DOS-AW-201645-SAS-1596185 Downstream Oil Sands – Shell Albian Sands March 2016

Mining – Metal to Metal Contact Theme – Incident #3

Target audience for this alert

 Mining Personnel

What happened?
On March 16th at 3:00pm, in the Muskeg River Mine (MRM) area, 789 haul
truck #454 (HH454) and 797 haul truck #162 (HH162) made metal to metal
contact. Both operators were assessed and returned to duty. The incident is
currently ranked 4B potential to People.

HH162 was loaded and traveling down the ramp from the shovel loading area,
Road conditions
towards the crusher. HH454 was loaded with sand and traveling on a flat area
before a ramp to deliver to a grader doing road work. HH454 started to slide while climbing a road hump and braked;
truck HH162 spotted HH454 and also braked and steered towards the berm to avoid contact.

After coming to a stop, HH454 began to slide down a hump in the road from its stopped position toward the parked
HH162 haul truck. Truck HH454 made contact with HH162 damaging the truck. The ramp was well used, at that time,
by both day and night shifts. Just prior to the incident, the ramp had experienced an incident where a truck spun out.
Why it happened
 Road was slippery enough to slide. Mine management relied upon the judgment of the field leadership to determine if
a road had enough traction. Field leaders relied upon operator feedback and visual checks to judge a road’s traction.
Prior to the incident, the field leaders judged the road to have enough traction for continued use.
 At the time of the slides, operators believed that if a road was in use it had been judged by leaders as good and was
approved for use.
 Operators believed that leadership wanted to continue to operate on roads that had been approved for use and that
by traveling slow enough the operators could stay safe.
 Operations (field leadership and operators) knew and accepted that slips (small deviations from rear tires, such that
the truck remains on its intended path) happened in the pit and believed they were part of oil sands mining.
Operations also accepted the risk of major slides and believed that if a slide with no contact happened, the best
response was to ensure immediate road maintenance was done in the area.

Lessons learned
 At the time of the incident, Visual Safety Leadership (VSL) activities and procedures were believed to guide decisions
made by team leads and shift leads. At the time these controls were focused on other topics, road conditions were
considered a known part of the job.
 One method that leaders use to judge both haul road width and traction is by relying upon operator feedback.
Operators will usually drive a road if they believe the team lead has judged and approved that conditions are
acceptable. Roads can remain open during poor conditions as a result of the leader waiting for feedback from
operators, and the operators believing the leader has approved the road.
 At the time of the incident, Operations would have ‘loss of equipment control’ incidents that resulted in continued
operation in combination with road maintenance only. Whether these incidents resulted in contact, was often
determined by road width and traffic patterns.

Recommendations
1. At both MRM and JPM, add road width and traction condition to documented daily pit audits, and display
findings in operator line up rooms.
2. Design a formal leader training program that will be delivered by the manager or production specialist to set
clear expectations with all current and upcoming leaders.
3. Implement VSL between Shift lead and each Team Lead during 7-day rotation which will include examination
of all critical pit conditions
4. Start a temporary Safe Operating Committee (SOC) program where SOC members utilize their operating time
to travel amongst other operators on selected routes, with the specific goal of road evaluation and
communication between the crew and the leads. This should demonstrate the commitment to open
communication on road conditions between operators and team leaders
5. Change how we deal with slides, by clarifying the difference between a slip and a slide to all leaders and
operators, as well as reporting all loss of control incidents:
 Slip – Small deviation by rear tires such that the truck remains on its intended path
 Slides – Any deviation from intended path by the front wheels or a deviation of the rear wheels that is
high enough for the rear of the truck to leave its lane (Loss of Control)
 Report all loss of controls incidents (slides), without a contact consequence, as a ‘Near Miss’

Further information
Clint Bachelder, Causal Learning Focal Point, can be contacted for more incident details or more information regarding
the lessons learned or recommendations. Incident #3: FIM Incident ID: 1596185
Incident #1: FIM Incident ID: 1576371
DOS-AW-201643-SAS-1576371 Mining – Metal to Metal Contact Theme – Incident #1 February 2016

Incident #2: FIM Incident ID: 1593571

DOS-AW-201644-SAS-1593571 Mining – Metal to Metal Contact Theme – Incident #2 March 2016