Bow-Tie Analysis of a Fatal Underground Coal Mine Collision

Details

• Personal Author:
  Burgess-Limerick, Robin ; Horberry T ; Steiner L
• Description:
  Background: Bow-tie analysis combines aspects of fault-tree analysis and event-tree analysis to identify an initiating event; its causes and consequences; and potential preventive and mitigating control measures or barriers. Aims: The aim of the research is to analyse a fatality which occurred in a Queensland underground coal mine in 2007 to illustrate this technique. Method: The case study concerns a fatality which occurred at an underground coal mine in Queensland in 2007. Results: A continuous mining machine operator was crushed against the mine wall by a shuttle car following a loss of situation awareness by the shuttle car driver. The causes included the use of shuttle cars in close proximity to pedestrians, and driver inexperience. A directional control-response incompatibility contributed to the severity of the final consequence. A range of potential control measures are identified including: (i) replacing shuttle cars with a mobile conveyer; (ii) non-line-of-sight remote control of continuous miners; (iii) proximity detection interlocked with shuttle car controls; (iv) "always-compatible" shuttle car steering design. Conclusions: Proximity detection sensors interlocked with shuttle car control systems is a technically feasible control measure which should be implemented at all underground coal mines. Non-line-of-sight remote control of continuous mining machines or automation of continuous mining machines would remove operators from this hazard entirely. A bow-tie representation provides an effective way of systematically examining the causes, consequences, and potential preventive and mitigating control measures or barriers associated with a previous incident. [Description provided by NIOSH]
• Subjects:
  Accidents, Occupational Automation Automobiles Case Reports Hazardous Substances Manufacturing And Industrial Facilities Mining Mortality Occupational Health Risk Assessment Safety

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• Keywords:
  Accident Analysis Case Studies Coal Mines Continuous Mining Control Methods Control Technology Drivers Equipment Design Failure Analysis Fatalities Hazard Controls Machine Operation Machine Operators Mining Equipment Mining Industry Mobile Equipment Motor Vehicles Proximity Detection Remote Control Risk Analysis Sensors Underground Mines Underground Mining Work Experience

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• Series:
  Mining Publications
• ISSN:
  1033-1875
• Document Type:
  Text
• Genre:
  Journal Article
• Place as Subject:
  OSHA Region 3 ; Pennsylvania
• CIO:
  National Institute for Occupational Safety and Health (NIOSH)
• Division:
  OMSHR - Office of Mine Safety and Health Research
• Topic:
  Workplace Safety & Health
• Location:
  North America
• Pages in Document:
  2
• Volume:
  10
• NIOSHTIC Number:
  nn:20055998
• Citation:
  Ergon Aust 2014 Oct; 10:2
• Contact Point Address:
  Robin Burgess-Limerick, Minerals Industry Safety and Health Centre, The University of Queensland, Australia
• Email:
  r.burgesslimerick@uq.edu.au
• Federal Fiscal Year:
  2015
• NORA Priority Area:
  Mining
• Peer Reviewed:
  True
• Source Full Name:
  Ergonomics Australia
• Collection(s):
  National Institute for Occupational Safety and Health
• Main Document Checksum:
  urn:sha-512:3f6836b7d460d0dd8a07cffbd5ecb11a1f51b44911caa3acf2a4ffc0ca5d6e0c5eb8c664faf98c2c7f1466f5ca747013d21ee45578d8cf04c482765fea82ae6a
• Download URL:
  https://stacks.cdc.gov/view/cdc/227855/cdc_227855_DS1.pdf
• File Type:
  [PDF - 629.68 KB ]