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SER Incident 2010 Okke Quarry SKorea
SER Incident 2010 Okke Quarry SKorea
15 am
Contractor – Joongang co.
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Dump truck overturned at Okke plant quarry
Title Descriptions
i) Incident Description
ii) Profile of Victim
iii) Immediate action
iv) RCA
- Team
- Chain of Event
- Sequence of Action
- Relevant Photos
- Root Cause Analysis (RCA)
- Main causes of the Incident
- System and Management Related Causes
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Incident Description
Company :
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Dump truck overturned at Okke plant quarry
Profile of Victim
Victim
Name : ************
Position : Dump Truck Operator
Age : 51 years old
Family Situation : Married and 2 children
Year of Experience at ******* : 10 Years
Driving License Category: 1st grade certificate for heavy truck
Work Location
Quarry 2 Centre
Work Activities
Transporting limestone to stock piles
Type of Injury
The injured worker had crack of 2 ribs after medical check up and
came back to his work now.
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Immediate Actions by Plant Team
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Dump truck overturned at Okke plant quarry
Root Cause Analysis
RCA Team
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Dump truck overturned at Okke plant quarry
Chain of Event (Before the Incident)
Time Activity
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Sequence of Action Before Accident - Sketch
B-0 Working Place
Accident Area
Point 1
Limestone was loaded
Level 1 Point 2
by excavator
Transporting limestone
Point 3
350 m
Dump truck was Overturned Along the Hauling Road B-0 Working place
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Dump truck overturned at Okke plant quarry
Photos
Berming 10M
Safety berm
backward
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Dump truck overturned at Okke plant quarry
Photos
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Dump truck overturned at Okke plant quarry
Photos
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Dump truck overturned at Okke plant quarry
Photos
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Dump truck overturned at Okke plant quarry
Accident Figure at Limestone Stock Yard
Safety Berm
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Dump truck overturned at Okke plant quarry
Root Cause Analysis
• The daily inspection of the dump truck was conducted by operator before
starting the work including breaking system and there was no defects
found.
• The dump truck has safety facilities like rear camera, frontal mirror,
reversing alarm and seat belt.
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Dump truck overturned at Okke plant quarry
Root Cause Analysis
Weak dumping Cause 1, physical condition
Dump truck Material taken at of the stockpile
Crest collapse area and
overturned the toe
unstable slope
Fine material
piled on the
upper slide
Misunderstood of
Direct dumping
dumping method Cause2 Mistranslation
at the crest
in advisory
Lack of risk
awareness about Insufficient
Immoderate
Witness change of Cause3 training of risk
backward
working management
environment
Lack of risk
The weight Insufficient
Observation/ Lack of risk
turned to one Witness Cause4 training of risk
Assessment in assessment skill
side management
real time
Not fully
Dump truck Inadequate
Daily work log Cause5 understanding
failure SOP
of Advisory
<System &
Management <Behavior related cause>
related causes>
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Dump truck overturned at Okke plant quarry
Root Cause Analysis
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Dump truck overturned at Okke plant quarry
Root Cause Analysis
Lack of risk assessment : Risk assessment of dumping work did not make
complex working condition which clearly identifies all potential & practical
risks (for example, multiple visible inspection for stable repose angle from
the pile upside and downside)
Lack of real time inspection system : Real time inspection needs to check
the risks of working condition and unsafe behavior depending on the
working environment and weather condition
Inadequate SOP : SOP of dumping work is in place but there is inaccurate
application for dumping work due to misunderstanding of stock pile
advisory
Insufficient communication : Lack of communication between inspector
and dump truck operators about the risks observed by inspector
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Dump truck overturned at Okke plant quarry
Root Cause Analysis
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Dump truck overturned at Okke plant quarry
Root Cause Analysis
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Dump truck overturned at Okke plant quarry
Other risks in Quarry
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Dump truck overturned at Okke plant quarry
Corrective and Preventive Action
(Immediate)
No Corrective Action By Whom By When Status
1 Stop all stock piling work Plant Mgr. Immediate Done
2 Sharing accident information to all teams and Regional Industrial Immediate Done
H&S director and Relation director. Director
Inspection of stock pile condition (stopped 4 activities on
prohibited stock piling and changed 1 activity from Industrial Dir.
3 secondary methods to preferred stock piling). Plant Mgr. Immediate Done
According to the inspection of all berms for road side, WG Kim
condition was good.
Conference call with regional safety director & relation Immediate
4 director. Technical support was coordinated by ATC geo- Industrial Done
Director
mining manager.
5 Removed unstable steep slope of the accident stock pile. YongIn Woo 13-5-2010 Done
6 Training of the revised Stock Piling method was Contractors 13-5-2010 Done
conducted to all workers in quarry.
Safety inspection of all working areas in quarry and
immediate actions for improvement were taken until May
14th, such as ;
· Installation of buffer zone at Q2T WG Kim
7 14-5-2010 Done
Contractors
· Expanded entrance road at Q2T development area
· Removed floating rocks at Q2C
· Expanded transporting road at Q2C
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Corrective and Preventive Action
(For Improvement)
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Key Lessons Learned
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Dump truck overturned at Okke plant quarry