Significant Incident Report No. 210
Subject: Electrician crushed between lift car and lift shaft structure - fatal
accident
Date: 15 December 2014
Summary of incident
Note: The Department of Mines and Petroleum's investigation is ongoing. The information
contained in this significant incident report is based on materials received, knowledge and
understanding at the time of writing.
An electrician received fatal injuries when he was crushed between a lift car and the lift shaft
structure and then fell to the bottom of the lift shaft.
A maintenance request had been raised for a service lift located in a powerhouse building. The lift
had stopped moving and some of the doors on the lift shaft were not closing. Two electricians were
sent to troubleshoot and fix the problems.
After an initial inspection of the lift, the electricians went to the lift motor room located above the lift
shaft. To get the lift moving again to help identify the problems, they bridged (i.e. bypassed)
sections of the lift control circuit.
One electrician left the motor room and went downstairs to the top floor where the lift car was
situated. He rode the car down to the ground floor to check if the shaft doors were closed.
The other electrician subsequently went to the shaft doors on the top floor. He tried to contact his
colleague on the radio a few times and then by telephone, but could not get a response. He then
went downstairs to the ground floor where he found the lift shaft doors open, but no sign of the lift
car. His colleague was lying on the bottom of the lift pit.
Direct causes
Sections of the lift control circuit had been bridged and the lift car was not isolated.
The lift may not have been in maintenance mode.
Part of the electrician’s body was projecting outside the lift car when it moved upwards.
Contributory causes
The preliminary investigation by the Department of Mines and Petroleum has been unable to
definitively determine why the lift car unexpectedly moved upwards. However, a number of factors
relating to work environment, safe systems of work, competency and supervision may have
contributed to this fatal accident.
Postal address: Mineral House, 100 Plain Street, East Perth WA 6004
Telephone: (08) 9358 8002 Facsimile: (08) 9358 8000 ResourcesSafety@dmp.wa.gov.au
www.dmp.wa.gov.au
wa.gov.au
Work environment
The lift involved in the incident is one of nine installed on the site in 1988, with three lifts installed
later. The original nine lifts are similar with only minor differences between them.
Since 2010, there had been 400 breakdown notifications for the 12 lifts, including 42 for the lift
involved in the fatal accident.
Scheduled maintenance is carried out by one site electrician working with the lift manufacturer’s
contract technicians.
Breakdown troubleshooting and repairs on site are typically conducted by shift electricians.
They have little or no formal training in lift maintenance, and learn on the job from more
experienced electricians.
The majority of shift electricians could not correctly identify the position of the lift maintenance
switch when shown a photograph of the maintenance switch on the lift involved in the accident.
Safe systems of work
Safe work instruction
There was a safe work instruction (SWI) for lift electrical maintenance but it did not cover all
aspects of the breakdown troubleshooting undertaken by electricians.
There was no reference in the SWI about:
the need to bridge some of the lift control circuits (and how to do this safely)
the potential for crushing hazards when the lift moves
the requirement for two people to undertake certain tasks (and the communication set-up).
Risk assessments
Lifts have moving parts with potential crush hazards — electricians deal primarily with electrical
hazards.
Shift electricians often did not write job hazard analyses (JHAs) or individual risk assessments.
JHAs were not stored or reviewed after the work had been completed. They only required
supervisor approval if the resultant risk was considered to be above “low”.
There appeared to be an established practice of using verbal or mental risk assessments.
Bridging of control interlocks
There are circumstances in lift maintenance and breakdown troubleshooting that require temporary
bridging of safety circuits so the lift can be moved to an accessible position.
While the shift electricians used bridging approval forms, some had not read the whole site
procedure covering the bridging of control interlocks.
The lifts had been treated separately from the rest of the site’s plant. It was commonly believed
a bridging approval form was needed for equipment, but not lift control circuits.
Competency and supervision
There appeared to be no formal system in place to check that electricians were correctly using
SWIs, JHAs and individual risk assessments.
Significant Incident Report No.210 Page 2 of 3
None of the four electricians on the crew rostered for the day of the fatal accident were familiar
with the SWI for lift electrical maintenance. However, electricians on the other crews were
aware of the SWI.
The supervisor had been appointed less than three months before the accident, and had not
worked in a supervisory role, nor received formal training as a supervisor before this
appointment.
The line superintendent had been in the role less than one month before the accident.
Actions required
The hazards that maintenance workers are exposed to can change with each job step. Unless the
troubleshooting and fault-finding steps are planned beforehand, then it will be difficult to assess the
risk of each step and implement controls.
Employers should ensure their safe systems of work also deal with maintenance activities that
cannot be carried out with the equipment completely de-energised, such as inching, jogging,
testing and troubleshooting live equipment.
Supervisors and workers should check that SWIs are provided that cover the specific work to
be undertaken. They need to take the time to risk assess each step of the job and confirm that
the work plan identifies and controls all hazards. If there are changes to the SWI, these need to
be reflected in a JHA.
The risks associated with maintenance or troubleshooting on lifts and hoists are not new or unique to
mining. Employers with lifts or hoists at their operations should review the comprehensiveness and
currency of their systems of work. Particular care is required when troubleshooting, especially if a
control circuit needs to be bridged, which allows the lift or hoist to move, potentially
exposing workers to crush hazards.
Further information
Visit www.dmp.wa.gov.au/ResourcesSafety for information on occupational safety and health in the
resources sector, such as the toolbox presentations, guideline and report listed below.
Assessing the risk within the task
www.dmp.wa.gov.au/documents/Powerpoint_presentations/MSH_MSR_2014AssessingRiskTask.pptx
Review of fatal accidents on WA mines 2000-12
www.dmp.wa.gov.au/documents/Powerpoint_presentations/MSH_MSR_2013ReviewFatalAccidentsMines.ppt
Effective safety and health supervision in Western Australian mining operations ‒ guideline
www.dmp.wa.gov.au/documents/Guidelines/MSH_G_EffectiveSafetySupervisionWA.pdf
Fatal accidents in the Western Australian mining industry 2000-2012 report
www.dmp.wa.gov.au/documents/Reports/RP_FatalAccidentsMINING_2000-12.pdf
This Significant Incident Report was approved for release by the State Mining Engineer on 15 December 2014
Significant Incident Report No.210 Page 3 of 3
