09 was not properly aligned with the dozer. 

• 62.2 Training done properly, not recalled when it was needed. The truck operator stated that she knew the proper practice of turning to the left but turned to the right.

  

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Incident Causation

Job Related Factors: 76.2 Incomplete implementation of procedures. The truck Operator knew the procedure but did not follow it therefore failed to realize the risk involved.

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Incident Causation

Critical Factor: The dozer operator notices a snowmobile pull up to the gate on the right hand side. Immediate Causes: 02 Failure to warn. If the dozer operator had been paying attention he could have stopped the truck operator and instructed her on the proper procedure. Personal Factors:64.1 Person was preoccupied. Routine, monotony, uneventful. Snowmobile broke the monotony of the day and caused the dozer operator to lose his focus.

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Incident Causation

Job Related Factors:71 Inadequate leadership reporting relationships. If the dozer operator owns the dump the dozer operator needs to be more aware and stay focused on what is happening and provide warning to truck operator.

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View of the dump head

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Contributing Factor:

DateEventThe truck driver has been with PGM for three months. Estimated 600 hours on truck. It is unclear whether her inexperience played a direct factor in this incident. However, the team believes that this contributed to the incident based on discussion.

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Recommendations

Refresher training for all new drivers/ operators after three months. Marcel Goyer/Mike Lepine--March 31st, 2013

Review training manuals to more reflect the operations. (Dumps, roads & special projects) Mike Lepine/Chris Bangs--March 31st, 2013

Investigate use of simulator for new operators and refresher training. Marcel Goyer/ Paul Miller--March 15th, 2013

Standardize training for all field trainers. (To make sure everyone does the same thing) Mike Lepine---June 1st, 2013

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Recommendations

Situational Training at tool box meetings for new conditions scenarios. Start with dump point safety Marcel Goyer February 19th, 2013

Testing back up cameras on Dozers / Loaders. Marcel Goyer/Ray McIver March 31st, 2013

Education for all crews on the focus, ownership and responsibility in loading/dozer and drilling areas. Marcel Goyer February 28th, 2013

Power point presentation to be completed and reviewed with each crew. Marcel Goyer/ Mike Lepine February 28th, 2013