DUMP TRUCK(35TON) OVERTURNED AT OKKE PLANT QUARRY

1. 12th May 2010, 10.15 am Contractor – Joongang co. DUMP TRUCK(35TON) OVERTURNED AT OKKE PLANT QUARRY

3. Incident Description • Date and Time of Incident: 12th May 2010, 10:15 a.m. • Person involved: (51 years) for the past 10 years as a dump truck operator • Company: • Type of injury sustained: Crack of two ribs (Injured worker is stable as reported after medical check at Gangneung Asan Hospital) • Incident Description: At 10:15 am, Dump truck(No.1222) was overturned at the limestone stock pile because the crest of stock pile was collapsed. • Based on the interview, dump truck reached crest of stock pile to dump the limestone as backward. • The dump truck was slid and overturned when the operator was about to dump limestone at the crest of stock pile.

4. Profile of Victim • Victim • Name : ************ • Position : Dump Truck Operator • Age :51 years old • Family Situation: Married and 2 children • Year of Experience at *******: 10 Years • Driving License Category: 1st grade certificate for heavy truck • Work Location Quarry 2 Centre • Work Activities Transporting limestone to stock piles • Type of Injury The injured worker had crack of 2 ribs after medical check up and came back to his work now.

5. Immediate Actions by Plant Team

6. Root Cause Analysis RCA Team

7. Chain of Event (Before the Incident)

8. Sequence of Action Before Accident - Sketch Dump truck was Overturned Along the Hauling Road B-0 Working place The operator reached the crest of stock pile as backward and was about to dump limestone but the crest of stock pile was collapsed and dump tuck was overturned. The material has been taken at the bottom on May 11th . Transporting limestone Limestone loading by excavator

9. Berming 10M Photos Sliding and overturned Safety berm backward

10. Photos

11. Photos

12. Photos Safety Berm gave away truck moving backward

13. Accident Figure at Limestone Stock Yard Sliding and overturned Safety Berm

14. Root Cause Analysis < Vehicle Inspection and operator’s condition > • The daily inspection of the dump truck was conducted by operator before starting the work including breaking system and there was no defects found. • The regular preventive and specific inspection was conducted by maintenance workshop in quarry. • The dump truck has safety facilities like rear camera, frontal mirror, reversing alarm and seat belt. • The condition of operator was in normal. • The operator was fasten seat belt.

15. Root Cause Analysis

16. Main cause of the Incident (Based on the RCA) Root Cause Analysis • Misunderstanding of working method : Main cause of the incident is misunderstanding of "where " with "when" According to stock pile advisory, “Secondary” Method of Stockpiling involvesdumping a load directlyover the crest of the pile. For this method to be performed safely, adequate berms must be maintained ~ …. It is critical to ensure thatmaterial is not removed from the toe of the pile when dumping is taking place at the top of the pile. → Applied “Prohibited” Method of Stockpiling involves ~ …. ~ wherematerial has been removed from the toeis prohibited. → Not applied

17. System and Management Related Causes Root Cause Analysis • Lack of risk assessment: Risk assessment of dumping work did not make complex working condition which clearly identifies all potential & practical risks (for example, multiple visible inspection for stable repose angle from the pile upside and downside) • Lack of real time inspection system : Real time inspection needs to check the risks of working condition and unsafe behavior depending on the working environment and weather condition • Inadequate SOP: SOP of dumping work is in place but there is inaccurate application for dumping work due to misunderstanding of stock pile advisory • Insufficient communication : Lack of communication between inspector and dump truck operators about the risks observed by inspector

18. Behavior related causes Root Cause Analysis • Mistranslation of the Advisory : Stock piling methods are not correctly translated to cause incorrect application of stock piling method. • Insufficient training of risk management : Workers are not skillful of risk recognition and assessment because of insufficient training of risk management including refresher training. • Not fully understanding of the Advisory: Especially stock piling method is not fully understood by workers even though repetitive training due to the mistranslation.

19. Root Cause Analysis

20. Other risks in Quarry

21. Corrective and Preventive Action (Immediate)

22. Corrective and Preventive Action (For Improvement)

23. Key Lessons Learned • Workers should clearly understand Standard and Advisory (e.g.If youtake materials at the toe of the pile direct dumping is strictly prohibited) • In order to set up a SOP, it should be based on the Group Safety Standard & Advisory fully understood by workers. • The risk management system including inspection, risk assessment and communication system should be working effectively on-site to control not only formal & visible risk but all potential & practical risks in real time and regular monitoring should be followed to make sure the system is working • All employees and non-employees that operate or ride in any mobile equipment or vehicle shall fasten seat belts at all times.