SIGNIFICANT INCIDENT – INVESTIGATION FINDINGS
MAR – Safe Boarding Ladder
Incident
Risk
Rating
Actual
Potential
Major
Major
Release of 748 gallons of fuel
Had the potential to release 1000 gallons
of fuel
Incident Details
3191
01/20/2024
Contact Person
Chet Creamer
775-502-4875
Incident Photos / Diagrams
Incident Summary
At 2:10am on Saturday, January 20, 2024, Haul Truck 493 was traveling across the
Northwest Trout Creek Waste rock Dump when the front boarding ladder came down
unexpectedly. The ladder contacted the ground, which tore the ladder off the truck,
subsequently striking the fuel tank, damaging the fuel pick-up tube. As a result of the
damaged fuel tank, an estimated 748 gallons of diesel fuel was released to the
ground. The volume of the tank is 1,000 gallons, making the actual and the potential
consequence a Level-3 Serious.
Shared Learnings – Key Recommendations
• Understand engineering and mechanics when aftermarket modifications are made to
equipment.
• Understand the training needed for operators and mechanics when new equipment is
added.
• Ensure warning/alarm systems are visible and audible by operators during operation of
equipment.
• Increase the availability of portable containments in the mining 1area to help reduce the
potential volume of released material.
SIGNIFICANT INCIDENT – INVESTIGATION FINDINGS
MAR – Safe Boarding Ladder
Incident Details
3191
01/20/2024
Contact Person
Chet Creamer
775-502-4875
Key Corrective Actions
Root
Cause/s
• Failed wire on ladder control solenoid allowing ladder to
lower during operation of truck.
Material /
Critical Action
ADM – Training for all haul truck operators on operation and alarm system of ladders and use of portable
containments on haul trucks. - 2/29/2024 Don Gerhard
ADM – Source and order portable containments for all haul trucks. Mark Mudlin – 2/22/2024
ADM – Create work orders in SAP to install portable containments on all haul trucks. Tyson Boulette –
2/29/2024
ENG – Installation of alarm system (warning light and audible) in Komatsu-5 haul trucks indicating the
ladder has lowered, implemented in phases:
• Engineer a solution for this system. Tyson Boulette – 2/13/2024
• Source and order parts for the system. Tyson Boulette – 2/22/2024
• Create work orders in SAP to install systems in trucks. Tyson Boulette – 2/29/2024
ENG – Installation of hydraulic system that will serve as a lock to prevent the ladder from coming down in
event of a primary failure, implemented in phases:
• Engineer a manual solution (short-term) and automatic solution (long-term) . Tyson Boulette –
2/13/2024
• Source and order parts for both manual and automatic solutions. Tyson Boulette – 2/22/2024
• Create work orders in SAP to install manual and automatic systems in trucks. Tyson Boulette –
2/29/2024
Other Actions
ADM – Update environmental response cards and retrain employee's timely clean-up of environmental
spills/releases. Craig Olsen – 3/15/2024
• Warning system didn’t alert the operator of ladder failure.
Control Failures
Hazard Identification – Operator training to clarify how the ladders
and alarms work. Caring and inspections of the ladder system during
pre-operations exams and planned maintenance. Design flaw to
prevent ladders from coming down in event of mechanical/electrical
failure.
ICAM Chart
Organisational Factors
Environmental / Task
Conditions
Individual / Team
Actions
• TR – Operators not
consistently trained on
operation and alarm
system of ladder.
• Hardware – Malfunction
of equipment, design
flaw in alarm so
operator could not hear
it.
• TE6 – Poor condition
of wiring to solenoid.
• IT4 – Operators and
mechanics not fully
understanding how
ladders work, park,
alarms, etc.
Absent & Failed Defences
• DF2 – Delayed communication to the environmental
group after the release occurred for guidance on handling
the release.
• DF3 – Operators not understanding how ladders work.
• DF7 – Alarm/warning system for ladder not detectable by
operators.
• DF16 – Portable spill containments are not readily
available in the mining area for quick responses on
equipment spills/releases.
• DF21 – The loss of the electrical harness caused the
ladder to release and lower and there was no secondary
safety system to prevent this occurring.
Incident Event
Release of 748 gallons of
diesel fuel.
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