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

Investigation Report
Level 1
(Incident Cause Analysis)

INCIDENT NUMBER

BAM122

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 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

Incident Level Rating Low Minimal Medium Serious Critical Catastrophic

Actual X
Potential X

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

Immediate Actions taken after the incident

Initial Response The operator contacted his immediate supervisor
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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

Control room alerted and security personnel informed

_The truck was safely barricaded with triangles and safety cones to
Securing the Site / Immediate Corrective Actions make it safe for other motorist at the rompad 3 to continue operating
_The workshop team came to the scene to change the wheels
Where? None
Treatment Received
By Who? None

4. Investigation Team

Investigation team to be nominated as per requirements

Name and Surname Designation Role Signature

Sekou Zoumana Sako Safety Advisor Lead investigator

Attie Hechter H&S Superintendent Investigator

Neale Spencer Mine Superintendent Production

Safety Representative Risk analysis and Data
Mohamed Issa Camara
(Maliguia) analysis

5. Data Collection/ Sources of Information

Who, What, When,

Data Category Details Collection Method
Where, How?
Statement and
Person Involved Abdoulaye Bah (Truck Operator)
Questioning
People
Statement and
Person Involved Gassim Fofana (Tyre Vulganizer)
Questioning
Weather Clear weather – Night time Observation
Rompad 3 Loading area
Environment Workplace The area was dark, one lighting plant was Observation
lighting the area
Incident Scene Clear, gravel road compacted Observation
Tools/ Equipment Truck Mercedes Actros Observation
Djoma truck DRT 02
The truck had the same rear trailer wheels
maintained during the day 14/11/2020
between 13hrs30 to 14hrs30 before the
Vehicles night of the incident after the bolts were Refer to the incident file
Equipment coming losing
Checklist for the night show that the truck
was road worthy – 14/11/ 2020

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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 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

Who, What, When,

Data Category Details Collection Method
Where, How?
_Site Driving evaluation and operator
deemed competent – 09/ 10/ 2020
_ Driver licenses and assessments – 27/ 09/
2018
Risk Assessments No mini risk assessment done
Medicals Refer to djoma HR
Truck pre start checklist in place but not
filled properly by the operator
Day shift Tally report – First Load was done
from 7hrs to 8hrs and last load from18hrs to
19hrs
Reports All in the file
The truck did four loads from rom3 to export
bin and 6 loads from rom3 to export loop.
The night shift tally report not available.
Employee attended pre start meeting
Shift Roster – 11hour shifts
Culture One team one goal zero harm
Organizational Factors Truck training evaluated and up to date 09
Training
October 2010

6. Notes/ Observations of Site visit and Statements of employees

Description Observation/ Statement concern By whom?

The incident occurred two 2 hours after starting the shift Safety team
The driver was alone in the truck Safety team
The incident occurred during night shift – lighting was sufficient at rompad 3 Safety team
Observed that the driver of the truck was fully fit during the investigation Sekou Z Sako
Most of the wheels did not have wheels indicators especially the trailer wheels Sekou Z Sako
The wheels were loose on the truck when the driver was positioned the truck at safest Driver statement and
area after the incident questioning
Road condition was good Safety Observation
According to the driver he only Tipped one load at export before the incident Statement
The truck was empty at the time of the incident entry rom3 to get loaded Safety Observation
7. Photos of Incident
Photo Description

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 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

Broken wheel stud on the drum and loose bolt

Sketch of the incident area

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 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

Abdoulaye Bah (Djoma Truck Operator)

Questioning conducted by Sekou Zoumana SAKO
Q. What time did you start your shift?
A.19hrss 00
Q. Can you tell us what happened?
A. After attending to the toolbox meeting at start of shift, I inspected the truck and all were good.
I get the first load and transported to the export and drive empty up to the rompad 3.
Arrived at rompad 3 closer to the lighting plant, I heard a noise from the back side. I got down from the truck and check.
I found out that some wheel nuts were not in place.
I decided to pull over the truck to the safest place. While moving, the two tyre came off.
Q. Did you notice anything or heard any noise from the truck along the haul road while driving to the rom3?
A. No because all along the windows were closed.
Q. Were you playing music in the truck while driving?
A.No
Q. What time did the incident occur?
A. 21hrs20
Q. Did you carry out pre-start checklist on the truck? If you did, how did you do it?
A. Yes. I walk around the truck and all were good
Q. Did you check the wheel indicators and nuts if they are tight and safe?
A. I check but some of the wheel were not having indicators.
Q. Visually do you know how to check the wheels?
A. Yes
Q. Why did you check the wheel nut indicators ok
A. I don’t know how to check properly
I was not trained on how to do it but one safety rep shows me once.
Q. How many loads did you do before the incident?
A. 1
Q. At the export facility, did you check the wheels nut at the at the loop before continuing to the rom3
A. I do check and all were good
Q. During the trips did you check the wheels at rom 3 and export?
A. Nothing
Whenever I saw stone in between tyre I removed it myself

Fabrice Kouakou Workshop Supervisor

Questioning conducted by Sekou Zoumana SAKO
Q. Did you work on the truck before the incident?
A Yes
Q. Did you inspect everything on the truck before it left for site?
A. yes
Three nuts were changed.
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 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

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

8. Contributing factors and Root cause

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
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 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

Supervisor Error or Violation_The

workshop supervisor did not make
sure that the employees had all of
the correct tools that they need to
perform the tasks

9. Preventative/Corrective Actions

Description Responsible person Due Date Completion Date

Provide a torque range so that the tyre Fabrice Kouakou 30 November 2020
men can use during wheel fitting on
trucks.
Train all the tyre men on the wheel/ Kante Ibrahima 30 November 2020
tyre repair, change and fitting SWP.
Check wheel nuts at loading and Operators Ongoing
tipping zones to see if the nuts are still
in position.
Put wheel nut indicators on all trailers Fabrice Kouakou 30 November 2020
wheel nuts.
Communicate with the Djoma Antoine Loua 30 November 2020
workshop supervisor to always compile
a service report every time they finish
services on the trucks in the workshop.
Train all operators on how to check Kante Ibrahima 30 November 2020
tyre and fill properly checklist.

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.
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 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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