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High Pressure Injection 06/10/29 256-162

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High Pressure Injection 06/10/29 256-162. Prelude To Incident. A Miner was assisting his partner was the operator of the Mclean Bolter. The Miner was new to the bolter, he was currently working as a miner in a non mechanized heading of the mine bolting with Stoper and Jackleg.

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Presentation Transcript
prelude to incident
Prelude To Incident
  • A Miner was assisting his partner was the operator of the Mclean Bolter.
  • The Miner was new to the bolter, he was currently working as a miner in a non mechanized heading of the mine bolting with Stoper and Jackleg.
  • The Miner did not have work in his particular area that day and was sent with the operator to act as helper for the day
  • The Miner did not have training in mechanized bolting through out his career.
how it happened
How It Happened
  • The Miner was attempting to locate a hydraulic leak in a hose cluster with the power off.
  • The Miner pulled three hoses to the side and was holding on to a fourth and instructed his partner to energize the unit.
  • The hose that the Miner was holding was the hose that was leaking.
what happened next
The pressurized oil penetrated the Miner’s glove and was injected into his right index finger.

The estimated pressure exiting the hose from the leak was 3000 p.s.i.

What Happened Next
what happened next1
What Happened Next
  • The Miner was not aware that the hydraulic oil had penetrated his finger and suspected that he may have received a splinter from the frayed metal in the hydraulic hose.
  • His finger then began to swell quite rapidly.
  • He and his partner then contacted his Supervisor and was transported to surface.
what happened next2
What Happened Next
  • The Miner was taken to the Medic Facility at site where the injury to his finger was examined, he was transported to Yellowknife NWT and then Edmonton Alberta for Medical treatment.
  • All during this time the Miner insisted it was not serious.
what happened next3
What Happened Next
  • The Miner arrived in Edmonton and underwent Surgery to remove any oil that had been injected into his finger.
  • The initial surgery was very extensive.
  • A initial incision was made from the tip of his right index finger through his palm extending to his right wrist.
what happened next4
What Happened Next
  • The Miner was kept in the hospital for one week after the incident.
  • His condition was monitored, and the prognosis of the finger was still unknown.
  • It was determined after the one week that the finger would have to be amputated to the second knuckle.
extent of surgery after the amputation1
The Miner was fortunate that the extent of his amputation only included the finger to the second knuckle.

If the injection had occurred into his palm he would have lost his hand.

Extent of Surgery after the Amputation
factors contributing to the incident
Factors Contributing to the Incident
  • Failure to warn: The Miner and his partner did not identify the potential of such actions.
  • Failure to make safe: The McLean Bolter was not in a zero energy state as per site requirements.
  • Improper placement: The Miner was manually searching the cluster of pressurized hydraulic hoses with his hands
  • Improper placement for the task: The Manufactures recommendation is for “visual inspection only”.
  • Servicing of equipment while in operation: The requestforhydraulic activation to locate damaged hose when the Miner was not certified to service or inspect equipment.
  • Failure to use appropriate PPE:The operators manual states “use a piece of tin or cardboard “ for inspection of hydraulic leaks.
root causes
Root Causes
  • Lack of knowledge: The Miner had not received any documented training or been made aware the potential hazards associated with the McLean Bolter.
  • Lack of skill: The Miner was not adequately trained in the use, operation and hazards of the McLean Bolter.
  • Inadequate Work Standards: The company had at the time, no written procedures for the inspection of high pressure lines. There was at the time no mention in the company orientation of the risk factors when dealing with high pressure hoses and maintenance of them.
hose separator tool
Hose Separator Tool
  • This tool was developed specifically for use on our mobile Electric/Hydraulic drills.
  • The tool is to be available for inspection and finding the location of leaking high pressure lines.
  • The operator is not to try to repair or remove any high pressure lines, this must be done by trained maintenance personnel.
manual update
Manual Update
  • Training manuals for all company equipment at the mine site have been updated with information outlining the hazards of High Pressure Injections.
snap lake swp 87
Snap Lake SWP #87
  • A review and sign off of a Safe Work Plan on “Checking for Hydraulic Leaks”, is required by current employees and all new personnel arriving on site.
out come
Out Come
  • The Miner will be off work for an undetermined amount of time. He has been subjected to extensive damage and surgery to his hand and finger.
  • He is currently attending Physiotherapy near his home in New Brunswick.
  • The pain and physiological problems that the Miner has endured will continue for some time.
  • In his own words, “he could not believe that it would have become this serious”