A 4 month Inspectorate Investigation into June 2016 Development Roof Fall Trapping 4 Mineworkers at the Face, immediately after a Unilateral Management Decision to stop installing 8 metre Cable Bolts. It just disappears into the Mines Inspectorate Veil of Secrecy.
If the Mines Inspectors had of made Anglo Management include their Contractor Workforce in Change Management and Risk Assessments in 2016 would the methane explosion on the 6th of May 2020 have happened?
On the 5th June 2016 there is a Major roof fall in Development that TRAPS 4 men at the Continuous Miner Face in MG 102 at C heading inbye 18 c/t nd the ERZC has to very quickly evade the falling roof.
06.06.2016 Fall trapping crew MRE – Grosvenor Coal Mine –
This is extremely close to a five person multiple fatality.
The Mines Inspectorate identify there are major problems/deficiencies with with the Change Management Process.
This being that the actual Workers who have to cut the coal and support the roof have not been part of the Change Management/Risk Assessment process to stop installing 2x 8.2m Megabolts at 4m spacing as part of the minimum support pattern and just install 8 x 1.8m bolts only.
The last time anything seems to be mentioned is a reference by now Deputy Chief Inspector Shaun Dobson in his MRE dated the 21st of September 2016.
On Wednesday 21st and Thursday 22nd September 2016, I conducted an inspection and assisted in an ongoing investigation at Grosvenor underground coal mine. I was accompanied by Inspector of Mines Jacqui Vinnicombe who was conducting a review on site to examine geotechnical aspects of the current investigation into the recent strata failures.
Inspector Vinnicombe will be issuing a separate Mine Record Entry detailing the inspection findings from the areas examined in the underground where failures occurred and her investigation findings.
In all the subsequent MRE’s, the Investigation into the roof fall and apparent findings of not involving workers in Change Management Risk Assessments never rates a mention again
In the MRE dated the 6th of June Inspectors Gouldstone and Callinan note
Support condition – The fall had occurred approximately 10m inbye of the support pattern for 18CT intersection and stopped approximately 20m from the face of the heading. A 8x 1.8mJX bolt per metre(roof) pattern was being utilised and failure had occurred between the 2 outermost bolts.
The support pattern had been changed from that installed in 102MG previously by removing the need to install 2x 8.2m Megabolts at 4m spacing.
This had been subject to a change management process dated 20/05/16.
Inspector Gouldstone asked if a staged reduction in roof support had been considered.
Inspectors Callinan and Gouldstone go to the Mine on the morning of the 6th to conduct an Investigation
The Fall is some 14m long to 5m high with only 0.8m width to either side of the fall remaining of the roof.
This would be just enough to crawl and climb through on your belly.
The Inspectors indicated in the MRE that they intend to –
- Identify the process the Mine has followed to deal with change management
- Understand how the Mine is to secure the fall by following a risk assessment process
- Discuss with Mine personnel why the failure occurred and what support will be installed in future in 102 MG to prevent a recurrence.
Mining in 102 MG has been halted until these matters have been addressed.
It was accepted by Inspector Gouldstone that development in the Mains could continue as the support regime and mining conditions are different to those in MG 102.
Nearly 3 Months after the Fall Inspector Gouldstone goes to Grosvenor Mines to Conduct Interviews with staff members one of which was a joint interview involving three persons.
MRE – Grosvenor fall Interview 1 Coal Mine – 31.08.2016.pdf
Inspector Gouldstone notes at the start of the MRE that
The Mine has subsequently provided a copy of their investigation as requested in the MRE which has prompted the need to conduct the interviews.
LINK to MRE MRE – Grosvenor fall Interview 1 Coal Mine – 31.08.2016.pdf
1.2 Next moves regarding Strata Control failures at Grosvenor
- Conduct interviews with ERZ Controllers and crew members involved in the original roof-fall incident.
- Consult with DNRM experts on the findings so far, with particular input from geotechnical expertise.
- Read through the reports provided by Mr Foulstone on the matter, generated by impartial personnel with appropriate expertise.(ie Terry Medhurst – Principal Geotechnical Engineer PDR Engineers & Lesley Munsamy Lead Geotechnical Engineer – AAC)
It takes over 3 months for the Mines Inspectors to conduct interviews with the Development crews from MG 102.
MRE – Grosvenor Coal Mine Fall Interviews – 13.09.2016.pdf
In the Group Interviews Inspector Gouldstone is told
- Neither crew were consulted following recognised risk assessment which should have been triggered by the change of management process
- Both crews were aware that the change was likely and had been briefed before they commenced the shifts on which the change took place, and, when the early signs of roof movement were detected
- No person predicted nor expected the rapid deterioration and roof failure that followed
- There was total reliance in the technical expertise applied during the change management process
- It was understood by the crews that the monitoring of tell-tales used in the reasoning for the change related to roadways where megabolts had been installed and that there was no data associated with convergence measurements relating to only 8x 1.8m steel bolts alone
- Specific reference was made to items discussed with management post failure – was elevated in situ methane content related to ply 1 & 2 given consideration?
- was there an interim support pattern/system which might have been considered?
- why was the change initiated immediately after 18ct conditions were seen as very heavy even in comparison with previous cut throughs?
It is over 3 Months from from the roof fall until the Mines Inspector Gouldstone conducts interviews with the two crews from MG 102.
MRE – Grosvenor Coal Mine Fall Interviews – 13.09.2016.pdf
In discussing my intentions with each crew they were comfortable with me addressing each crew as a group since there were no issues that the individuals concerned felt they needed to speak of in confidence.
By conducting a series of Group Interviews instead of Interviewing them individually is a very poor.
It is very likely all the verbal evidence would not be accepted in a Court of Law
2
I spoke, after the interviews with Mr Adam Foulstone, regarding his response to my last MRE dated 6 September 2016 which sought further explanation of geotechnical issues posed by Inspector Deon Esterhuizen.
I indicated that he should respond as soon as possible and that would allow some consideration of the matter before Inspectors Shaun Dobson and Jacqui Vinnicombe attend the Mine next Wednesday 21 September 2016.
EXCERPTS FROM MRE 6th June 2016
06.06.2016 Fall trapping crew MRE – Grosvenor Coal Mine –
Our attendance at the Mine had been prompted by the telephone call from Mr Bull to Inspector Graham Callinan at 5am earlier in the day.
Inspector Gouldstone makes the following observation about an Inspector being notified Seven (7) hours after 5 potential fatalities.
Inspector Gouldstone indicated to those present that the notification of the incident ought to have been as soon as was reasonably possible after the event. This could reasonably have been within an hour of the incident.
In the Mine Record the Inspectors indicated that they intend to –
- Identify the process the Mine has followed to deal with change management
- Understand how the Mine is to secure the fall by following a risk assessment process
- Discuss with Mine personnel why the failure occurred and what support will be installed in future in 102 MG to prevent a recurrence.
Mining in 102 MG has been halted until these matters have been addressed.
It was accepted by Inspector Gouldstone that development in the Mains could continue as the support regime and mining conditions are different to those in MG 102.
The full MRE is in the Link Below
06.06.2016 Fall trapping crew MRE – Grosvenor Coal Mine –
Mr Bull reported a High Potential Incident in 102 MG ‘C’ heading where a roof fall had occurred approximately 36m inbye from 18CT. The dimension of the fall was 14m long to 5m high with only 0.8m width to either side of the fall remaining of the roof.
The fall occurred at 22:10pm Sunday 5 June, after the ERZC had noticed rapid movement on a tell-tale at chainage 45m.
He directed the shuttle car driver to park the vehicle at the boot end and told the CM crew to tram the Joy 12CM12 outbye to commence Code B secondary support.
However the roof failed as the ERZC was again reading the tell-tale he took evasive action, running outbye of the fall.
Once the dust cleared he returned to the edge of the fall and guided the four crew members from inbye the fall to safety outbye of the fall.
Movement on the tell-tale had been reported from the previous shift and deteriorated quickly at the commencement of the nightshift
