MECHANIC RUN OVER BY
HEAVY HAUL TRUCK
Type of Incident: Fatality
Date of Incident: July 8, 2008
File:F-671981
TABLE OF CONTENTS
SECTION
TITLE
PAGE NUMBER
1.0
DATE AND TIME OF INCIDENT
3
2.0
NAME & ADDRESS OF PRINCIPAL PARTIES
3
2.1
Owners
3
2.2
Prime Contractor
3
2.3
Employer of Injured Worker
3
2.4
Employer of Other Workers
3
2.5
Worker
3
3.0
DESCRIPTION OF PRINCIPAL PARTIES
4
3.1
Owner of the Heavy Haul Truck
4
3.2
Owner of the Site
4
3.3
Prime Contractor
4
3.4
Employer
4
4.0
LOCATION OF INCIDENT
4
5.0
EQUIPMENT, MATERIAL AND OBSERVATIONS
5
5.1
Equipment and Material
5
5.2
Observations
6
6.0
NARRATIVE DESCRIPTION OF INCIDENT
7
7.0
ANALYSIS
11
7.1
Direct Cause
11
7.2
Contributing Factors
11
8.0
FOLLOW-UP/ ACTION TAKEN
16
8.1
Occupational Health and Safety
16
8.2
Industry
17
8.3
Additional Measures
17
9.0
SIGNATURES
17
10.0
ATTACHMENTS
17
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Alberta Employment and Immigration, Occupational Health and Safety
July 9, 2009
File:F-671981
SECTION 1.0
1.1
DATE AND TIME OF INCIDENT
The incident occurred on July 8, 2008 at approximately 11:30 a.m.
SECTION 2.0
NAME AND ADDRESS OF PRINCIPAL PARTIES
2.1
Owner(s)
2.1.1
Site owner
Suncor Energy Inc.
P.O. Box 4001
Fort McMurray, Alberta
T9H 3E3
2.1.2
Owner of the 797F heavy haul truck
Caterpillar Canada Corporation
10243-178 Street
Edmonton, Alberta
T5S 1M3
2.2
Prime Contractor
2.2.1
Suncor Energy Inc.
P.O. Box 4001
Fort McMurray, Alberta
T9H 3E3
2.3
Employer of Injured Worker
2.3.1
Finning (Canada)
118 MacDonald Crescent
Fort McMurray, Alberta
T9H 4B2
2.4
Employer of Other Workers Present
2.4.1
Suncor Energy Inc.
P.O. Box 4001
Fort McMurray, Alberta
T9H 3E3
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Alberta Employment and Immigration, Occupational Health and Safety
July 9, 2009
File:F-671981
SECTION 5.0
EQUIPMENT, MATERIAL AND OBSERVATIONS
5.1
Equipment and Material
5.1.1
Caterpillar 797F Heavy Hauler Truck
5.1.1.1 The Caterpillar 797F truck was a 400 ton capacity heavy haul truck. The Caterpillar
797F truck was an experimental model developed by Caterpillar. It was being tested
by Caterpillar for reliability and performance under field conditions at the Suncor
Energy Inc. mine site. The 797F heavy haul truck was leased to Suncor Energy Inc.
by Caterpillar Canada Inc. and given the designation Unit 190. Suncor Energy Inc.
operated the 797F heavy haul truck while Finning (Canada) monitored and serviced
the truck. (Attachment A – Photographs #1, #2, #3, #12).
5.1.2
Auxiliary Power Unit
5.1.2.1 The Auxiliary Power Unit (referred to as the tow module) was manufactured by
Norcan Fluid Power Ltd. and was owned and serviced by Suncor Energy Inc. The tow
module consisted of a diesel engine, hydraulic pump and air compressor. The
primary use of the tow module was to provide hydraulic pumping and pressure to the
steering and braking functions of equipment while being towed. The tow module was
attached to the back of the 797F heavy haul truck to provide hydraulic pumping and
pressure to the steering and braking functions. (Attachment A – Photographs #11,
#12).
5.1.3
Front End Loader
5.1.3.1 The Komatsu WA 800, unit #6601, front end loader was owned and operated by
Suncor Energy Inc. The front end loader was used in the mine to primarily load
material into smaller heavy haul trucks. The front end loader was also utilized to tow
heavy haul trucks. (Attachment A – Photographs #1, #2, #3).
5.1.4
Tow Cable
5.1.4.1 The tow cable consisted of two 6.5 m long by 3.8 mm diameter wire cable slings
connected by a 35T Crosby shackle. One end of the tow cable was attached to the
heavy hauler truck tie-down eye with a 35T Crosby shackle and the other end of the
cable sling was attached to the Komatsu tow pin system. (Attachment A –
Photographs #4, #5, #6).
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Alberta Employment and Immigration, Occupational Health and Safety
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5.1.5
Portable Two-Way Radios
5.1.6.1 The portable two-way radios used by the Finning (Canada) mechanics and the Suncor
Energy Inc. operators were Motorola model HT1000, Handie-Talkie Fm Radio model
#H01KDC9AA3DN. The portable two-way radios were owned and serviced by
Suncor Energy Inc.
5.2
Observations
When the Workplace Health and Safety Compliance investigators arrived at the
incident site, the following observations were made:
5.2.1
The 797F Unit #190 heavy haul truck was lodged into the berm of the centre ramp
with wheel chocks on both the left front and left rear wheels. (Attachment A –
Photographs #1, #2, #12).
5.2.2
The Norcan Fluid Power Ltd. auxiliary power unit was hitched onto the back of the
797F heavy haul truck with the hydraulic lines attached to the service brake, steering
and emergency brake tanks on the truck. The auxiliary power unit was towed behind
the heavy haul truck. The auxiliary power unit was shut down. (Attachment APhotographs # 11, #12).
5.2.3
The Komatsu WA 800, unit #6601, front end loader was parked on the centre ramp
roadway with the tow cables attached to the tow pin assembly at the back of the
loader. (Attachment A-Photographs #1, #2, #3, #4).
5.2.4
The tie-down eye that had broken away from the 797F heavy haul truck was on the
floor inside the cab of the Komatsu WA 800. The Equipment operator
had recovered the broken tie down eye from the centre ramp roadway and
placed it inside the cab of the Komatsu. (Attachment A-Photographs #8, #9).
5.2.5
The centre ramp had a large puddle of hydraulic fluid where the 797F heavy haul
truck had stopped when the tow cable broke away. (Attachment A-Photograph #2).
5.2.6
There were two Finning (Canada) field mechanic trucks parked at the top of the
centre ramp. The trucks’ cabs were both locked. One of the mechanic trucks was
assigned to the Finning (Canada) Journeyman Heavy Duty Mechanic
and the other truck was assigned to the Finning (Canada) 3 year
Apprentice Heavy Duty Mechanic
. (Attachment A-Photograph #7).
5.2.7
The incident site on the centre ramp was covered with tarpaulins. (Attachment APhotographs #1, #2).
5.2.8
June 25, 2008 was a clear, sunny day. The ambient temperature was 13 C and the
centre ramp roadway was dry.
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July 9, 2009
Alberta Employment and Immigration, Occupational Health and Safety
File:F-671981
SECTION 6.0
NARRATIVE DESCRIPTION OF THE INCIDENT
6.1
On June 25, 2008 the 797F Caterpillar heavy haul truck was hauling material to the
mud dump at the end of the MD8 haul road when the motor became disabled. The oil
filter housing assembly broke off from the truck resulting in the loss of engine oil and
seizing up of the heavy haul truck’s motor.
6.2
The loaded 797F heavy haul truck was left disabled on the side of the MD8 haul road
while a new motor was ordered and a service bay became available at the Suncor
Energy Inc. Steepbank truck shop. Suncor Energy Inc. built a berm around the 797F
heavy haul truck to protect it from other heavy haul truck traffic.
6.3
On July 7, 2008 Suncor Energy Inc. started to tow the 797F heavy haul truck from the
MD8 haul road to the Suncor Energy Inc. Steepbank truck shop. Suncor Energy Inc.
heavy duty mechanics towed the Norcan Fluid Power Ltd. auxiliary power unit to the
797F heavy haul truck and positioned it along side the berm near the back of the 797F
heavy haul truck. The Suncor Energy Inc. heavy duty mechanics did not hook up the
hydraulic lines of the Norcan auxiliary power unit to the 797F heavy haul truck
because they were advised the field follow contract stated only Finning (Canada)
mechanics could work on the 797F heavy haul truck. The Suncor Energy Inc. heavy
duty mechanics transported two 6.2 m long by 3.8 mm diameter wire cable tow slings
with two 35T shackles to the 797F heavy haul truck.
6.4
On July 7, 2008 two Finning (Canada) journeyman heavy duty field mechanics,
Mechanic #1
and Mechanic #2
were dispatched by
Suncor Energy Inc. to hook up the Norcan auxiliary power unit hydraulic lines to the
797F heavy haul truck to allow Suncor Energy inc. to tow the 797F heavy haul truck
to the Suncor Energy Inc. Steepbank truck shop.
6.5
The two Finning (Canada) journeyman heavy duty field mechanics, Mechanic #1
and Mechanic #2
attached the hydraulic lines from
the Norcan auxiliary power unit to the 797F heavy haul truck and manually dumped
the 797F load onto the side of the MD8 haul road. They arranged for a Suncor
Energy Inc. dozer to remove the birm from around the front of the heavy haul truck
so it could be towed ahead to hitch the Norcan auxiliary power unit onto the back of
the 797F heavy haul truck. Mechanic #1
attached the tow cable shackle
onto the tie-down eye located under the right side of the front bumper of the 797F
heavy haul truck. However, they were unable to arrange to have the 797F heavy haul
truck towed forward to hook up the Norcan auxiliary power unit and Suncor Energy
Inc. decided to tow the 797F heavy haul truck the next day.
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Alberta Employment and Immigration, Occupational Health and Safety
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7.2.2
The Finning (Canada) journeyman heavy duty field Mechanic #1
was
not trained in the front bumper tow pin configuration of the 797F Caterpillar heavy
haul truck and attached the tow cable shackle to the right front bumper tie-down eye.
The tie-down eye was engineered for holding truck parts in transportation to prevent
damage and for use in the assembly of the truck. The 797F truck tie-down eyes were
not engineered by Caterpillar as tow pins. (Attachment A-Photographs #8, #9, #10,
#15, #17).
7.2.3
The two Finning (Canada) field mechanics
were not trained in the operation of the Norcan auxiliary power unit and did not
realize that there would be a resulting loss of hydraulic pressure in the 797F truck
steering and service brake accumulators within a few minutes of shutting off the
Norcan auxiliary power unit.
7.2.4
The Finning (Canada) field mechanics
were
not trained in the front bumper tow pin configuration of the 797F and were attempting
to attach the tow cable shackle to the left front bumper tie down eye. The tie down
eye was not engineered for towing the 797F truck. (Attachment A-Photographs #15,
#17).
7.2.5
The Finning (Canada) field mechanics
were
not trained in the Suncor Energy Inc. heavy hauler truck towing procedures. This was
the first heavy haul truck towing job for the two Finning (Canada) field mechanics
.
7.2.6
The 797B heavy haul Truck Operator
operation of the 797F heavy haul truck.
7.2.7
This was the first time the 797B heavy haul Truck Operator
the 797F heavy haul truck.
7.2.8
The 797B heavy haul Truck Operator
Energy Inc. heavy haul truck towing procedure.
7.2.9
The 797B heavy haul Truck Operator
heavy haul truck that was being towed.
was not trained in the
operated
was not trained in the Suncor
was not trained to operate a
7.2.10 This was the first time for the 797B heavy haul Truck Operator
to
operate a heavy haul truck that was being towed with the Norcan Auxiliary power
unit. (Attachment A-Photograph #11).
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Alberta Employment and Immigration, Occupational Health and Safety
July 9, 2009
File:F-671981
7.2.16 As the 797F was towed around the right hand turn of the centre ramp and began to go
down the access ramp hill, the tow cable became slack. The 797F heavy haul Truck
Operator
applied the service brake to avoid running over the tow
cable and take up the cable slack. There was no radio communication between the
797F Truck Operator
and the Equipment Operator
to
coordinate the activity. The Equipment Operator
was pulling on the
tow cable with the front end loader to take up the slack when the tow cable broke free
of the 797F heavy haul truck and snapped back striking the back railing of the
Komatsu front end loader. The 797F truck stopped on the downhill grade of the
centre ramp.
7.2.17 Although the Equipment Operator
radioed that the tow cable had
broken away from the 797F truck, the Suncor Energy Inc. Mine Operation Supervisor
did not direct the tow crew to follow Suncor Energy Inc. mine policy
to secure the 797F truck from movement by setting the park brake, the Truck
Operator to exit the haul truck and chocking the heavy haul truck wheels before
approaching the 797F heavy haul truck.
7.2.18 The Suncor Energy Inc. Mine Operations Supervisor
did not direct
the tow crew to conduct a new hazard assessment of the tow procedure when the
conditions had changed due to the tow cable breaking away from the 797F heavy haul
truck.
7.2.19 As the 797F heavy haul truck braked on the ramp hill with the Norcan auxiliary
power unit shut off and no longer providing hydraulic pressure to the 797F truck, the
hydraulic pressure drained from both the steering and service brake accumulators and
dropped below the minimum 900 psi operating pressure. The 797F truck service
brakes and steering suddenly failed, without warning, due to a loss of hydraulic
pressure after approximately 4 minutes and 20 seconds. The 797F heavy haul truck
began to move forward and accelerate down the hill towards the two Finning
(Canada) mechanics.
7.2.20 The heavy haul Truck Operator
attempted to alert the two Finning
(Canada) mechanics on the roadway in front of the 797F truck by sounding the horn
using the left foot floor horn button that he was familiar with using; however, while a
floor horn bracket was installed in the 797F heavy haul truck, the floor horn itself had
not been installed. The horn did not work to alert the mechanics. (Attachment APhotograph #13).
7.2.21 The 797F Truck Operator
applied the retarder brake and the service
brake; however, the 797F truck had lost hydraulic pressure in the service braking
system and the truck continued to roll downhill towards the two Finning (Canada)
mechanics. (Refer to Attachment A-Photographs #13, #14).
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Alberta Employment and Immigration, Occupational Health and Safety
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7.2.29 The Caterpillar 797F draft operator manual did not identify the tie-down eyes on the
front bumper of the 797F truck as tie-down eyes and not to be used for towing the
heavy haul truck. (Attachment A-Photographs #8, #14).
7.2.30 Caterpillar Canada Inc. did not train the Finning (Canada) field follow mechanics on
the towing procedures to be used for towing the 797F heavy haul truck. Caterpillar
Canada Inc. did not advise the Finning (Canada) field follow mechanics that the two
pins under the front bumper of the 797F truck were the engineered tow pins to be
used to tow the 797F truck forward. Caterpillar Canada Inc. did not advise the
Finning (Canada) field follow mechanics that the tie-down eyes located underneath
the 797F truck front bumper was not to be used for towing. (Attachment APhotographs #8, #9, #15, #17).
SECTION 8.0
FOLLOW-UP/ ACTION TAKEN
8.1
Employment and Immigration; Occupational Health and Safety
8.1.2
Occupational Health and Safety issued Stop Work Orders to Suncor Energy Inc. for
the 797F heavy haul truck, the Komatsu WA 800 front end loader and the Norcan
auxiliary power unit for mechanical inspections.
8.1.3
Occupational Health and Safety issued a Stop Work Order to Suncor Energy Inc. on
towing heavy haul trucks in the Suncor Energy Inc. mine and to develop an
engineered heavy haul truck towing procedure and training of the Suncor Energy Inc.
mine operations towing crew on the procedure.
8.1.4
Occupational Health and Safety issued orders to Suncor Energy Inc. for training
records, equipment maintenance records, towing procedures, radio dispatch records,
survey maps and readings, manufacturers and operators manuals for the Norcan
auxiliary power unit and 797F truck, mine health and safety policy and procedures
and for an investigation report.
8.1.5
Occupational Health and Safety issued orders to Finning (Canada) for training
records, 797F truck maintenance records as well as the 797F truck and 797B truck
manufacturer’s and operator’s manuals.
8.1.6
Occupational Health and Safety issued orders to Caterpillar Canada Inc. for the 797F
truck front bumper tie-down eyes and tow pins specifications.
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Alberta Employment and Immigration, Occupational Health and Safety
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8.2
Industry
8.2.1
Suncor Energy Inc. completed the mechanical inspections on the 797F truck, the
Komatsu WA 800 front end loader and the Norcan auxiliary power unit. They
developed an engineered heavy haul truck towing procedure. They provided the
training records, maintenance records, dispatch records, weather reports, health and
safety manual and an incident investigation report.
8.2.2
Finning (Canada) provided the requested training records, 797B truck and 797F truck
operators manual and assisted in testing the 797F truck hydraulic system.
8.2.3
Caterpillar Canada Inc. provided the specifications for the 797F truck front bumper
tie-down eyes and tow pins specifications.
8.2.4
An industry alert on towing heavy haul trucks was released by Suncor Energy Inc.
8.3
Additional Measures
8.3.1
No additional measures are required.
SECTION 9.0
SIGNATURES
ORIGINAL
REPORT SIGNED
____________________________
Lead Investigator
_____________________
Date
ORIGINAL
REPORT SIGNED
____________________________
Investigator
_____________________
Date
ORIGINAL
REPORT SIGNED
____________________________
Compliance Manager
_____________________
Date
ORIGINAL
REPORT SIGNED
____________________________
Regional Senior Manager, North
_____________________
Date
SECTION 10.0
ATTACHMENTS:
Attachment A
Attachment B
Photographs
Map
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Alberta Employment and Immigration, Occupational Health and Safety
July 9, 2009
File:F-671981
Attachment “A”
Page 5 of 17
Photograph #5
Shows a close-up photo of the tow cable attached to the
Komatsu tow pin at the back of the Komatsu WA 800
front end loader. The tow cable was used to tow the
797F heavy haul truck. Photo taken by Lead
Investigator,
July 9, 2008
Alberta Employment and Immigration, Occupational Health and Safety