January 26, 2012 Porcupine Northeastern Ontario Mines Safety Groups Mario Vottero

1. January 26, 2012 Porcupine Northeastern Ontario Mines Safety Groups Mario Vottero KAPUSKASING PHOSPHATE OPERATIONS

2. PNOMSG, January 26, 2012 December 22 2011 Lost Time Injury • KPO Surface Mine Contractor • Flipped 100 Ton 777D • Critically Injured • Multiple fractures to right leg • Fracture to neck • Injuries to hip • MOL is investigating this critical injury

3. PNOMSG, January 26, 2012 December 22, 2011 7:25 pm On December 22, 2012, 7:25 pm a Haul Truck Operator was in the process of dumping his first load of waste material in the centre pit dump area. As he backed up to the dump edge he failed to stop before the berm, drove through it backwards, down the embankment (angle of repose approximately 70 degrees, 15 meters high).

4. PNOMSG, January 26, 2012 Pictures

5. PNOMSG, January 26, 2012 Pictures

6. PNOMSG, January 26, 2012 Pictures

7. PNOMSG, January 26, 2012 Injuries The momentum caused the 100 ton haul truck (777D Caterpillar dump truck) to flip over and land upside down on top of its load. The Emergency Response Team was immediately activated; the injured haul truck operator was lifted onto stretcher and transported by ambulance to the hospital. As a result of the impact forces and not wearing a seat belt the injured worker suffered fractured neck, multiple fractures to his upper right leg, and injuries to the right side of his hip.

8. PNOMSG, January 26, 2012 Pictures

9. PNOMSG, January 26, 2012 Pictures

10. PNOMSG, January 26, 2012 Pictures

11. PNOMSG, January 26, 2012 Causes • Poor visibility – Night time operation with insufficient illumination of dump area, and due to cold temperature (-27ºC) vehicle exhaust fumes blocking line of sight of intended path of travel.

12. PNOMSG, January 26, 2012 Causes • Procedure not followed – The Contractor’s Dumping Procedures were not followed by the dozer operator, haul truck operator and supervisor; • Haul Truck Operator failed to stop when visibility was impaired. • Dozer Operator failed to spot haul truck operator. • Supervisor failed to ensure operational readiness and also allowed dumping operation to continue without proper illumination. • Seat belt was not worn, which aggravated the injury

13. PNOMSG, January 26, 2012 Key Recommended Actions • Contractor Dumping Procedures will be revised to; • clearly define roles and responsibilities, • Implement a checklist to ensure requirements are met before dumping, • And communication directives between the Dozer Operator and Haul Truck Operator.

14. PNOMSG, January 26, 2012 Key Recommended Actions • Seat belts will include a high visibility shoulder strap. When worn the high visibility strap will enable compliance monitoring. • Modifying exhaust system on haul trucks to minimize poor visibility during cold conditions outside. • Implementing procedure outlining responsibilities for light plant set up in dump areas. • Haul truck involved in the incident will be inspected by the manufacturer for defects that may have caused or contributed to the incident.

15. PNOMSG, January 26, 2012 Key Recommended Actions • Investigating the use of camera system to mitigate visibility issues. • Evaluating berm construction standard with respect to mining material available at KPO • Implement a routine planned inspection process for Contractor’s Supervisor, Management and EHS Personnel to assure compliance. • Conduct a root cause analysis using cause mapping process to understand why procedures were not followed

16. PNOMSG, January 26, 2012 Root Cause Analysis For more information on Root Cause Analysis ThinkReliability www.thinkreliability.com 281-489-2904 office

17. PNOMSG, January 27, 2011 Questions ?