MINING SIGNIFICANT INCIDENT

Section 1 Description of Incident:

After completing the lifting of several loads of formwork, varying in weight up to 8000kg and used for the development of a vertical shaft, a main hook from one of the four 5 tonne chain blocks used for the lifts, came away from the block. The BOSS 5 tonne chain blocks had been stored on the shaft working stage after the lifts had been completed and were being removed from the stage by a shaft employee when the main hook separated from the block. The hook is retained in the block using 16 ball bearings kept in place by a grub screw. The grub screw, in this instance, had come out which allowed the ball bearings to also become free and the hook to separate. No load was on the chain block at the time of the incident and no persons were injured.

Chain Block Failure

Division: Mining Shaft Sink Project: George Fisher- KJ76 Date of incident: 03/06/2011 Incident Number: #7518 Applicable to: All sites

Preliminary Findings:
The block was inspected and the grub screw and all 16 ball bearings were noted to be missing which allowed the hook then to fall from retainer race. The chain blocks are tested quarterly and are in current test range - All other blocks onsite have been inspected. The supplier of the chain blocks (Bullivants) has been notified and response received.

Section 2

Missing grub screw

Photograph 1: Depicting hook out of retainer block body.

Photograph 2: Depicting ball bearing retainer ring with balls and grub screw missing.

Immediate Actions to Prevent Recurrence on Site:

All other blocks onsite inspected. Out of service blocks removed from site for inspection and response from supplier. Alert Originator: Rob McBride, HSEQ Superintendent

Preliminary Issue Date: 08 /06 /2011

Section 3 Findings and Recommendations from Investigation:

Hierarchy of Control
Administrative Administrative Administrative

This section is for recommended actions or comments from Macmahon Senior Management and the Project Investigation Team

All similar blocks on sites to be inspected, and grub screws checked for security. Supplier- Bullivants notified and response received. The 5 tonne blocks had passed a visual inspection before dispatch April 2011. The blocks were re-chained without dismantling any part of the bottom hook and or the block body. Improve inspection criteria to focus more on hook retaining grub screws, bearing block assembly. Apply Loctite adhesive to the hook retainer block grub screws to prevent loosening. Fill top of grub screw with Silastic as a visual indicator screws are still in place.

Elimination Engineering/Administrative

Supplier to repair out of service blocks and then proof load all blocks and provide test certificate with results. Provide theory as to why grub screws may come loose and action required to prevent loosening. Final Issue Date: 13 /06 /11

Authorised By: Antony Osborne

This Alert is to be placed on all safety notice boards and discussed at pre shift and toolbox discussions

Section 4

Significant Incident Confirmation:

110603 Chain block failure

This is confirmation that the actions below have been reviewed and implemented accordingly on site to prevent a similar occurrence happening. Action How will the action be monitored? Audits, inspections, verification. Comments
(This section must be filled out to explain why you have chosen Yes, No or N/A) Implemented On Site
Yes No N/A

All similar blocks on sites to be inspected, and grub screws checked for security.

Apply Loctite adhesive to the hook retainer block grub screws to prevent loosening. Fill top of grub screws with Silastic as a visual indicator screws are still in place. Ensure all blocks in use have test/proof loading certificate from suppliers. Add information to lift register. Check and ensure that the prestart inspection for chain blocks includes a thorough check of the lifting hook and retaining grub screws. Silastic in place on grub screw heads.

Audits, inspections, verification.

Audits, inspections, verification.

Audits, inspections, verification.

Risk Register & Corrective Action Register Reviewed and updated

(Note what changes were made to the risk register)

Discussed with all crews and subcontractors in toolbox meeting.

(Minutes to be documented)

<insert the dates of each toolbox meeting here>

Recommendations from Project Managers for additional actions to prevent recurrence

As Project Manager I have reviewed the findings and actions from this significant incident. I will implement all actions relevant to this site and monitor the effectiveness of each action. Site: Project Managers Name: Date: Signature:

General Manager Name: Comments from General Manager:

Signature:

Once completed a copy of this notification sheet is to be sent to the Safety Department, the original to be filed with the original incident alert and maintained for auditing purposes. FAX: + 61 8 9334 8641 Email: HSEQ_Mining_Reports@macmahon.com.au

Library Ref: M-049

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