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.
 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

 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.
The Ruptured Hose
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 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 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 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 Amputation
Extent of Surgery after the Amputation

 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.
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 request for
hydraulic 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

 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

 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.
Hose Separator Tool
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

 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

 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”