MINERALS COMMISSION Mineral House # 12 Switchback Road Residential Area, Cantonment GL.060-1131 P.O. Box M248, Accra-Ghana [BE (238 302) 772789 1 779828/773053 / 771318 FAX: (239 302)773524 E-mail info@mincom.gov.gh, Website: wwwmincom.gov.gh ID/F/Vol.2187 May 4, 2021 The General Mine Manager Ghana Manganese Company P.O. Box M183 Aoora. RE: REPORT OF INVESTIGATION INTO A FATAL ACCIDENT INVOLVING MB. ROLAND KUTULAM ON STH APRIL 20217 — MINERALS AND MINING (HEALTH, SAFETY& TECHNICAL) REGULATIONS 12f, 16, 17, 26 OF 2012 (L, |. 2182). GHANA MANGANESE COMPANY (GMC) LIMITED We refer to an accident investigation report in respect ofthe accident on the above subject matter as conducted by the Principal Inspector of Mines (Machinery) of the Takoradi Office. ‘The investigations conducted indicated the following Findings, Recommendations and Sanctions: 1. Findings Having inspected the scene of the accident and interviewed the witnesses present during and after the accident and workmen from some auxiliary departments, we find that: i. The deceased (Roland Kutulam) and other three injured workmen (Edward Fynn, Robert Quansah and Patrick Obeng Afum) went on night duty on the 8" April 2021 ii, The workmen were tasked to remove interlocked boulders from the ROM bin discharge end. il The workmen were using a lifting chain sling and an overhead crane in aiding the removal of the interlocked boulders from the ROM bin. \v. It appears the night workmen did not go through proper risk assessment before commencement of the task.vi. Vii viii. xi xii xii xiv. The workmen reported to work at about 6:00pm and started work at about 6:15pm making it impossible for them to have gone through proper risk assessment and the isolation procedures in less than 15 minutes before starting the task. One person's handwriting was found to have written the names for three workmen involved in the activity on the risk assessment form. Different signature for the deceased (Roland Kutulam) was found on the risk assessment sheet and other training sheets indicating that somebody signed the risk assessment for the deceased after the accident had occurred. No supervisor or safety officer took part in the risk assessment and isolation procedures for the task. Isolation (lockout, tag out and tryout) was not properly done. This is because the deceased (Roland Kutulam) had his padlock inside his locker as at 15" April 2021 when the locker was forced opened by the investigation team. His isolock should have been on the isolation panel. Ill trained and incompetent contract plant operators were hired from K. KANSCO Company Limited to undertake services on the mine. The crane was inspected and tested on the 8" April 2021 by the maintenance team before commencement of the task and found to be in good condition. The overhead crane operator was not trained and certified. The Safety Department failed to ensure proper documentation and best safety practices on the mine. The accident occurred in the presence of the production superintendent and two supervisors. The process used for dislodging or removing the interlocked boulders from the ROM bin discharge end was wrong. The use of a chain sling and the overhead crane for removal of boulders at this area is only acceptable when the crusher has chocked with boulders. To dislodge interlocked boulders from the ROM bin discharge end, a metal bar is normally used. The metal bars for the removal of the boulders when chocked in the ROM bin were at their disposal but they did not make use of them.vill xix. xx xxi xxili, wiv. xxv, There were traces of yellow paint from the cross beam on the runways at where the cross beam of the crane was positioned. This indicated that there was structural stress between the cross beam and the runways due to overloading of the crane and this pulled the cross beam together with the crane hoist down. There were dents on the upper parts of the discharge point of the ROM bin and the lifting chain sling as well as the throat of the hoist lifting hook. Some of the metal components at the upper part of the discharge end of the ROM bin had broken off with shinny surfaces indicating fresh cuts. There was a deflection (bend) in the cross beam holding the hoist after the beam was removed and positioned outside the accident scene. The evidence at the scene of the accident appeared to suggest that while the workmen were lifting the interlocked boulders the lifting chain got entangled with the upper part of the ROM bin discharge end. Because the bin was heavier than the capacity of the crane, there was a generation of tension between the ROM bin, the lifting chain sling and the crane resulting in the failure of the cross beam of the. hoist. ‘The boulders the workmen claimed to be lifting were not heavy enough and under no circumstance should the weight from these boulders bring a whole cross beam together with the crane down. ‘The production supervisors and the superintendent were present during the time the task was being carried out but they did not ensure that the right procedures were followed. The production supervisors and the superintendent were negligent in the discharge of their duties as the supervision was very poor. Those who were not directly involved in the task found themselves (Isaac Adade and Emanuel Baidoo) among the team. Workmen were not paying attention during the dislodging of the interlocked boulders at the Osborn crusher discharge end because they would have seen that the chain sling had entangled with the upper part of the ROM bin discharge end causing heavy tension between the ROM bin, the chain sling and the overheadwowvi. xxvii xxviii xxix. 200 xii, worl, rx. xxiv, crane. They would have also heard a heavy noise among the steel members. Thus, the crane super structures and the ROM bin. The negligence and incompetence exhibited by the crane operator during lifting operations contributed to the failure of the cross beam of the crane. He overloaded the crane and the support structures. The accident was poorly reported to the Emergency Respond Team (ERT) as the reporter did not indicate the nature of the accident and the number of injured involved. Emergency response and rescue procedures were not properly carried out. Thus, * One ambulance for multiple injured workmen. + People without first aid training were the first to handle the injured. * Aperson with waist injury was asked to sit at the front seat of the ambulance instead of putting him at the recovery position. ‘* The rescue procedures were delayed as the ambulance stopped and picked an injured person who was standing at the roadside even though the ambulance was carrying seriously injured casualty. The ERT breached the emergency response procedures which had been established in the mine. There were inadequate drivers for the ERT. The injured were not accessed on the scene by the ERT before taking them to the. mine hospital. There was no paramedic in the ERT. The three injured persons (Edward Fynn, Robert Quansah and Patrick Obeng Afum) were discharged from the mine hospital on 10! April 2021 Only the staff in the IT Department had access to the IT server. The only camera for the Osborn crusher area where the accident occurred was found not to be working. Meanwhile, all the remaining 35 cameras on site were working,rowvii il. vi vii. vill, xi, xii. xill The last footage recovered from the camera monitoring the Osborn crusher CP01 area was dated 28 August 2020. Neither the staff in the IT Department nor the control room operators were able to detect the malfunctioning of the only camera at the Osborn Crusher CP01 area where the accident occurred. . Recommendations Proper risk assessment should be carried out prior to commencement of every task on the mine. The supervisors and the safety officers should partake in the risk assessment, The risk assessment should be approved by the supervisors before commencement of every task Isolation procedures (lockout, tag out and tryout) should be done before every equipment is worked on. Every team member should endorse on the risk assessment form before commencement of every task. Approved SOPs should be followed when executing every task on the mine. There should be continuous and effective supervision for every task on the mine. Only the workmen who took part in the risk assessment for a particular task can partake in that activity, Workmen should concentrate fully when executing any task on the mine. Only competent and certified equipment operator shall operate a crane and any other machine on the mine. Only trained and certified riggers should be used in lifting operations. There should be effective training for the workmen on the emergency response procedures established on the mine. Qualified emergency response personnel and paramedics should be maintained at the Emergency Response Department. Management should engage adequate and trained drivers for the Emergency Response Department. Every supervisor in operational areas should be provided with two (2) way radio for communicationxiv, xviii xix. xxiii, Management should engage the services of training officers for Engineering and Production Departments. Management should engage the services of competent and certified electricians and mechanics to undertake maintenance works on all lifting equipment and machines on the mine. Qualified and certified supervisors should be engaged in all operations on the mine. The overhead crane should not be used in dislodging interlocked boulders in the ROM bin. The metal bars should be used for the removal of chocked boulders in the ROM bin discharge end. Management should engage qualified and competent workmen to undertake services at the mine. The Safety Department should ensure proper documentation and best safety practices on the mine. The IT Department should have a maintenance schedule for the cameras and other IT facilities on the mine site. Operational Managers should have access to the footages from cameras for the operational areas. The control room operators should have access to full display of the footages from all the cameras on one screen at all time. . Sanctions For exhibiting gross incompetence and negligence during lifting operations resulting in the death of Mr. Roland Kutulam, Mr. Edward Fynn (overhead crane operator) is in breach of Regulations 550, 553 of 2012, L. |. 2182 and shall be relieved of duty from the mine with immediate effect as per Regulation 2 (11) (a) of 2012, L. |. 2482. For exhibiting gross incompetence and negligence, for not ensuring due procedures were followed and for not ensuring good supervision on the mine, resulting in the death of Mr. Roland Kutulam, Mr. Vincent Essuman (Production Supervisor) is in breach of the Regulations 287, 300, 515 (3) (4), 850, 553 of 2012,ii vi vii L. |. 2182 and shall be relieved of duty from the mine with immediate effect as per Regulation 2 (11) (a) of 2012, L. |. 2182. For exhibiting gross incompetence and negligence, for not ensuring due procedures were followed and for not ensuring good supervision on the mine, resulting in the death of Mr. Roland Kutulam, Mr. Godsman Ashemond (Senior Production Supervisor) is in breach of the Regulations 287, 300, 515 (3) (d), 550, 553 of 2012, L. |. 2182 and shall be relieved of duty from the mine with immediate effect as per Regulation 2 (11) (a) of 2012, L. 1. 2182. For exhibiting gross incompetence and negligence, for not ensuring due procedures were followed, for not engaging competent workmen and for not ensuring good supervision on the mine, resulting in the death of Mr. Roland Kutulam, Mr. Francis Alibah (Production Superintendent) is in breach of the Regulations 287, 300, 515 (3) (d), 550, 563 of 2012, L. |. 2182 and shall be relieved of duty from the mine with immediate effect in accordance with Regulation 2 (11) (a) of 2012, L. 1. 2182 For exhibiting gross incompetence and negligence during the removal of interlocked boulders from the Osborn crusher ROM bin, resulting in the death of Mr. Roland Kutulam, Messrs. Robert Quansah and Jonas Boadi (Plant Operators) are in breach of the Regulations 287, 300, 515 (3) (d), 550, 553 of 2012, L. |. 2182 and shall be given a one (1) month suspension from all duties on the mine without pay with immediate effect as per Regulation 2 (11) (a) of 2012, L. 1. 2182. For not ensuring proper documentation and best safety practices on the mine, Messrs. George Bentum and Edem Galley, the Safety Officer and Health & Safety Superintendent respectively, are in breach of the Regulations 42 (c), 287, 300, 515 (3) (@), 550, 553 of 2012, L. |. 2182 and shall be given waming letters in conformance to Regulation 2 (11) (a) of 2012, L. |. 2182 For not ensuring the cameras on mine site are maintained in good working condition and for not been able to produce footages from the only camera at the Osborn crusher area where the accident ocourred:viii. a) Mr. Adu Gyamfi (Acting IT Manager) is in breach of the Regulations 287, 515, 550, 553 of 2012, L. |. 2182 and shall be given a three (3) month suspension from all duties on the mine without pay with immediate effect in conformance to Regulation 2 (11) (a) of 2012, L. 1. 2182. b) Mr. Bernard Kwame Kramo (IT System Administrator) is in breach of the Regulations 287, 515, 550, 553 of 2012, L. |. 2182 and shall be given a three (3) month suspension from all duties on the mine without pay with immediate effect in conformance to Regulation 2 (11) (a) of 2012, L. |. 2182. ©) Mr. Razak Salifu Taylor (IT Technician) is in breach of the Regulations 287, 515, 550, 553 of 2012, L. |. 2182 and shall be given a two (2) month suspension from all duties on the mine without pay with immediate effect in conformance to Regulation 2 (11) (a) of 2012, L. |. 2182. For poor control and management of the cameras on mine site and for not been able to notice that the only camera monitoring the Osborn crusher area was faulty, Messrs. Jonathan K. Mensah and Benjamin Mensah, the Electrical Supervisor and Senior Electrical Supervisor respectively, are in breach of the Regulations 287, 515, 850, 553 of 2012, L. |. 2182 and shall be given a one (1) month suspension from all duties on the mine without pay with immediate effect in conformance to Regulation 2 (11) (a) of 2012, L. 1. 2182 For not ensuring best safety practices on the mine site, Ghana Manganese Company Limited is in breach of the Regulations 35, 55, 550, 553 of 2012, L. |. 2182 and shall pay a fine of cedi equivalent of USD 5,000.00 to Minerals Commission in conformance to Regulation 56 of 2012, L. |. 2182. Yours, KOFI ADJEI (CHIE! FOR: hfully, F INSPECTOR OF MINES) AG. CHIEF EXECUTIVE OFFICER Cc, Head of MinCom — Takoradi Office