Fatalities Focus Action

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The tragic death of two maintenance fitters focuses attention on organizational safety; behavioural safety; heavy mobile plant design; the CE mark; the EU Machinery Directive; European and international standards; regulatory activities; as well as the huge consequential losses to an organization. The global ‘Safer by Design’ initiative offers an acclaimed structure to co-ordinate action on many of these fronts

By Martin Isles1, Director, Health & Safety, with MPA, and President of The Institute of Quarrying

On 3 November 2011, the IQ President attended a CoalPro2 meeting at Terex’s factory near Coventry, UK, to discuss the Pennyvenie fatal accident, details of which have only recently entered the public domain following the completion of the Fatal Accident Inquiry and the publication of the Scottish Sheriff’s legal Determination3. Addressed by Andrew Foster, managing director of Scottish Coal and Castlebridge Plant, the meeting was attended by representatives of manufacturers4, users5, standards-makers6 and the UK regulator7.

Double fatality

In 2007, Scottish Coal, part of Scottish Resources Group (SRG), suffered a double fatality at their Pennyvenie Opencast Coal Site at Dalmellington, Ayrshire. As with previous similar incidents, the legal Determination cited a combination of causes involving human error compounded by serious shortfalls in mobile equipment design – the latter highlighting the shortcomings of compliance with CE-mark requirements, and hence the inadequacy of current European and International Standards referenced by the EU Machinery Directive.

The Sheriff’s Determination stated ‘the cause or causes of the accident resulting in the deaths was the absence of an effective system of segregation between large and small vehicles, whereby a Terex TR100 dumptruck turned sharply to the right on moving off from a stationary position and collided with and crushed a Land Rover which was sitting stationary to the front offside of the dumptruck in an area which would have afforded no or limited visibility to the dumptruck driver, killing both of the occupants of the Land Rover’.

Events that led up to the tragedy at Pennyvenie were that several large rigid dumptrucks, including Terex TR100 number 4262, were waiting to be loaded at a face where a Terex O&K RH120E excavator – situated on an elevated rockpile – had encountered operational difficulties. 

Two maintenance fitters entered the operational area in a Land Rover, stopping approximately 7m from the offside front of the dumptruck. The RH120 was signalled to come down off the rockpile. On seeing this, the TR100 driver decided to leave the area but took a short cut by turning immediately on to full lock to his blind side, collided with the Land Rover, backed up a fraction on encountering resistance, then ‘had another go’, this time crushing the Land Rover and killing the two occupants.

Reasonable precautions

The Determination describes ‘reasonable precautions whereby the deaths and the accident resulting in the deaths might have been avoided’, as follows:

1. If the deceased had obtained access to a radio and used it to request the leading driver, the supervisor or the excavator operator to alert others to their entry to the dig area
2. If the driver of Terex TR100 number 4262 had been alerted to the presence of the Land Rover in close proximity by means such as direct communication with TR100 4262 by another operator
3. If the driver of TR100 4262 had paid more attention and in particular had not been reading a newspaper in the cab of his vehicle
4. If the driver of TR100 4262 had reversed or stopped when faced with an obstruction large enough to offer resistance to a 100-tonne truck that had 2m diameter wheels
5. If Scottish Coal had ensured that dumptruck drivers drove forward before turning right wherever possible
6. If Scottish Coal had ensured that dumptruck drivers reversed or stopped when faced with an obstruction large enough to offer resistance
7. If Scottish Coal had ensured that light vehicles did not travel along blind areas on the offside of dumptrucks without advance communication with the dumptruck operator
8. If there had been universal radios on site and there had been clear rules and protocols requiring the use of such radios for communication in relation to the interaction of vehicles
9. If there had been improved conspicuity of light vehicles, in particular by the attachment of ‘buggy-whips’ to all Land Rovers
10. If there had been installation of front offside cameras and monitors on dumptrucks
11. If an effective system for the segregation of large dumptrucks and smaller vehicles, such as Land Rovers, had been implemented and managed.

The Health and Safety Executive (HSE) gave evidence where it was, in effect, conceded that in determining whether or not a particular measure should properly be described as a ‘reasonable precaution’, regard should be had to the industry standard; and there was no industry standard applicable at the time whereby offside cameras and monitors were required to be fitted. Though recognizing that the installation of offside CCTV ‘would be ahead of the industry and standards’, the Sheriff disagreed with the HSE and concluded that the installation of offside CCTV would have been a reasonable precaution.

Learning points

This article highlights the lessons that are still to be learned by most manufacturers and many users. For manufacturers, it illustrates the ‘design vacuum’ that is addressed by the internationally acclaimed ‘Safer by Design’ initiative on: http://www.Safequarry.com. For users, the emphasis is placed on significant organizational and behavioural shortcomings. 

In summary, the Pennyvenie double fatality illustrates factors which include:

1. Site rules need to be realistic, well communicated and strictly enforced.
2. Clear-cut logistical controls are required.
3. Light vehicles need to be segregated from heavy vehicles wherever possible, and fitted with ‘buggy-whips’.
4. Avoidance of in-cab distractions, eg mobile phones, newspapers, iPods etc.
5. Necessity for good communications and clarity of vehicle identification.
6. Necessity for 100% all-round vision, preferably to ground level.
7. Avoidance of driver sensory overload in the provision of aids to all-round vision.
8. If vehicles are of the same/similar colour, apply perimeter (or all-over) markings in a contrasting colour.

‘Safer by Design’ addresses many more issues at: www.safequarry.com/safer_by_design.html

The Sheriff also allotted learning points for the Health and Safety Executive, including:

• That the HSE, in consultation with industry, should consider the introduction of a speedier, more efficient mechanism for disseminating good/best practice.
• That HSE Inspectors should, as a matter of course, make enquiries about radio usage and traffic management as part of their inspections.
• That awareness should be raised more generally as to the availability, benefits and utility of offside front cameras and two-way radios, such as by:
• placing information on the Health and Safety Executive’s website
• raising these matters with working groups concerned with update of the guidance attached to the relevant Approved Code of Practice (L118: ‘Quarries’ ACoP)
• advisory organizations concerned with safety within the industry, such as the Quarries National Joint Advisory Committee (QNJAC) and CoalPro.

• That consideration should be given to updating of the ‘Quarries’ ACoP to make crystal clear the dangers of blind spots in dumptrucks and that segregation is the key to addressing such dangers. The HSE should work with the QNJAC to raise these issues ahead of the proposed update of the ‘Quarries’ AcoP8.

Taking consequential civil liability settlements into account, the financial learning point for Scottish Coal Company was a total penalty well into seven figures, of which the Court fine of £400,000 was the lesser component. 

Lack of all-round visibility highlighted by reconstruction

A reconstruction was carried out by Scottish Coal based on information from a detailed survey carried out shortly after the accident, as well as evidence from eye witnesses. From the TR100 driving position, a small area of the Land Rover roof was just visible. However, both vehicles were white so there was no contrast. The Land Rover did not have a roll-cage, nor was it equipped with a ‘buggy-whip’. The TR100 driver would have had a better chance of seeing the Land Rover arrive had it not been for the obstruction caused by a large battery box with adjacent fire extinguishers, located on the bonnet area to the offside of the driver. Crucially, there was no offside CCTV camera supplied.

Detailed charts were systematically assembled showing the visible and non-visible areas around the TR100. Today, SRG dumptrucks have at least seven mirrors, rear-view CCTV and offside CCTV to complement the driver’s direct vision. Radios are required; as are bumper-height fast-fill refuelling points, plus a machine isolator switch operable from ground level. No mobile phones, iPods, MP3s etc are allowed to be used. The reading of a newspaper in the cab is a disciplinary offence, as is unauthorized entry into an operational area. Soft-skinned vehicles now have physically segregated access routes wherever possible; radios must be operational at all times; and ‘buggy-whips’ are fitted with flags at eye level for visibility to dumptruck drivers.

An interesting new development in all-round vision is being trialled by Terex at an SRG site. It comprises a four-camera system, deployed one at each corner of a large quarry vehicle, the outputs from which are electronically ‘stitched’ to produce a view covering 8m out from the truck, in all directions.

Manufacturers and standards-makers

Of particular note to manufacturers and standards-makers, the Sheriff stated:

• It is incumbent upon manufacturers and users of dumptrucks to regularly monitor and ensure the introduction of suitable and sufficient controls so as to keep up with technology in a manner that maintains or indeed improves safety.
• Consideration should be given to the development of international standards or at least standard industry practice on the use of offside cameras in dumptrucks which will promote the safe use of such cameras to improve visibility for operators.
• Evidence has indicated that effective offside front cameras and radios can be installed at relatively low cost.

Essential health and safety requirements are set out in Annex I of the EU Machinery Directive, as well as Directive 98/37/EC on the approximation of the laws of the Member States relating to machinery. The essential health and safety requirements laid down in the Directive are mandatory. ‘However, taking into account the state of the art, it may not be possible to meet the objectives set by them. In this case, the machinery must as far as possible be designed and constructed with the purpose of approaching those objectives’.

Requirement 3.2.1 of the Machinery Directive deals with driving position and provides:

‘.........Visibility from the driving position must be such that the driver can, in complete safety for himself and the exposed persons, operate the machinery and its tools in their intended conditions of use. Where necessary, appropriate devices must be provided to remedy hazards due to inadequate direct vision’.

Machinery Directive Regulation 12(2) places responsibility on the manufacturer of relevant machinery ‘to carry out the necessary research or tests on components, fittings or the completed machine to determine whether by its design or construction the machine was capable of being erected and put into service safely’.

In the UK, Regulation 28 of the Provision and Use of Work Equipment Regulations 1998 states: ‘Every employer shall ensure that, where self-propelled work equipment may, while in motion, involve risk to the safety of persons....

(e) where the driver’s direct field of vision is inadequate to ensure safety, there are adequate devices for improving his vision so far as is reasonably practicable’.

The installation – as standard – of offside CCTV has now proven to be ‘reasonably practicable’.

Collaboration recommendation focuses attention on ‘Safer by Design’

One of the main determinations from the Fatal Accident Inquiry was that there should be collaboration between operators (users), manufacturers and the HSE to establish common industry standards. CoalPro, one of the founding members of the ‘Safer by Design’ initiative, has established a technical working group for plant specifications. 

Encouragingly, there was agreement on 3 November 2011 that all parties should aim for a minimal number of alternative ‘build cards’ and that this would represent a major step forward. The positive role of ‘Safer by Design’ is thus drawn into sharp focus.

Message from users to manufacturers

In addition to focusing on the human failings, this Fatal Accident Inquiry presented graphic, irrefutable and overwhelming evidence demonstrating beyond reasonable doubt that users/operators need heavy mobile plant that is ‘Safer by Design’ as standard, and not by retro-fit.

Manufacturers: Do not let the Pennyvenie tragedy count for nothing. It is your commercial future – as well as your moral duty – to rise to this challenge, not only for ‘all-round-visibility,’ but the whole range of criteria that comprise the international ‘Safer by Design’ initiative. Review your priorities and bring to the top the real health and safety rights of those that operate, maintain or are affected by your products. Users are increasingly voting with their cheque books by favouring those manufacturers whose products are truly ‘state of the art’ in preference to those that merely claim minimal conformance with a weak and inadequate CE mark.

Fatal accidents involving large and small quarry vehicles are still occurring, as shown by recent incidents in the USA in 2010 and South Africa in 2011 (see images below).

We all have a part to play in supporting the quicker development of improved standards, but we cannot put more lives at risk while awaiting these new standards. Action is needed now!

References

1. Chair, UEPG Health & Safety Committee; Chair, European Commission Sectoral Social Dialogue Committee for the Extractive Industries.
2. Confederation of UK Coal Producers.
3. http://www.scotcourts.gov.uk/opinions/2011FAI32.html
4. Terex; Marubeni-Komatsu/Komatsu; Liebherr; Hitachi; Caterpillar and Finning.
5. Scottish Resources Group (Scottish Coal & Castlebridge Plant); Celtic Energy; UK Coal; Kier; Banks; ATH Resources; Miller Argent; and the Mineral Products Association/Institute of Quarrying.
6. Chairman, ISO/TC127 Safety of Earth-Moving Machines.
7. Health and Safety Executive (HSE).
8. HSE’s mandate does not allow Inspectors to enforce requirements beyond the legal minimum.

Acknowledgement

Thanks are due to Scottish Coal for permission to publish this article.