This is NOT an investigation report. It is a WARNING of a significant incident.
The information below is a preliminary assessment and not a formal investigation.
Incident Injury Property Process
DATE: February 16, 2008
TIME: 4:25 pm
LOCATION/DEPARTMENT: Mine Shaft Rehab
INCIDENT DESCRIPTION: A two man team working from the cage work deck platform in the
Shaft having just completed their immediate tasks was preparing
to join the other two members of their crew in order to finish the
shift end procedures. The employee acting as Cager asked his
partner if he was all clear and secured in order to move the
conveyance, but neglected to check the second leg of his lanyard
which was still secured to a steel member in the shaft. After
notifying the Hoistman to move the conveyance up to the Next
Station, he was jerked over the top rail when his lanyard came
taut landing on the #1 & #5 dividers where he clung to the steel.
His partner immediately radioed the Hoistman to stop. Both 6’
lanyards were extended to the full extent, the beam strap had 4’ of
play, and the top rail of the work deck was deformed
approximately 1’, so the total length was close to 24’ with the
employee in the middle. His partner initiated emergency
procedures and after evaluating him for injuries transported him
to the collar where an ambulance was waiting.
DETAILS OF INJURY TYPE: Damaged right knee and bruises to the middle of back and chest
where harness was attached.
Fatality Lost-Time Permanent Other Potential
POTENTIAL FOR INJURY: Disability
Potential High Potential for Fatality
PROBABLE IMMEDIATE Failure to use Personal Protective Equipment Properly
PROBABLE BASIC Mental Capability. Shift change was approaching at 5 pm and
CAUSES: employee was looking ahead to next task.
IMMEDIATE CORRECTIVE Procedure reviewed and upgraded with all crews to reflect partner
ACTION TAKEN: checking cager. Investigation was initiated by Company.
REQUIRED ACTIONS Review incident with all employees. Discussions are to take place
FROM OTHER SITES: on all tasks involving 100% Tie-Off requirements.