Investigation into the fatal collision between a
CAT 793 & LV at the Ravensworth Mine on 30th
November 2013
Brief summary of the investigation report 31st March 2015
Incident overview
At 11.50 pm on Saturday, 30 November 2013, 38-year-old
Ingrid Forshaw, a trainee plant operator employed by TESA
Mining (NSW) Pty Ltd, was fatally injured while working at the
Ravensworth open cut mine, near Singleton NSW.
Ms Forshaw suffered fatal injuries when the Toyota
Landcruiser she was driving collided with and was run over
by the front right-hand side wheel of a haul dump truck
(Caterpillar 793D), weighing approximately 351 tonnes
(including 186 tonnes of coal).
Ms Forshaw had earlier parked the haul truck she was
operating at the ULM stockpile and collected a Landcruiser
that was parked at the stockpile by another operator at the
start of the shift. Ms Forshaw was driving to collect other
workers and go to a crib break.
The truck operator was hauling coal along the 9th haul road
(a main haul road in the Narama area). As he approached
the T-intersection with the stockpile ramp (8th ramp) he saw
the Landcruiser travelling down the 8th ramp. As the truck
operator approached the T-intersection he saw the
Landcruiser enter the 9th haul road to his right and then he
lost sight of it.
At the time, vehicles approaching the T-intersection on the
8th ramp were required to give way to vehicles on the 9th
haul road.
The Landcruiser driver turned right onto the 9th haul road into
the path of the truck. The truck and Landcruiser collided and
Ms Forshaw was crushed inside the Landcruiser and died
immediately from multiple injuries.
Pictures of the 8th ramp & intersection
View looking down the 8th ramp towards the
intersection with the 9th haul road
View looking across the 9th haul road at
the intersection & up the 8th ramp
Picture from truck operators perspective
View up the
8th ramp
Truck left hand drive.
Blind spot to right
Position of LV within right hand blind
spot & path of LV denoted by red arrow
Visibility of the truck
The truck operator had on bumper lights
& low beam
The bumper lights were heavily obscured
by mud at the time of the incident
The right hand low beam light was
recessed and difficult to see from the side
What did the LV operator see
•
No direct artificial lighting at intersection
•
The left hand windrow of the 8th ramp was
2m high (vs design of 1m) & only the top half
of the truck was visible approaching the
intersection. This part of the truck had no
lights & minimal reflective tape
•
In the background of the intersection were
spot lights as well as light reflecting off water
ponded at the intersection that may have
obscured visibility of the truck
Mine site experience
•
Drivers experience:
•
Whilst the haul truck operator had
nine+ months experience in CAT 789s
this was his first shift operating a CAT
793 on his own.
•
The LV operator had 9 months
experience at the time of the accident
•
WA fatality statistics from 52 fatalities
that occurred between 2000- 2012:
•
48% of fatalities occurred within the
first 24 months of the job or role;
•
49% of fatalities occurred within the
first year at the mine;
•
44% of fatalities occurred under
supervisors who were within their first
year of supervision.
Human factors
•
The truck operator observed the LV entering the intersection but assumed that the vehicle
was pulling out to slip in behind the truck as it went by
•
This suggests that there was complacency in maintaining correct separation distance at
the mine site
•
This assumption by the truck operator cost Ms Forshaw her life
•
All the critical controls identified were administrative controls (procedures) which in term
place a high reliance on human factors
Causal factors were in the safety statistics
From 289 hazards / improvements raised up to November 2013:
• Road related hazards were the top hazard (12% or 35 reports); and
• Windrows were equal second top hazard (8% or 23 reports).
Presentations on LV & HME interactions were given in November 2013 at
safety talks due to these statistics:
• Ms Forshaw had attended one of these safety talks 3 days prior to the
incident but the truck operator had not yet attended a session.
Contributing factors from the investigation
Key observations
• No distinction was drawn in risk assessments & controls measures
concerning interaction of HME & LVs between night & day time operation
• There was no recent risk assessment on the suitability of reflective devices
on HME & LVs
• There was no formal analysis conducted to determine the need to separate
light & heavy vehicles on mine haul roads & access roads
Recommendations from the investigation