DOS-AW-201644-SAS-1593571 Downstream Oil Sands – Shell Albian Sands October 2016

Mining – Metal to Metal Contact Theme – Incident #2

Target audience for this alert

 Mining Personnel

What happened
On March 13th at 11:26 pm, in the JPM mine area, 785 haul truck’s #471
(HH471) and #465 (HH465) made metal to metal contact. Both operators were
assessed and returned to duty. The incident is currently ranked 4B potential to
People.
Road Conditions
HH471 was loaded with sand and traveling towards a sand stockpile, which was made on the road for
Turnaround. The alternate route was judged to have traffic interaction risks and required longer travel time. The
road (Truckshop haul road) was restricted to 20m of the road surface in use and was largely covered in water in the
incident area. The truckshop haul road had previously been deemed closed for heavy hauler traffic but was in
periodic use by both day and night shifts. At the time of the incident, both trucks recognized that road conditions
were poor and were traveling slowly (<15 Km/hr).

HH471 lost traction on its rear tires and began to slide, the rear end slid on the road surface and slid down toward
the lane of travel of the oncoming traffic. Truck HH471 tail end made contact with HH465 damaging the side of the
box of HH471.
Why it happened
 Road was slippery enough to slide. Mine management relied upon the judgment of the field leadership to
determine if a road had enough traction. Field leaders relied upon operator feedback and visual checks to judge
a road’s traction. Prior to the incident, the field leader judged the road to have enough traction for continued use.
 Road was narrow enough to allow contact during a slide. Mine management relied upon the judgment of the field
leadership to determine if a road was wide enough. Field leaders relied on visual inspection and operator
feedback to determine if a road was wide enough and prior to the incident, the field leaders judged the road to
be wide enough for continued use.
 the time of the slides, operators believed that if a road was in use it had been judged by leaders as good and
At
was approved for use.
 Operators believed that leadership wanted to continue to operate on roads that had been approved for use and
that by traveling slow enough the operators could stay safe.

Lessons learned
 At the time of the incident, Visual Safety Leadership (VSL) activities and procedures were believed to guide
decisions made by team leads and shift leads. At the time, these controls were focused on other topics; road
conditions were considered a known part of the job.
 One method that leaders use to judge both haul road width and traction is by relying upon operator feedback.
Operators will usually drive a road if they believe the team lead has judged and approved that conditions are
acceptable. Roads can remain open during poor conditions as a result of the leader waiting for feedback from
operators, and the operators believing the leader has approved the road.
 At the time of the incident, Operations would have ‘loss of equipment control’ incidents that resulted in continued
operation in combination with road maintenance only. Whether these incidents resulted in contact, was often
determined by road width and traffic patterns.

Recommendations
1. At both MRM and JPM, add road width and traction condition to documented daily pit audits, and display
findings in operator line up rooms.
2. Design a formal leader training program that will be delivered by the manager or production specialist to
set clear expectations with all current and upcoming leaders.
3. Implement VSL between Shift lead and each Team Lead during 7-day rotation which will include
examination of all critical pit conditions
4. Start a temporary Safe Operating Committee (SOC) program where SOC members utilize their operating
time to travel amongst other operators on selected routes, with the specific goal of road evaluation and
communication between the crew and the leads. This should demonstrate the commitment to open
communication on road conditions between operators and team leaders

Further information
Clint Bachelder, Causal Learning Focal Point, can be contacted for more incident details or more information
regarding the lessons learned or recommendations. Incident #2: FIM Incident ID: 1593571

Incident #1: FIM Incident ID: 1576371

DOS-AW-201643-SAS-1576371 Mining – Metal to Metal Contact Theme – Incident #1 February 2016

Incident #3: FIM Incident ID: 1596185

DOS-AW-201645-SAS-1596185 Mining – Metal to Metal Contact Theme – Incident #3 March 2016