12th May 2010, 10.

15 am
Contractor – Joongang co.

DUMP TRUCK(35TON) OVERTURNED

AT OKKE PLANT QUARRY

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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

v) Corrective and Preventive Action

vi) Key Learning Lesson

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 Incident Description

 Date and Time of Incident : 12th May 2010, 10:15 a.m.

 Person involved : (51 years)

for the past 10 years as a dump truck operator

 Company :

 Type of injury sustained : Crack of two ribs (Injured worker is stable as

reported after medical check at Gangneung Asan Hospital)

 Incident Description : At 10:15 am, Dump truck(No.1222) was overturned

at the limestone stock pile because the crest of stock pile was collapsed.
Based on the interview, dump truck reached crest of stock pile to dump the
limestone as backward.
The dump truck was slid and overturned when the operator was about to
dump limestone at the crest of stock pile.

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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

No. Corrective Actions Action Party Time

line
1 - Stop all stock pile work

2 - Sharing accident information to all teams

- Inspection of the condition of 9 stock piles located
in quarry site and improved stockpiling method
: “Preferred” Stockpiling : 2 → 7
Industrial
“Secondary” Stockpiling : 3 → 2 Director
3 (Discussed with ATC : we have determined what &
Plant 12thMay
is the status and possible action for the
remaining 2 stockpiles where "secondary Management
Team
dumping method" is applied)
“Prohibited” Stockpiling : 4 → 0
- Conference call with regional safety coordinator
and ATC
4 : Further investigation by technical point of view,
develop communication material for the other BU
to avoid any recurrence

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Dump truck overturned at Okke plant quarry
 Root Cause Analysis

RCA Team

No. Name Designation

1 JongGoo Moon Industrial Director
2 SungRae Chung Plant Operations Manager
3 SeYong Lee Production Manager
4 WeonGyoo Kim Mining Team Leader
5 KwanKyo Chung Mining Team Engineer
6 JunYong Pyun Mining Team Engineer
7 YongIn Woo Contractor - Joongang Co.
8 DongGun Park Contractor (foreman) - Joongang Co.
9 WonWai Kim Contractor - YeGun Co.

10 SangWoong Lee Contractor - DaeLim Co

11 TaeHun Kim Contractor - SooKwang Co.

12 SooChang Kim Plant Health & Safety Coordinator

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Dump truck overturned at Okke plant quarry
 Chain of Event (Before the Incident)

Time Activity

The injured worker conducted visual inspection of dump truck before

08:10 am
operating
The injured worker drove first load to the stock pile from bench(B-0) at
08:30 am
quarry 2 central
10:14 am Dump truck reached the stock pile to dump 8th limestone transporting
Dump truck reached the crest of stock pile as backward and was about
10:15 am
to dump
Dump truck was slid and overturned at the crest of stock pile when the
10:15 am operator was about to dump limestone due to collapse of the crest
(Stockpile height : 10m)
The accident was witnessed by inspector (Mining manager) and the
driver rescued by contractor’s foreman (DongGeun Park). Then
transferred to the hospital by 119 (Emergency Ambulance) at 10:40 a.m.
10:15-
The truck driver arrived at the hospital at 11:20 a.m.
11:20 am
- Mining manager and Foreman : First Aid trained
- 119 : Korean rescue staffs by government (Branch office is located in
Okke)

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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

The operator reached the

crest of stock pile as
backward and was about to
begin to dump limestone
Level 2

350 m

Dump truck was Overturned Along the Hauling Road B-0 Working place

The material The operator reached

has been the crest of stock pile as
backward and was Transporting Limestone loading
taken at the limestone by excavator
bottom on about to dump
May 11th . limestone but the crest
of stock pile was
collapsed and dump
tuck was overturned.

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Dump truck overturned at Okke plant quarry
 Photos

Sliding and overturned

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

Safety Berm gave away

truck moving backward

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Dump truck overturned at Okke plant quarry
 Accident Figure at Limestone Stock Yard

Sliding and overturned

Safety Berm

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Dump truck overturned at Okke plant quarry
 Root Cause Analysis

< Vehicle Inspection and operator’s condition >

• 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 regular preventive and specific inspection was conducted by

maintenance workshop in quarry.

• The dump truck has safety facilities like rear camera, frontal mirror,
reversing alarm and seat belt.

• The condition of operator was in normal.

• The operator was fasten seat belt.

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Dump truck overturned at Okke plant quarry
 Root Cause Analysis
W eak d um p ing C ause 1, p hysical co nd itio n
D um p truck M aterial taken at o f the sto ckp ile
C rest co llap se area and
o verturned the to e
unstab le slo p e

F ine m aterial
p iled o n the
up p er slid e

W et and untig ht
slo p e d ue to
p revio us rain

W eig ht o f d um p ap p ro x.
truck 52t

M isund ersto o d o f
D irect d um p ing
d um p ing m etho d C ause2 M istranslatio n
at the crest
in ad viso ry

Lack o f risk
aw areness ab o ut Insufficient
Im m o d erate
W itness chang e o f C ause3 training o f risk
b ackw ard
w o rking m anag em ent
enviro nm ent

Lack o f risk
The w eig ht Insufficient
O b servatio n/ Lack o f risk
turned to o ne W itness C ause4 training o f risk
A ssessm ent in assessm ent skill
sid e m anag em ent
real tim e

N o t fully
D um p truck Inad eq uate
D aily w o rk lo g C ause5 und erstand ing
failure SO P
o f A d viso ry
< S ystem &
M anag em ent < B ehavio r related cause>
related causes>

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Dump truck overturned at Okke plant quarry
 Root Cause Analysis

Main cause of the Incident (Based on the RCA)

 Misunderstanding of working method : Main cause of the incident is

misunderstanding of "where " with "when"

According to stock pile advisory,

“Secondary” Method of Stockpiling involves dumping a load directly over the
crest of the pile. For this method to be performed safely, adequate berms must
be maintained ~ ….
It is critical to ensure that material is not removed from the toe of the pile when
dumping is taking place at the top of the pile. → Applied

“Prohibited” Method of Stockpiling involves ~ …. ~

where material has been removed from the toe is prohibited. → Not applied

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Dump truck overturned at Okke plant quarry
 Root Cause Analysis

System and Management Related Causes

 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

Behavior related causes

 Mistranslation of the Advisory : Stock piling methods are not correctly

translated to cause incorrect application of stock piling method.

 Insufficient training of risk management : Workers are not skillful of risk

recognition and assessment because of insufficient training of risk
management including refresher training.

 Not fully understanding of the Advisory : Especially stock piling method is

not fully understood by workers even though repetitive training due to the
mistranslation.

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Dump truck overturned at Okke plant quarry
 Root Cause Analysis
Good/ Positive
• Experienced 10 years
• Safety training – MEA, Stock & Surge
pile, Standard & Advisory, etc.
• Emergency Evacuation : quick
• Protection canopy of the truck
• Seat belt
• Camera installed in the rear
• Vehicle – good condition
• Inspection, shift check
• No alcohol, Day worker, Looked okay
• No overloading (35 ton)
Dump truck overturned at Okke plant quarry
Risks / Issues
• Reconsider the remaining 2 stock piles
method – under review
• Need front-end loaders – if we want
preferred stock piles method
• Location of truck at crest & toe (2m –
10m)
• Flexible movement of the dump point &
Stock pile & crest (3 or 4 times within 6
months/ 2-3-5-8m)
• Rain-wet material impacted compact
• Incorrect method used prohibited –
understanding (how come for years
happening?)
• Risk assessment – awareness on
changing environment & situation /
supervision & real time
• communication – joint assessment of
risk
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 Other risks in Quarry

Risks Safety Measures

Fog/Snow/Rain _ Frequent monitoring by supervisor in real time and

situation change sharing information of working condition
Managers conduct specific inspection of bench face
Floating rocks considering climate change more frequently while raining
or snowing (install buffer zone or isolate the risky area)
Changing current blasting direction to safety area where
Flying rocks
no risk zone from blasting when drilling work
Establish robust communication system to share all risk
Communication process
situation in real time using radio.
Road condition
Gradually improve the gradient and width of the roads
(Gradient/Width)
Falling risk of equipment
Install strong side berm
_ side berm

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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 Industrial Done
director. Technical support was coordinated by ATC geo- 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)

No Corrective Action By Whom By When Status

Develop risk assessment of dumping work which
Contractors On-
1 clearly identifies all potential & practical risks under JY Pyun 20-5-2010
going
support of ATC geo-mining manager.
Effective inspection system should be established with
a series of visits at suitably frequent intervals to ensure Contractors
2 JY Pyun Done Done
that work activities are monitored and that any unsafe
acts and conditions are observed and corrected
Improve communication between inspector and dump Contractors
3 KK Chung 25-5-2010 Done
truck operator about risks observed in real time
Revise standard & FHRA of dumping work and training
(revision of SOP)
- Material should be pushed by loader or dozer to the
crest of stock pile where material is removed from the Contractors
4 WG Kim 24-5-2010 Done
toe.
- If dozer or loader can’t operate, prohibit the dumping
directly. Otherwise dumping work should be done at
the toe of stock pile
Training of risk management skills and stock pile
Contractors
5 advisory in detail to make sure all contractors fully JY Pyun 31-5-2010 Done
understanding

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 Key Lessons Learned

 Workers should clearly understand Standard and Advisory (e.g.If

you take materials at the toe of the pile direct dumping is strictly
prohibited)

 In order to set up a SOP, it should be based on the Group Safety

Standard & Advisory fully understood by workers.

 The risk management system including inspection, risk

assessment and communication system should be working
effectively on-site to control not only formal & visible risk but all
potential & practical risks in real time and regular monitoring
should be followed to make sure the system is working

 All employees and non-employees that operate or ride in any

mobile equipment or vehicle shall fasten seat belts at all times.

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Dump truck overturned at Okke plant quarry