A contractor plant operator (agency labour) was found above the mobile crusher jaws attempting to clear bridged material. They had left the designated walkway, climbed over the handrails and had not implemented LOTOTO. The machine was running, the crusher jaws were turned off but the engine and conveyor were still operating.

A review of key factors that contributed to contractor being exposed to potential for fatal or very serious injury concluded the following;

• The worker did not follow the communication process as required by the Risk Assessment and Method Statement (RAMS)
• The worker was prepared to defeat the provided access restriction when they climbed over rails to access the mobile crushing area
• The worker was prepared to deviate from instruction and take action even though they knew they were not authorised.

Local actions

• Review Task Authorisation process

• Review incident scene management

• More disciplined approach to maintaining contractor induction records

• Review site RAMS – including best practice

• Share report with agency

National actions

• Check task authorisation for long term contractors (see MPA Guidance on Safequarry)

• National Ops meeting to discuss the standardisation of contractor management post incident where non-compliance is identified

• Review site safety meeting frequency and improve quality of record keeping

• National Ops meeting to discuss review of high hazard RAMS in line with 'The Fatal 6'