Multiple Amputations on BHP Billiton Drill Rig ppt

Drill ICAM-preliminary information
For information purposes only. Managers & Supervisors should
evaluate this information to determine if it can be applied to their own
situations and practices.
Feed Cylinder
Steel wire rope
Drill string
Sheave wheel
Hydraulic hose
 Time: Between 11h04 -11h17
Fitter had completed daily checks on Drill and was undertaking the repair to an oil leak on the left side feed cylinder of
the drill. Mechanic was observing Fitter as, Mechanic, was being coached on the workings & maintenance aspects of
the drill. Fitter had requested the drill operator to raise the drill string [for] better access the leaking hose fitting to
work on. Fitter took up a kneeling position with their right leg over the drill platform hole through which the drill string
passes during drilling operations.
Fitter loosened the hydraulic hose fitting which connected to the feed cylinder. This resulted in the loss of hydraulic
stored energy within the cylinder, resulting in the release of the drill string which plunged down and as it passed
through the platform drill hole it resulted in the amputation of the right leg below the knee.
Mechanic had taken up a position on the right side of Fitter with back to the [drill] operators cabin. Mechanic was
probably holding on to the steel rope, which passes under a sheave wheel for the control of the up & down movement
of the drill string, with their right hand. When the pressure was released from the feed cylinder the power head ...[the]
drill string moved downwards as did the steel rope [and the] Mechanics right hand was pulled through the sheave
wheel resulting in the amputation of four fingers & thumb.
Slide 3
Fitter’s leg position prior to the accident – simulated
with a mannequin
Drill string in
a raised
position (drill
bit seen here)
position of
the Fitter with
his right leg
over the drill
Hydraulic hose fitting on feed cylinder
Hydraulic hose fitting that
was loosened resulting in
the release of stored
Root causes
•Loosening the hydraulic hose fitting connecting the hose to a hydraulic feed cylinder, and in doing so there was
an uncontrolled release of oil pressure from the cylinder causing the drill string to fall.
•Stored energy not released prior to commencing activities.
Key contributing factors
Did not take the time to plan and reflect on the risks of the task at hand.
No formal risk assessment performed prior to the task.
Insufficient understanding of the hydraulic system on the drill.
Insufficient knowledge on the concept of stored energy.
No guarding in place covering the moving sheave wheel.
Key learning's
• Awareness campaigns not enough to embed understanding of sources and consequences of stored energy.
• There is no substitute for taking time out to perform proper planning and understanding the risks involved prior
to commencing any task.
To address this incident, this Asset is considering
the following:
• Launch a communication campaign in regard to stored energy in simple and clear terms
• Review, Verify, Sign off Risk Assessments that all stored energy risks are captured and high risk areas are covered by training interventions
• Guards to be fitted on all bottoms of sheave wheels on drills.
• Formally review guarding to ensure all moving parts are guarded
• Supervision verification through quality PTO’s and CTO’s. The one up line manager must verify the quality of a sample of PTO’s and CTO’s.
• Assess the capability of Supervisors in key critical areas to ensure they are competent to execute their responsibilities safely.
• Include stored energy in the COP for isolation, lock, test and tag.
• Update procedures to ensure that unplanned work (subsequent work) is properly planned and executed.
• Supervisors are notified of, pre-approve, and adequately mitigate risk in Remote work.

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