C e m e n t a t i o n # 1 S h a f t I n c i d e n t

J u l y 6 t h 2 0 1 1

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• Incident overview

• Incident Timeline

• Incident Causation

• Recommendations

Cementation #1 Shaft Incident

Porcupine Gold Mines

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CANADA

ARGENTINACHILE

DOMINICAN REPUBLIC

MEXICO

GUATEMALA

USA

OPERATING MINES

DEVELOPMENT PROJECTS

Safe Enough for our Family

Hoyle Deep Project is located at the Hoyle Pond Mine as part of Porcupine Gold Mines.

Incident Overview

• A Cementation crew of 4 men were preparing to install the final set of guides in the #3 compartment. In order to complete the guide installation the crew was removing a steel beam obstruction in the centre of the #3 compartment.

• During this process the working platform dropped due to the work platform resting on the steel obstruction and rope being paid out on top of the work platform, the beam was then cut allowing the work platform to fall ( approximately 20’ ) to the bottom of the shaft. Only minor injuries were reported.

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Incident Timeline

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1. At 8:00 a.m. Cementation crew planned to install the final two sets of guides in the #3 compartment. Cementation crew was aware that this would require the removal of a wooden bulkhead, 12” x 12” wooden beam and a steel beam.

2. 9:00 - 9:45 a.m. Cementation crew removed bulkhead from set 316.

3. 10:50 a.m. Cementation crew notified of high water and returned to spill pocket with mechanic to get pump going. A number of trips were made between the loading pocket and 720ml.

4. 12:30 p.m. Cementation crew returned to surface with mechanic. The crew stops for lunch

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5. 13:34 p.m. Cementation crew returned down and installed guides extending down to set #317.

Incident Timeline

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6. Cementation crew moved down to remove a 1” x 6” plank protruding into compartment.

7. Cementation crew cut the bell cord and let the tail go to bottom of shaft.8. Cementation crew moved down to remove 12” x 12” timber from compartment (set 318) and took it to 200. (2:40 p.m.) 9. Cementation crew went back down (3:03 p.m.) to the steel beam, at set 318

and started to cut off beam off the timber (3:08 p.m.). Ran out of acetylene.

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10. Cementation crew returned to surface for acetylene. Approximately 4:10 p.m.

11. Cementation crew went back down (app. 4:30 p.m.) to complete cutting off the beam. Hoistman stopped at the mark (4:39 p.m.). A single bell was rang from the lower deck when they arrived at the beam. Hoistman hears 2 bells and begins to lower 4 seconds after stopping at the mark. Hoist chart show that 26.3’ of rope was paid out.

Incident Timeline

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12. Cementation crew resumed removal of the beam by cutting the bolt from the manway side (compartment 3, 4 side) and then moved to the 2, 3 side. They were unable to complete the cut from the top. Jason moved below to complete cut from the bottom. While completing the cut the beam let go and the platform dropped. (App. 4:55 p.m.) 13. At the time of platform drop, Joe and Kevin are on deck #4, Justin is on deck #3 and Jason is standing on set 319 wall plate.

16. After the platform dropped Justin jumps off deck 3 onto manway landing and then jumped back onto #3 deck and opened the doors for the others to climb up.

15. When the platform drops Jason was struck on the right hand by the platform. Knocks the lit torch out of his hand. He climbs back onto the platform to help the others.

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14. When the platform drops, Joe was on his hands and knees attaching a clevis on one side of the beam and ended up face down on the floor of #4 deck in water. Lost his hat and light.

Incident Time Line

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17. After the platform dropped Kevin helps Joe up and the two climb from deck #4 to deck #3.

18. Dan received a call from Jason that there was a problem and an investigation was required. (4:56 p.m.)

19. Hoistman discussed with Dan (in the hoist room) that he thought something was wrong. (4:57 p.m.)

20. Dan received another call from Jason explaining that the platform had fallen. (5:00 p.m.)

Immediate Causes

Incident Causation

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1. Poor communication with bell knockers.

2. Failure to secure platform resting on the beam.

3. Inadequate warning system - no slack rope indicator on the conveyance.  

Incident Causation

• Person was trained for job but did the job infrequently. Hoistman felt he was not familiar with the shaft guide installation process for shaft maintenance. This was the hoistman’s second shift operating service hoist for guide installation.

• Lack of knowledge. Hoistman did not know what the plan was at that moment in time.

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Personal Factors

Job Related Factors• Inadequate standards or specifications. Inconsistent application of bell

ringing being used by shaft crews.• Lack of procedures for the task. We don't state the bells sequencing to

be used in the Cementation procedures.•   Inadequate assessment of needs and risks. Crew did not assess the

risk associated with the platform sitting on the beam.• Lack of procedures for the task. No procedure or non-routine done for

removing shaft obstructions.• Inadequate monitoring of construction. There were no “as built”

drawings for the shaft below the loading pocket.• Inadequate communication of rules. Inadequate communication of

shaft maintenance in #3 compartment in the shaft log book and hoist log book.

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Incident Causation

After platform dropped

Top of work platform Beam to be removed

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Top shoe remains on guide

Bottom of guide string Top shoe position after

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Recommendations

• No work to proceed when shaft signals cannot be heard clearly. • Conveyance cannot be allowed to contact any shaft obstructions.• An indicator to be installed for monitoring slack rope throughout the

working length of the shaft.• Standard set of bell signals to be included with the procedure for

guide installation.• All work including obstructions to be noted in shaft and hoist

operator’s log books by the people doing the work.• Improve documentation for hoist specific training.• Install cameras and video recording of hoist operator activities.• HMI’s to record shaft signals sent and returned.• “As built” drawings of the shaft are to be kept up to date and must

show shaft obstructions.

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