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ICAM fails to deliver conclusive findings in Queensland fatality

ICAM Investigation BHP Saraji Allan Houston
AN ICAM investigation has been inconclusive regarding the death of dozer Driver Allan Houston.

An ICAM investigation has failed to reach conclusions surrounding the death of dozer operator Allan Houston at the Saraji Mine on the 31st December 2018. In the midst of the report release, some miners believe that there have been ommissions of factual data surrounding the incident (more below).

Allan Houston died after his dozer plummeted off a wall at the BMA Saraji Mine in Queensland.

BHP conducted an internal ICAM investigation into the incident and has prepared an extensive report covering the incident. AMSJ has been provided with a version of the facts, findings and recommendations made by BHP through the conduct of its’ investigation.

We stress that the information is intended for industry awareness only. We note an inquiry made by a court of law may find other issues contributing to this tragic loss of life.

What BHP investigators found?

On 31 December 2018 at approximately 10.25pm, Allan Houston was operating a dozer at BHP Mitsubishi Alliance’s (BMA) Saraji Mine when the dozer travelled over a bunded low wall edge and rolled down the embankment.

The dozer came to rest upside down in a pool of mud and water approximately 17.8 metres below.

Allan was in the cabin with his seatbelt still fastened. He did not survive the incident. On the night of the incident, Allan was completing a dragline bench preparation task (where the operator uses the dozer to ‘push’ material to level it and create a ‘bench’ ahead of a dragline entering the area).

Testing of the dozer after the incident did not reveal any mechanical issues. There was no evidence of radio broadcasts indicating there was a problem with Allan or the machine. The ICAM team were also able to confirm that, on the night of the incident, Allan was undertaking the work in accordance with the applicable safe work instruction (SWI-231 Bulk Push Dozer Operations).

From interviews with his supervisors, and other operators, it was clear to the ICAM team that Allan was regarded as an experienced and respected dozer operator. Allan is survived by his mother, brother, sister and daughter. He was a friend to many in the Saraji team.

BHP Saraji Mine – ICAM Investigation Summary

How did the accident happen?

After a lengthy and thorough investigation, the BHP ICAM team could not determine the direct cause of the incident. Based on the evidence available, it concluded that there are three scenarios that represent possible direct causes.

Scenario one

Allan struck his head in the cabin of the dozer and due to partial or total loss of consciousness, he was unable to regain control in time to stop going over the edge, or to operate the dozer down the embankment safely. Improvement areas

Scenario two

Allan was affected by medications and/or an underlying medical condition, which impaired his ability to operate the dozer and respond appropriately to his environment, or caused him to otherwise operate the dozer in an unsafe manner.

Scenario three

Allan lost control of the dozer because he was impaired by environmental factors, such as dust, or encountering a large rock. Because he was close to the edge, he was unable to regain control in time to either change course or operate the dozer down the embankment safely. 

BHP Saraji Mine – ICAM Investigation Summary

The ICAM team identified four improvement areas at Saraji. These centred on reviewing dozer risks, improving the Saraji risk management procedure, enhancing detailed mine scheduling and design, and management of medication.

BHP Saraji ICAM Investigation Summary

BHPs Lesson: Better manage medications

BHP said that the one lesson arising from the ICAM that is applicable across BHP is how the organisation better manage the risk associated with medications.

It said that some medications can impair the ability to work safely. and encouraged its’ staff to always talk to a medical professional for advice about potential risks regarding fitness for work from medications.

It said it will develop Global Guidelines surrounding the medication issue.

Mines Inspectorate recommendations

In March 2019 the Queensland Mines Inspectorate said it had not determined that cause of the incident however it issued a safety alert with a number of recommendations

It said that mines should ensure that there is adequate edge protection to prevent equipment and persons from inadvertently going over the edge of an excavation. It also highlighted that need to ensure that there is adequate protection to prevent equipment from entering bodies of fluid and where practicable remove the fluid before work commences.

It said that work methods used on benches must achieve an acceptable level of risk and that work methods contain a specific traffic management plan for entering and exiting work areas.

The inspectors report also highlighted that if a machine is introduced to site and has the capability to transmit function/operational data, the system should be enabled.

It also highlighted issued surround access to areas in an emergency. It said that vehicle access into pits where machinery is working on benches above should be provided.

Miners question the omission of crucial information from findings

Several miners have contacted AMSJ and confirmed that information provided by BHP fails to state that the dozer was potentially a ‘hire’ machine and had been recently brought onto the site and not been fitted with the capability to transmit operational data to the sites control room.

Others said the report summary fails to mention the possibility that the operator’s cab was inundated by water and slurry after it landed upside down.

Another said the report failed to identify potential ‘adjustment’ of the incident scene prior to the arrival by Queensland Police.

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