Coal Inspectorate |
Alert |
No.440
V 1 |
17 November 2023
Fluid injected into CMW's skin
What happened?
Fluid injections are incredibly serious and can lead to the loss of limbs. It's important that all workers at Queensland coal mines follow the recommendations below to avoid serious injuries occurring on site. Fluid injection occurs when a substance (i.e. fluid which may be air, water, oil, solvent, paint, etc) punctures the skin and enters the body tissue.
In the past week, two fluid-system incident reports were received by the Mines Inspectorate.
Incident 1
On 8 November, a CMW was injected with fluid while re-hosing a powered roof support. The hydraulic system had been isolated and confirmed. The injured CMW received a fluid injection injury to the wrist when they attempted to replace a hose which proved to be charged with system pressure. The injured CMW was transported to Brisbane and had surgery to treat the injury. Investigations are continuing.
Incident 2
A CMW identified an emulsion leak on a powered roof support. Attempting to find the exact location of the leak, the CMW operated individual powered roof support functions. Upon operating the side shield function, emulsion vented from a failed hydraulic hose, drenching the CMW. The CMW was transported to hospital and checked for fluid injection. Fortunately, no injury was sustained. Investigations are continuing.
How did it happen?
Incident 1
- A nonstandard isolation system had been installed into the powered roof support.
- The nonstandard isolation system does not isolate the power take-off circuit.
- As of the publication date, change management for the nonstandard isolation system has not been identified.
- The safe work instruction for powered roof support isolation only refers to the standard isolation procedure.
Incident 2
- Hose damage may have been obstructed from view by hose burst protection sleeves.
- The CMW may not have considered all of the available options for adjacent and remote operation.
Recommendations
All Site Senior Executives (SSE) should:
- review all fluid power isolation documentation and verify that:
- fluid power is effectively isolating as intended.
- pressure can be dissipated from isolated fluid power circuits.
- review the strategies for managing fluid power hose maintenance by:
- identifying known areas prone to wear and damaged hoses.
- applying the tools of risk management to fluid power hoses and fittings.
- considering the installation of guards over and above hose burst protection sleeves.
- considering the potential of burst protection camouflaging hose damage.
All operators should:
- consider available options for remote operation of powered roof supports when testing circuits for leaks and select the safest option.
- take time to consider the risk before starting a task.
- verify that all pressure is isolated, and pressure is dissipated before starting work. If you are unsure consult your supervisor.
- not start work until isolation and pressure dissipation is verified.
Investigations are ongoing and further information may be published as it becomes available. The information in this publication is what is known at the time of writing.
We issue Safety Notices to draw attention to the occurrence of a serious incident, raise awareness of risks, and prompt assessment of your existing controls.
References and further information
Authorised by
Jacques le Roux
-
Chief Inspector – Coal
Contact:
Mick Scully,
Inspector of Mines
,
+61 7 3199 8001
QldMinesInspectorate@rshq.qld.gov.au
Issued by Resources Safety & Health Queensland
Safety: This information is issued to promote safety through experience. It is not to be taken as a statement of law and must not be construed to waive or modify any legal obligation.
Placement: Place this announcement on noticeboards and ensure all relevant people in your organisation receive a copy, understand the content, findings and recommendations as applicable to their operation. SSEs should validate that recommendations have been implemented.
All information on this page (Fluid injected into CMW's skin - https://www.rshq.qld.gov.au/safety-notices/mines/fluid-injection) is correct as of time of printing (Sep 1, 2024 11:54 am).