The Coronial inquest into the death of mine electrician Paul McGuire is underway at Mackay Magistrate’s Court. AMSJ has prepared a developing timeline of events leading up to the moment when Paul opened a hatch and was asphyxiated. We stress that information is developing and may change accordingly as additional information comes to hand.
Anglo American completes risk assessments for goaf seal areas
Anglo Amercan Grasstree Mine identifies risk of asphyxiation during risk assessment process for sealing goaf areas. Former Ventilation Officer Shannon Coppard said that that the risk assessment completed on a sealing activity did not identify the possibility of a mine worker opening a hatch and being overcome by an irrespirable atmosphere. Mr Coppard said that “because of controls in place, it was considered a minor risk” Read more A previous risk assessment document ‘807 sealing document’ was used as a basis for the assessment. A design change was also made in the new 901 tailgate seal to incorporate a hatch.
Preliminary discussions regarding calibration
On 5 May 2014, the Outbye Engineering Co-ordinator at the mine had a discussion with Mr McGuire in
relation to the scheduled calibrations of gas sensors. In order for the mine to maintain statutory compliance, the calibrations of gas sensors were required to be
completed by 6 May 2014. On the 6th May 2014 the longwall was on a scheduled shutdown for maintenance and was due to be online at 4.30 pm. The Outbye Electrical Co-ordinator told Mr McGuire that he was to
complete the task the next day but he was not informed of the order of the tasks to be completed or, that a job card had not been amended to reflect the disconnection of a sensor in the goaf.
Grasstree Mine Day Shift Commence
The day shift of 6 May 2014 commenced at 6.00am with a Mine Senior Official (MSO) briefing meeting. During the meeting, the Outbye ERZ Controller was requested to conduct a statutory inspection of the 901 tailgate so that an electrician could access the area to complete calibration work. He was not provided with a job card.
Outbye ERZ Controller completes inspection
The Outbye ERZ Controller completed the inspection of 901 tailgate area at 6.50am and noted this
time with his initials on the 19a cut through A-B Heading man door. It was a statutory requirement that
return airways be inspected and that the inspection approval would remain valid for 6 hours. The ERZ Controller was not provided with a job card. On some occasions he was shown the job cards and others he wasn’t. The no road tape was not in the door in the morning
The inspection boards are at the entry to a particular area, there was no such board for the 901
tailgate, as a result he wrote his inspection notes on the door.
MSO Handover from nightshift
The handover from the night shift MSO to the day shift MSO was conducted at 7.00am. No discussion
was held regarding the calibration of 901 tailgate gas monitoring detectors. The task to calibrate the
901 tailgate gas monitoring detectors was not documented in the mine’s 24 hour plan which had been
compiled on the previous day but was included on a job card given to Paul McGuire.
Paul arrives on-site at Anglo Grasstree underground coal mine
On 6 May 2014 Mr McGuire was rostered on the afternoon shift. He arrived onsite at approximately
11.15am. It was a maintenance day at the mine, meaning that the Longwall was not producing that
day so that various maintenance tasks could be performed.
Mr McGuire attended the pre-shift briefing and collected the Job Cards for his scheduled tasks for the shift. This included Job Card 00913709, which incorrectly identified station 5 channel 7 sensor as being located at 6-7 cut through B Heading 901 tailgate. In fact the sensor was no longer at that
location; it had been disabled and was no longer in use but the job recording system had not reflected changes and the Outbye Engineering Co-ordinator did not check the card in entirety before leaving it for Paul to pick up. The location identified on the Job Card – 6-7 cut through B Heading 901 tailgate – was by that time located in a goaf and disconnected.
Pressure to get the job done
The Longwall was to come back on line after the maintenance day at 4.30 pm and an uncalibrated sensor would have meant that the longwall may have been taken off line. This meant production bonuses would not have been achieved.
Arrival at Pit Bottom
Paul McGuire travels underground and arrives at pit bottom.
Notification to control room
At 12.23pm Paul McGuire made a call to the control room and stated that he was going to perform gas
calibrations at the sensors located at both Station 3 and Station 5.
Completes initial gas sensor calibrations
Paul McGuire completed the gas calibrations at Station 3 sensors at approximately 12.53pm as required in his job card. He then contacts the control room and informed the operator that he was going to undertake calibration at
Station 5, 901 tailgate.
Walk to 901 tailgate
Paul walks towards 901 tailgate via one of several routes.
Meets another mineworker on his way
At approximately 12.55pm Mr McGuire had a conversation with another coal mine worker at 27a cut through B Heading. Mr McGuire told the coal mine worker that he was going to 901 tailgate.
Places sensor control unit in calibration mode
The walks toward the 901 Seal. There is reportdely No Raod tape in the area. The ‘no road tape’ is not reflective nor fluorescent.
Opens hatch in seal
At approximately 1.05pm, Mr McGuire opened the hatch at 0-1 cut through B Heading 901 tailgate by
using a spanner to access the sensor. The hatch had been closed with a single nut and bolt arrangement. It was not secured with locking devices and only remained barricaded with ‘no road’ tape.
Irrespirable atmosphere in goaf enters area
As the hatch is opened, the irrespirable atmosphere enter the area outside the seal where Paul is standing
Paul McGuire dies from irrespirable atmosphere
As a result of opening the hatch, Mr McGuire inhaled irrespirable atmosphere and was fatally injured.
High gas alarm activated in control room
Scott Adams, electrical engineer identifies a “high gas alarm” which signalled that levels of methane had exceeded 1.25 per cent.
Staff go underground to investigate the alarm
A mine electrical engineer (Scott Adams) goes underground to check what was believed to be a ‘gas sensor problem’. Using a handheld gas monitor he checks levels, recalibrates and replaces a sensor then waits 20 min before raising alarm that the sensors are working fine and the gas concentrations are ‘real’. Fairweather (Mines Supervising Officer (MSO) and Zerner (Fmr Ventilation Officer) then travel underground. “You could see the door was open like a small tunnel and the goaf gas was coming out,” Mr Fairweather said. He added they struggled to open a door to the goaf due to pressure differences. The pair also had to ensure they ventilated the area appropriately. “I opened the door and Garth grabbed a disused pallet nearby,I opened and cracked the door and Garth got the pallet around and shoved it into the door so it was wedged open.
Body of miner found
Fairweather and Zerner find Paul’s body and call emergency Mine Staff attempt CPR and made an emergency call just after 3 pm. He was found with his right calf in the door. He was reportedly transferred to the surface where attempts to revive him were unsuccessful.
Anglo American notifies Queensland Mines Inspectorate
Deputy Chief Inspector of Mines was notified of a serious accident involving a Coal Mine Worker (CMW) by Grasstree Mine’s Site Senior Executive (SSE).
Police advise mines inspectorate
Police advise mines inspectorate of fatality
Police attend site
Queensland Police attend the mine site and commence preliminary inquiries.
Mines Inspectors arrive on-site
6.00 pm Mines Inspectorate arrive on-site and commence preliminary inquiries
Police surrender site to mines inspectors
Police surrender jurisdiction to mines inspectors after confirming the accident did not involve criminal conduct.
Additional inspectors arrive on-site
Additional Mines Inspectorate officers arrived on site to assist with the investigation. Investigation commences
Incident details published in media
Media receive initial reports of the incident from Mines Inspectorate READ ORIGINAL AMSJ ARTICLE
Anglo American implements changes to system
Anglo American Grasstree mine implements changes to lock out goaf seal hatches. Reviews accident and makes radical changes in procedures including the use of ERZ controllers in Goafs. The more significant changes that have been made across Anglo mines through working groups include Hard barriers, Signs on the door, Redesigns of the hatches for the lock, barricading with steel mesh and acro props. There has also been a change in the job card and work order process.
Calibration training:electricians are now trained to a competency and Australian standard specifically in gas calibration and hazardous areas. Occurs every two months and competencies are tracked and if they do not require it they cannot carry out the calibration.
Job cards are now required to be scheduled for 3 weeks in advance of when they are needed. The job cards have the old location attached on the back. There is now a system with many quality control checks including the electrician and the ERZ controller are then to validate the attachments to job cards.
MINES DEPARTMENT ISSUES ALERT
Mine Safety Alert 304 is issued highlighting a “Fatal accident in an irrespirable atmosphere” The alert highlights a fatal accident occurred at an underground coal mine when a coal mine worker appears to have been overcome by an irrespirable atmosphere. It also highlights the other incidents involved:
• an ERZ Controller entered an area of a mine while it was being inertised with boiler gas;
• a senior official and a ventilation officer investigated a fixed gas monitor alarm by walking towards increasing levels of gas while their personal gas monitors were also alarming.
Job Card sends another worker to goaf
Another mineworker was sent to a goaf on a job card despite processes in place to eliminate the accident. The worker did not attend but alerted the site.
Prosecution of Anglo American
Anglo American is charged with failing to discharge safety obligations and pleads guilty to one charge while another is dropped by the Queensland Mines Inspectorate. Charges are also dropped against the site’s manager. Anglo recieves a $137,500 without conviction.
Union Lashes out at ‘Dirty deal’ between Anglo and Queensland Mines Inspectorate
A second charge against the company for failing to discharge safety obligations and two counts of failing to discharge safety obligations against site’s manager were dropped by the Queensland mines department. The miner’s union calls a dirty deal “It’s disgraceful Anglo was offered a dirty deal that saw negligent culprits walk free while a young family mourns at the loss of their father” Read more.
Timeline recreated from available evidence presented at Coronial Inquiry and reports by Queensland Mines Inspectorate into the incident. We note that the final findings of the coroner may vary and the information provided in general in nature.
Images: for Illustration Purposes only
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