Boggabri rigger death investigation report released

A report prepared by the NSW Mine Safety Investigation Unit into the death of a rigger at Boggabri Coal Mine in May last year has been released. 

An extract of the report, which investigates the death of 51-year-old Mark Galton after he was killed from crush injuries, is below.

SUMMARY

At 8.48am on Wednesday, 21 May 2014, Mark Daniel Galton, a rigger employed by Thiess Sedgman Joint Venture (Theiss Sedgman) died when his head and neck were crushed between a mobile elevated work platform (MEWP) and the underside of a large, horizontal steel beam.

The incident occurred inside a partly constructed multi-level steel frame referred to as ST202 at the coal handling and preparation plant construction site at Boggabri Coal Mine. The underside of the steel beam was 12.5 m above the concrete floor.

Mr Galton, 51, was relocating the platform to ground level after tightening bolts on the structure. During the movement of the platform over walkway handrails, a crush point was created between the platform frame above the control console rising towards the steel beam. Mr Galton was alone in the platform.

He had a designated spotter on the ground and asked a leading hand rigger on a nearby level to observe him during movement of the platform over a walkway.

The leading hand rigger called out a warning to Mr Galton when he saw there was a gap about 5cm between Mr Galton’s head and the steel beam above. Mr Galton stopped the platform and verbally acknowledged the warning.

Neither Mr Galton’s designated spotter nor the leading hand rigger saw the actual incident.

The leading hand rigger next observation was that Mr Galton was trapped between the frame above the platform control console and the overhead beam. He initiated an emergency response over the two-way radio.

The first attempts to free Mr Galton were unsuccessful. The platform was then tilted using its ground controls. Mr Galton was released and he fell to the floor of the platform. Workers
accessed the platform and transferred Mr Galton to the second floor landing and began first aid.

Emergency services attended the scene at 9.16am. NSW Ambulance paramedics ceased CPR about 9.30am.

The platform involved in the incident was a JLG 600 AJ 18.3m rough terrain diesel knuckle boom. It was owned and maintained by Coates Hire Operations Pty Ltd and was on a hire
agreement to Theiss Sedgman at Boggabri Coal Mine since 22 March 2014.

Theiss Sedgman was contracted by the mine operator to build the coal processing plant at Boggabri Coal Mine about 17 km northeast of Boggabri in the Gunnedah coalfields of NSW.

CAUSE OF DEATH
The direct cause of Mr Galton’s death was cervical spine trauma.

The autopsy report summarised the following:
• Transected upper cervical column and spinal cord (C2-C3 level).
• Fractured larynx with extensive soft tissue haemorrhage.
• There was no evidence Mr Galton had suffered a heart attack leading up to the incident.
• Toxicology negative for drugs and alcohol.
• Normal blood carbon monoxide saturation (1%).

INVESTIGATION OBSERVATIONS
The specific cause of the platform rise cannot be established. The platform was over a walkway handrail and rotated to the right (relative to the operator’s control console) and nearly parallel to the alignment of the raised jib and boom. The incident happened during a day shift. Mr Galton arrived at the mine site at 5.55am and was onsite for 2 hours and 53 minutes when the incident occurred.

Mr Galton was working his ninth consecutive 11-hour shift of a 10-day roster. The investigation is unable to establish if Mr Galton’s fatigue level contributed to the incident. The investigation has considered five potential cause theories and ranked them in the order of most likely to least likely.

These are:

1. An unintended platform rise caused by Mr Galton coming in contact with one or more control switches on the platform console, which activated the platform rise functions. In this
scenario the main rise control device (the lift swing joystick) was not activated by Mr Galton, however the covered footswitch was activated enabling a seven-second window for potential machine movement. The reason for the movement of Mr Galton forward over the console could either be considered as:

Voluntary – he made a decision to look over the console to obtain a better view of the position of the platform jib and boom relative to steel structures below, or;
Involuntarily – his head came into contact with the steel beam, which moved his body forward over the console.

2. An unintended platform rise as a result of Mr Galton either incorrectly selecting a platform control switch or applying the wrong direction of movement to one or more platform control devices. Or Mr Galton selected the base drive/steer joystick to move the platform base to move the platform sideways over the walkway handrail. As the rear wheels moved down the ramp it caused the platform to rise (platform pendulum effect). Or excessive platform movement caused by incorrect control function ramp time settings.

3. An intended platform rise activated by Mr Galton as he accepted the risk of moving the platform in proximity to the beam. In review of the circumstance of the incident there was no evidence of intentional self-harm by Mr Galton.

4. Inadvertent movement of the platform caused by a defect.

5. External force applied by the environment to the plant caused the platform to rise.

OBSERVATIONS CONCERNING SYSTEMS TO CONTROL THE RISK OF CRUSH INJURY
Apart from the steel frame above the platform control console, which was directly involved in the crush injury there were no secondary protection devices to prevent Mr Galton from being crushed while operating the MEWP.

The risk of a person being trapped between the platform and a fixed overhead structure was foreseeable. The risk was clearly identified in risk assessments and equipment manuals published before the incident. The risk was also identified in a range of risk management documents found at the mine site.

The controls put in place to manage the known risk were lower order hierarchy of risk control measures.

The documented controls included:
• MEWP training qualifications awarded by a registered training organisation.
• High risk licence awarded to the platform operator by a government regulatory agency.
• Verification of competency to operate the specific model of platform at the site.
• Risk assessment of the specific model of platform introduced to the work site.
• Work area plans, Work Area Plan Risk Assessment, Critical Safety Controls.
• Safe Work Method Statements (SWMS) and Job Safety Environment Analysis (JSEA)
included use of platform.
• Shift tool box talks.
• ‘Start Card’ created by operators at the start of the work task.
• Working at height permit (WAH permit) (Noting that Mr Galton had not signed onto a permit
for the platform task on the day of the incident).
• Operator pre-start inspection and defect report for the MEWP (signed by Mr Galton on 21
May 2014).
• Spotter being present during MEWP tasks.
• While there were examples of documented generic risk assessments for use of MEWP at the site there was no specific risk assessment considering the task of using a MEWP under a fixed structure within ST202. These risk control measures did not prevent the incident from occurring.

OBSERVATIONS CONCERNING THE USE OF SECONDARY GUARDING DEVICES ON MEWPS

1. In July 2010, overseas regulatory authorities and platform end user groups published best practice guidance for MEWPs and information on secondary guarding. The Australian hire and rental industry was informed of the guideline in February 2011.
2. In October 2011, a secondary guarding device registered as SkyGuard® was designed and manufactured by JLG (America). By late 2012, the device was made available to European MEWP user groups.
3. In May 2012, JLG informed the Australian hire and rental industry that SkyGuard® could be previewed at the 2012 hire and rental industry convention.
4. In February 2013, JLG informed the Australian hire and rental industry that SkyGuard® was available as an aftermarket kit on all JLG booms manufactured from 2004. Australian
Design Registration had not been obtained for SkyGuard® at that time.
5. In May 2013, a United Kingdom equipment hire registry web page published information to MEWP user groups related to SkyGuard®. An extract of the publication stated:

‘JLG SkyGuard® provides operators with enhanced control panel protection. When activated by approximately 23 kg of force, SkyGuard® stops all functions in use at the time. The reverse functionality momentarily “undoes” most functions that were in use at the time of activation for less than a second’s worth of time.’

6. In July 2013, European Standard EN280:2013 Mobile Elevating Work Platforms was updated (with a transition period of 18 months to January 2015) to require secondary guarding options to be fitted to all MEWPs. The current Australian MEWP Standards for safe use is dated 2006.
7. On 14 May 2014, Australian Design Registration (ADR) for SkyGuard® was submitted by JLG.
8. Before 14 May 2014, JLG had not received any purchase orders from Australian JLG MEWP users to fit the SkyGuard® secondary guarding device.
9. On 30 May 2014, ADR for SkyGuard® was awarded by Worksafe Western Australia and received by JLG for the 600 AJ model on 10 June 2014.
10. ADR for SkyGuard® was received after Mr Galton’s incident and approximately 17 months after the device was made available in Europe.
11. Australian regulatory authorities had published information relating to fatal incidents and risks associated with use of MEWP before Mr Galton’s incident.
12. In November 2014, Safe Work Australia (SWA) identified that there were seven fatal
incidents involving users of elevating work platforms being crushed against roofing beams
during the period 2006 to 2011.

Remedial safety measures
Following Mr Galton’s incident, Thiess Sedgman undertook a range of continuous improvement programs:

• After the incident, Thiess Sedgman reviewed available secondary guarding device options that could be fitted to the various brands and models of MEWP at the site.
• In July 2014, Thiess Sedgman revised the MEWP spotter training package and completed the training.
• In or about July 2014, Thiess Sedgman updated the generic site induction assessment and the Boggabri Coal CHPP induction PowerPoint presentation to incorporate information from the MEWP skills review (VOC) package.
• From 20 August 2014, Thiess Sedgman required secondary control devices to be fitted to MEWPs operating in and under structures or where an overhead crush risk exists at BCM.
• In August 2014, Thiess Sedgman developed and implemented a supervisors MEWP
presentation and supervisors MEWP scenarios assessment program to help supervisors and leading hands to better understand the specific controls which should be used in various circumstances.
• In August 2014, Thiess Sedgman developed and implemented a VOC authorisation
assessment for MEWP authority levels for operators.
• In August 2014, Thiess Sedgman developed other initiatives as part of Work Area Pack Risk Assessment (WAPRA) for working in MEWPs. This included toolbox talks on MEWP
selection, revising and processing work packs to incorporate information identified in the
WAPRA, and revising the WHS Area Inspection Form to incorporate a MEWP section based on the Thiess Critical Safety Control (CSC) Prevention of Falls.

RECOMMENDATIONS
The incident highlights the importance of having an effective risk management program in relation to specific complex three dimensional movements of mobile elevated work platforms in proximity to fixed structures.

When a MEWP is required to move in proximity to fixed structures, higher order risk management controls to prevent crush injury should be identified and implemented. This is in addition to the existing industry emphasis on lower order risk controls such as operator high risk work licence, specific MEWP operator certification, verification of competency, work at heights permit and a spotter being present.

When considering the recommendations below, mine operators are reminded of their obligation to take a combination of measures to minimise risk, if no single measure is sufficient for that purpose.

For the full report, including more recommendations, click here.