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Level 1 Investigation Report - MHI - Djoma Truck DRT#2 Tyres Came Off at ROM3
Level 1 Investigation Report - MHI - Djoma Truck DRT#2 Tyres Came Off at ROM3
Level 1 Investigation Report - MHI - Djoma Truck DRT#2 Tyres Came Off at ROM3
Investigation Report
Level 1
(Incident Cause Analysis)
INCIDENT NUMBER
BAM122
Page 1 of 9
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When downloaded from the BAM database, this document is uncontrolled and the responsibility rests with the user to ensure it is in line
with the authorized version on the database
Document Number
BEL AIR MINING S.A.S BAM-IMP-TM-001
Revision Number
FORM
03
Revision Date
INVESTIGATION TEMPLATE LEVEL 1
12 November 2020
1. Incident Details
At 21hrs 46, when the operator of the DRT truck was getting ready for loading at
Rompad 3, suddenly a noise came from the right side, he went down to see and he
Incident Description
noticed that the two (2) rear left tires had detached from the truck.
Wheel studs and hub were damaged. No injuries were recorded.
Incident Classification Major Hazard Incident (MHI) Repeat Incident no
Incident Date 14 November 2020 Incident Time 21h 46
Incident area Rompad 3 Incident number BAM 122
Person involved name Abdoulaye Bah Badge number DJ0026
Shift roster (Day/Night) Night Days into shift 4
Statements completed Yes Date of Statement 14 November 2020
Supervisor name Kaba Bangaly Supervisor contact number 628305545
Check Risk level Requirement Investigation level and Investigation Team minimum requirements
Box:
Mini Investigation If NO potential Harm is identified to People, Equipment, Material and
Low
optional Environment no investigation is required
Level 1 Investigation Investigation Trained Supervisor/Safety responsible leads investigation team:
to be completed 1. Involved person
2. Safety Representative
Minor
3. Witnesses
4. Full time Safety Representative (Optional)
5. Safety officer or supervisor
Level 2 Investigation Level 2 Trained member of Management, or designate, leads investigation
team:
1. As per Minor Risk team
Moderate
2. Health and Safety Superintendent/Manager to facilitate
3. Department Manager
4. Engineer if applicable
Level 2 Investigation Level 2 / Independent Trained member of Management leads investigation
Major team (GM to decide):
1. As per Moderate Risk team
2. Health and Safety Superintendent/Manager or delegate to facilitate
3. Department Manager
Critical 4. Other technical Experts that may be required
5. Legal advisor (GM to decide)
6. Other as may be deemed appropriate
3. Immediate Response
4. Investigation Team
Plant N/A
Gravel, compacted rompad and haulroad
Infrastructure
surface
Existing maps Will be added
Procedures
Documents _Truck wheels maintenance reports In the incident file
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CONTROLLED COPY DISCLOSURE
When downloaded from the BAM database, this document is uncontrolled and the responsibility rests with the user to ensure it is in line
with the authorized version on the database
Document Number
BEL AIR MINING S.A.S BAM-IMP-TM-001
Revision Number
FORM
03
Revision Date
INVESTIGATION TEMPLATE LEVEL 1
12 November 2020
Page 4 of 9
CONTROLLED COPY DISCLOSURE
When downloaded from the BAM database, this document is uncontrolled and the responsibility rests with the user to ensure it is in line
with the authorized version on the database
Document Number
BEL AIR MINING S.A.S BAM-IMP-TM-001
Revision Number
FORM
03
Revision Date
INVESTIGATION TEMPLATE LEVEL 1
12 November 2020
The position of the truck after the wheel came off while
the truck was in motion and the section of the trailer
where the 2 x wheels came off
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CONTROLLED COPY DISCLOSURE
When downloaded from the BAM database, this document is uncontrolled and the responsibility rests with the user to ensure it is in line
with the authorized version on the database
Document Number
BEL AIR MINING S.A.S BAM-IMP-TM-001
Revision Number
FORM
03
Revision Date
INVESTIGATION TEMPLATE LEVEL 1
12 November 2020
Interview/ Questions
Q. Did you complete a service report indicating everything was ok with the truck including the wheels?
A. Yes. You will be referred to the service report
Q. Where do you put your service reports after completion?
A. In the store with the store manager.
Gassim Fofana– Tyre Man who maintained the wheels on the truck
Contact: 664 57 77 65
Questioning conducted by Sekou Zoumana SAKO
Q. did you work on that Truck tyre wheels at the workshop?
A. Yes, I once on it
Q. Did you use a torque range?
A. for the truck DRT#2 we did not
Q. why you did not use a torque range?
A. we used Brute one but that day it was not functioning.
Q. Did you do any report after the wheel repaired?
A. we do not have a report form
Q. Do you have training on how to works on wheels
A. Yes Check with training department
Root Cause There were no wheel repair criteria, and no one was assigned to develop and implement the wheel
repair procedure at Djoma.
The wheel nut indicator system was introduced to Djoma but not fully applied.
Tyre men not having proper tool for tyres work.
Absent of Failed Defenses Individual/Team Actions Task/Environmental Organizational factors
Conditions
Wheel repair procedure_No Overloading_Trucks are Daily Truck Wheel Repair
Hazard Recognition_The truck
clear procedure used when overloaded sometimes Plan _ No daily truck wheel
operator did not think that the tyre
repairing wheels and tyres at posing a risk of too much repair procedure indicating
can come off due to lack of
the Djoma workshop. weight on trailer axles and what is checked on wheels.
procedure and of training.
wheels.
Control Systems_Torque range Tools/ Equipment Training_the employees who
as a control for tightening the Condition/ Availability_ were performing the tyre
nuts was not used by the tyre Torque range was not used repaire task were not
men when the truck came to while mounting the wheels trained on the applicable
the shop for repairing. nuts SWP of wheel/tyre
The service report was not Work Method Error_There was no Djoma was using Brute mounting, dismounting,
done properly after servicing clear method of tyre repairing. As no torque range that was not inflating, and deflating.
the truck. SWP in place at Djoma. functioning that day). No records available to say
Only a steel pipe was used that they had undertaken
on the wheel spanner to this training even though
tighten the nuts they said that they had the
procedure communicated to
them
Supervisory error _The haulage Pre start checking_The
Page 7 of 9
CONTROLLED COPY DISCLOSURE
When downloaded from the BAM database, this document is uncontrolled and the responsibility rests with the user to ensure it is in line
with the authorized version on the database
Document Number
BEL AIR MINING S.A.S BAM-IMP-TM-001
Revision Number
FORM
03
Revision Date
INVESTIGATION TEMPLATE LEVEL 1
12 November 2020
Supervisor did not discuss the task driver was not train on how
risks with the operators during to properly do prestart and
toolbox talk so that operator can fill the checklist.
properly check the wheel not before No record available
and during operation
Pre start checking_ The driver was Hard ware: Torqueing of
not train on how to properly do nuts (Wheel nuts were not
prestart and fill the checklist. torqued because of no
torque range available at
Djoma workshop.
Djoma tyre men were using
Brute torque range that was
not functioning that day).
Only a steel pipe was used
on the wheel spanner to
tighten the nuts
9. Preventative/Corrective Actions
10. Endorsement
o I am satisfied that all reasonable steps have been taken to:
o Thoroughly investigate this incident.
o Identify all “Contributory Factor Types” and “Absent or Failed Defenses”
o Develop appropriate Corrective Actions / Preventive Actions, based on the “Hierarchy of
Control” and “SMARTER” principle.
o Identify key learnings for distribution to all concerned.
Page 8 of 9
CONTROLLED COPY DISCLOSURE
When downloaded from the BAM database, this document is uncontrolled and the responsibility rests with the user to ensure it is in line
with the authorized version on the database
Document Number
BEL AIR MINING S.A.S BAM-IMP-TM-001
Revision Number
FORM
03
Revision Date
INVESTIGATION TEMPLATE LEVEL 1
12 November 2020
o Take into considerations all aspects covered in the checklist on the following pages
Investigation
Investigation Team
Sekou Zoumana Sako Team Leader Date 24 November 2020
Leader name
Signature
Manager/HOD
Manager/HOD name Neale Spencer Date
signature
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CONTROLLED COPY DISCLOSURE
When downloaded from the BAM database, this document is uncontrolled and the responsibility rests with the user to ensure it is in line
with the authorized version on the database