Emergency Exercise: Kestrel Coal Mine Tuesday, 27 November ... · Emergency Exercise: Kestrel Coal Mine Tuesday, 27 November 2001 SCENARIO Longwall panel 205 is a 3.5km block with

Emergency Exercise: Kestrel Coal Mine Tuesday, 27 November 2001

EXECUTIVE SUMMARY

Having focussed the previous 3 exercises on the testing and validation of the Self-Escape philosophy, this year’s exercise concentrated its efforts on an evaluation of the other major component in an integrated emergency preparedness and response system – Aided Rescue. While still maintaining its coverage of the evacuation protocols, this exercise moved the attention away from the surface control room with its flood of gas alarms and emergency calls, into the Incident Management Room and the Mines Rescue Service’s Fresh Air Base.

The scenario provided a studied look at the decision making processes used by the Incident Management Team during its emergency response and the ability of the Incident Management Team to accurately pass on critical information to a replacement team. Additionally, the exercise provided for the full and extended deployment of mines rescue teams charged with the search and recovery of missing and injured workers in hot, humid and difficult circumstances.

The scenario itself involved a significant fall of ground in and around the newly formed goaf of a longwall panel. The strata collapse resulted in the injury of 1 person, severe restrictions to the airflow onto the longwall face, the blocking of access to the intake escapeways and the contamination of the face and tailgate return with large (although non-lethal) concentrations of carbon dioxide and methane. The only access to the injured worker was via the 3.3klm length of the tailgate return with real-event temperatures of approximately 29.5qC Wet & 31qC Dry. The initial methane concentration exceeded 2.5%, prohibiting the use of diesel vehicles in the recovery.

The Incident Management Team and the Mines Rescue Service were thus challenged with the development and selection of options for the recovery of the missing worker/s – a most rigorous task given the circumstances. The results of the exercise demonstrated a well-conceived and (more importantly) well-practiced emergency preparedness and response system. The solution by the workers on the longwall face when confronted with the imminent loss of their oxygen supply, was first class, ingenious and worthy of congratulations.

As always, the exercise provided a number of learning opportunities both for Kestrel in the application of its internal systems, and for the industry in general as we continue the process of continuous improvement in emergency management.

This report details some 50 Recommendations for consideration and provides an extensive assessment of the activities that occurred. As a further aid, included as an Appendix to the report are some brief descriptions of a number of proven decision making process techniques that can be used for the generation, capture and analysis of options and solutions.

In conclusion, the assessment team found the entire Kestrel workforce to be most professional, willing and capable in the approach and application of their emergency response. I would like to thank them, and the assessment team, for their contributions and trust that this report will further add to the growing pool of experiences in our industry’s emergency response capability and that it will act as a starting point for the debates regarding Aided Rescue protocols that I trust will be generated by its publication.

Greg Rowan Senior Inspector of Mines Chairman – Emergency Exercise Management Committee

20 December 2001

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TABLE OF CONTENTS

EXECUTIVE SUMMARY ..........................................................................................................................................1

SCENARIO ...............................................................................................................................................................5

SCENARIO OPTIONS ..............................................................................................................................................6

PLANNING AND CONDUCT OF EXERCISE...........................................................................................................8

SCOPE .....................................................................................................................................................................9

OBJECTIVES .........................................................................................................................................................10

ASSESSMENT OF CONTROL ROOM OPERATIONS ..........................................................................................12

ASSESSMENT OF LONGWALL 205 FACE CREW ESCAPE...............................................................................15

ASSESSMENT OF FIRST AID RESPONSE – LONGWALL 205 FACE CREW ....................................................17

ASSESSMENT OF INCIDENT MANAGEMENT AND EMERGENCY CONTROL .................................................19

ASSESSMENT OF INCIDENT MANAGEMENT TEAM CHANGE-OVER..............................................................22

ASSESSMENT OF IN-SEAM INTERVENTION – QUEENSLAND MINES RESCUE.............................................24

ASSESSMENT OF SURFACE AND MINES RESCUE CONTROL........................................................................27

KESTREL TIMELINE – SURFACE AND UNDERGROUND ..................................................................................31

LONGWALL CREW ESCAPE AUDIT TOOL .........................................................................................................38

205 MAINGATE AUDIT TOOL ...............................................................................................................................41

INCIDENT MANAGEMENT TEAM AUDIT TOOL ..................................................................................................44

MINES RESCUE AUDIT TOOL ..............................................................................................................................56

QUEENSLAND MINES RESCUE SERVICE – PERFORMANCE CRITERIA AUDIT TOOL..................................63

QUEENSLAND MINES RESCUE SERVICE RESPONSE AUDIT TOOL...............................................................65

SURFACE COMMUNICATIONS AUDIT TOOL......................................................................................................66

SITE RESCUE CO-ORDINATORS EFFECTIVENESS AUDIT TOOL....................................................................70

TECHNICAL SUPPORT TEAM AUDIT TOOL .......................................................................................................71

SUMMARY OF RECOMMENDATIONS .................................................................................................................75

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APPENDIX 1 - VENTILATION CONTAMINANTS OVER TIME .............................................................................80

APPENDIX 2 - VENTILATION AND GAS READINGS...........................................................................................92

APPENDIX 3 – EXTRACT FROM INERTISATION ANNUAL INSPECTION REPORT..........................................95

APPENDIX 4 – DECISION MAKING TECHNIQUES..............................................................................................97

APPENDIX 5 – LETTER TO QMRS FROM KESTREL COAL ...............................................................................99

APPENDIX 6 - THE EXERCISE MANAGEMENT COMMITTEE ..........................................................................100

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SCENARIO

Longwall panel 205 is a 3.5km block with a 250-metre face-line. It had only recently commenced extraction and by Tuesday, 27 November 2001 had advanced some 120 metres. Primary caving of the goaf had occurred as usual for the mine.

At 2131 hours on Tuesday evening 27 November 2001, a major fall of ground occurred in the “A” heading belt road of the 205 maingate associated with significant secondary caving of the newly formed goaf.

At the time of the fall, the face line was approximately 50 metres inbye of cut-through 33 and the fall extended from the No. 1 chock on the longwall face to a point some 20 metres outbye of cut-through 33 and approximately half way through cut-through 33 itself. The fall was some 5 to 6 metres high with the lips of the fall being broken, heavy and continuing to fret. The fall restricted the ventilation entering the longwall face to 6.3 m3/s at 0.4 m/s and made maingate entry or egress from the longwall face impossible.

The secondary caving in the goaf expelled large quantities of goaf gas onto the face and significant distances up the tailgate return. These contaminants measured 6.3% CO2, 2.51% CH4 and 11.8ppm CO along the face. Slowed by the restricted air velocity due to the maingate fall, this plug of contaminants would not reach the tailgate CONSPEC or Tube Bundle monitoring points located at the head of the 205 tailgate for 91 minutes (2302 hours).

As a result of the fall onto the longwall BSL and pan-technicon, power was tripped back to the panel isolators, phones were cut and DAC communications were not possible back to the 205 panel drive-head. Air and water services in the maingate were disrupted and all computer communication data links from the longwall to the surface control were lost.

There were 6 persons working on the wall at the time, 1 person was seriously injured with a broken femur suffered as he fell.

The temperatures in the tailgate of 205 panel are (typically) approximately 29.5qC wet, 31qC dry. As the evacuating crew members travel down the 3.5 km length of this roadway, they become increasingly dehydrated and distressed. At 15 cut-through, tailgate 205, one of the crew members can continue no further and remains behind.

No other parts of the mine were effected.

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SCENARIO OPTIONS

Assessor: Greg Rowan

This scenario was developed deliberately to challenge the decision-making processes of the Incident Management Team. That is not to say that the circumstances surrounding the event were in any way “artificially” enhanced – quite the opposite, considerable effort is expended to ensure that the circumstances that evolve during the conduct of these exercises are as realistic as possible. In fact, should a fall of ground such as this occur at Kestrel, it will generate precisely the same circumstances that the IMT grappled with during this exercise.

In searching for the “solution” to this scenario, it was anticipated that the following options would be considered

Option 1 The IMT knew that the injured worker/s were located on the longwall face – some 3.3klms from the panel entrance. They also knew that the only road into the face was via the tailgate return currently carrying 6.3% CO2, 2.51% CH4 and with ambient temperatures of approximately 29.5qC Wet and 31qC Dry. It was quickly identified that Mines Rescue Teams were the only way to retrieve the workers, but that there was no way a team could walk in and carry out an injured patient.

Thus Option 1 was the deployment of a Mines Rescue Team driving a flameproof diesel vehicle through the contaminated return airway.

The unknown implications for �� the increase in engine and exhaust manifold surface temperatures certain to arise from a diesel

operating in such a fuel rich, oxygen deficient atmosphere �� the probability of engine “run-on” in such an atmosphere �� time delays in hand held gas detector sensor heads would not provide sufficient warning of the vehicle

driving from the 2.51% general body into a 5% (LEL) body

As such, the Exercise Assessment Committee did not consider Option 1 as feasible – at least until the CH4 concentrations had been reduced.

Option 2 Breaching the seal across “B” heading 33-34 C/T. This would provide an additional ventilation path onto the face via “B” heading supply rd Æ across 34 C/T Æ up along the pillar side rib line in “A” heading belt road Æaround No1 chock and onto the face. It was considered reasonable to assume that given the intense primary roof support installed along the “A” heading belt road and the proximity of the face line to 34 C/T, that a reasonable air path would still exist along the rib line.

The Exercise Assessment Committee considered that this option provided the fastest means of getting fresh air onto the face line. It also had the added benefit of the increased ventilation flow diluting the CH4 levels in the tailgate to less than 1% - thus allowing vehicles to enter the tailgate and complete the recovery of the missing workers.

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Option 3 Reverse the ventilation flows down the tailgate and convert it to intake. The facility and infrastructure existed that would allow for the (relatively) simply reversal of the ventilation flow in the tailgate. If successful, this option would provide for the contaminants to be diluted such that a diesel vehicle could be deployed down the tailgate to complete the recovery of the missing men. The IMT knew that the maximum airflow available in the tailgate (due to the severe restrictions placed by the fall) was 0.4 m/sec.

The Exercise Assessment Committee considered that the approximately 50,000 m3 of hot, humid, heavy CO2 already filling the tailgate return would not be easily shifted by this method. Coupled with the syncline lay of the tailgate roadway, it was considered that an airflow velocity of 0.4 m/sec would more likely result in simple bi-laminar airflow and not provide any real flushing potential. Altering panel regulators (see Option 4) would have increased the airflow velocity to approximately 0.58m/sec, but it was still considered unlikely for this airflow to flush the tailgate of the contaminants – at least in the short term.

Option 4 Alter regulators to provide increased ventilation pressures across the fall. This option was considered viable by the Exercise Assessment Committee, although of itself having limited effect.

Other Options

�� Access to the face via the BSL tunnel �� Surface bore hole recovery �� Rib/pillar boreholes �� Fall support, clean-up and recovery

All these options were considered by the Exercise Assessment Committee as being outside the time-line parameters of this exercise.

Conclusion The Exercise Assessment Committee considered that a combination of Options 2 and 4 followed by Option 1 (once atmosphere had cleared) provided the best “solution” to this scenario.

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PLANNING AND CONDUCT OF EXERCISE

A number of planning meetings were conducted and a detailed risk assessment process was undertaken during the development of this exercise scenario. The scenario and subsequent events were based on the hazards and risk profile specific to Kestrel mine.

All mine atmospheric and ventilation monitoring data was provided through the mine control room, in real time and in a format compatible to computer assisted analysis and system interrogation. As in previous years, the software program developed by SIMTARS proved invaluable in the provision of this data. The data was presented in formats identical to those used at Kestrel and with which the personnel at Kestrel were familiar.

It was anticipated that the exercise would be attacked on four fronts:

1. In-seam self escape of personnel using self-rescuers. 2. Detailed planning, risk assessment, options and decision analysis for the search and rescue of missing persons. 3. Establishment of appropriate re-entry protocols. 4. Search and Aided Rescue by Queensland Mines Rescue Service teams.

No constraints were to be placed on the extended deployment of the Queensland Mines Rescue Service teams, or the mine’s internal emergency response teams, other than those imposed by their own respective internal policies and procedures.

The practice previously adopted by the Emergency Exercise Management Committee of providing advance notice of the “window” during which the exercise was to be conducted was continued, and advance notice was provided to all stakeholders, including the police, community, media and emergency services.

In recognition of the international interest now being generated by these exercises, the Exercise Management Committee has been requested to detail the names, qualifications and experiences of its members. It is imperative that these exercises be conducted with the greatest regard for transparency and it is with pleasure that I include this information as an Appendix to this report.

In variance to the previous exercises, this year’s scenario did not involve the deployment of the GAG inertisation device. In deference to the Approved Standard for the Conduct of Emergency Procedures Exercises it was deemed by the Exercise Management Committee that the requirements of this standard had been previously met by a recently completed Inertisation Inspection Report conducted by the Queensland Mines Rescue Service. An extract of this report is included as an Appendix to this report.

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SCOPE

To conduct an Emergency Exercise in accordance with the Approved Standard for the Conduct of Emergency Procedures Exercise as established by the Moura Inquiry Task Group 2.

These guidelines proposed that exercises:

�� Be systematic; �� Be consistent with the concept of mutual assistance from other mines; �� Require direct reference to the risks at the mine; �� Recognise that exercises should not necessarily be held on day shift; �� Be inclusive of external agencies such as QMRS, police, media and senior company officials; �� Have an audit and evaluation process; �� Be subject to risk assessment principles to ensure that exercises do not introduce new safety risks to persons at a mine; �� Require inertisation equipment to be put in place, as well as confirming airlocks and emergency stoppings on the

surface are found to be safely accessible and operative.

In recognition of these guidelines:

�� A strategy was developed for establishing the systematic initiation, control and assessment of the exercise; �� A scenario was development strictly in accordance with the hazards present at Kestrel mine; �� The exercise was conducted on the afternoon shift of Tuesday, 27 November 2001 commencing at 9:31pm; �� QMRS, police, media, senior company officials, SIMTARS, Department of Natural Resources and Mines, Industry Safety

and Health Representatives, hospitals and ambulances were involved; �� Formal risk assessments were conducted at the inaugural meeting of the Emergency Exercise Management Committee

held in Emerald on Wednesday, 26 September 2001. This risk assessment covered risks at the mine and risks to the general community;

�� Formal audit tools were developed and validated by members of the Emergency Exercise Management Committee. Formal de-briefings of assessors and Kestrel personnel were conducted to evaluate the results. This report is the result of this audit and evaluation process;

�� Inertisation equipment was NOT called to site.

All audit and assessment tools were developed against the internal procedures of the agencies involved and in line with accepted practice for systems audits.

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OBJECTIVES

The objectives of the exercise were to:

�� Ensure no personnel injury, equipment damage or introduction of additional risks. Please note that the design of the emergency exercises was done using risk assessment methods.

�� Test the ability of the current Mine Emergency Procedures, to meet the desired outcomes of an emergency response. �� Demonstrate a coordinated response involving both Kestrel permanent employees and external contractors. �� Demonstrate a coordinated response involving Kestrel, QMRS, NR&M, Industry Safety and Health Representatives,

SIMTARS, Emergency Services and other stakeholders. �� Enhance the confidence and ability of personnel to respond to an emergency. �� Allow for a performance analysis and debrief to occur following the exercise, with the outcomes recorded and relevant

information disseminated to industry.

To meet these objectives, audit and assessment tools were developed to cover the following functions:

�� Emergency Initiation; �� Emergency Response Plan, including the Duty Card System; �� Incident Management, Emergency Control and Incident Management Team Change-Over; �� Emergency Evacuation; �� In-seam Emergency Response; �� QMRS – ability to respond, mutual assistance, Mandatory Performance Criteria;

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TTHHEE AASSSSEESSSSMMEENNTT
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ASSESSMENT OF CONTROL ROOM OPERATIONS

ASSESSOR: MARTIN WATKINSON

Modelling of the scenario was conducted by the use of two simulations of the gas monitoring system. The Conspec system was modelled by a PowerPoint simulation indicating the modelled gas readings at the outbye end of 205 tailgate.

Modelling of the situation was undertaken by utilising the mine ventilation model and simulating the gases as a pollutant so the anticipant alarm times were derived from the resultant gas velocities.

The other system used for modelling the environmental monitoring system was to utilise the existing Safegas system and the SIMTARS program Safesim which simulates the situation and sends the relevant gas readings to an exact replica of the mines Safegas system all functions of the Safegas system are available to the mine management. Both models run independent of the existing mine environmental monitoring system.

The incident was initiated some 2½ hours after the start of the Control Room Operator’s (CRO) shift, providing the opportunity for the him to adjust to the fact that the incident was being conducted on his shift. The incident was initiated by handing the CRO a card with the following information:

Kestrel Emergency Exercise You have just received an alarm from the longwall informing you that the BSL is stopped. The power has tripped and you

have no computer information from the Longwall.

The CRO then tried to contact the longwall to investigate and was given the following information:

Kestrel Emergency Exercise You cannot reach the longwall face by DAC or telephone..

The CRO then contacted the nearest mine deputy to go and investigate. As communications were made with the other mine officials he made them aware of the developing situation on the longwall. This meant that as this incident developed the rest of the mine was well informed of the situation. The CRO declared an incident at 2234 hours after he had heard from the investigating Deputy. At 2309 hours, after telephone discussions with the Mine Manager, a mine evacuation was ordered.

The CRO explained the logic of his actions as he was searching for information and confirmation of the situation on the longwall so the actual initiation of the incident was realistic.

Due to the scenario and the location of the gas monitoring points, the first gas monitoring alarm from the Conspec system occurred at 2302, some 91 minutes after the incident and tube bundle information was available some 25 minutes later.

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There was only one period when the CRO had two phones in his hand and a gas alarm at the same time and at no time was he overwhelmed by information as the incident developed. Frustration was experienced due to the CRO continuously having to log back into Safegas to acknowledge alarms.

During the incident there was a problem with the mine Conspec system. This was not part of the exercise and happened in real time. The CRO was able to deal with this due to the fact that he had assistance from the Gas Chromatograph Operator and there were not a lot of different gas alarms coming into the control room. (This was effectively dealt with and the system was up and running at 0207).

The CRO was well assisted by the arrival of the night shift with one of the Deputies being rescue trained and he initiated the deployment of personnel to cover the lamp room, mine entrance and to both portals.

The coverage of the portals was most effective and no one was allowed underground without confirmation from the control room. However, on some occasions, after the arrival of IMT and the dispatch of rescue personnel underground, the CRO had not been informed of the intended movements of all personnel.

Once the IMT had arrived on site various duty card holders came into the control room and verified the actions which had been taken. At some stages the CRO had to confirm actions and status to more than one duty card holder.

Information from the IMT was given to the CRO by different duty card holders, including the briefing of the CRO by the Mines Rescue Co-ordinator who used the Gas Chromatograph Operator phone to communicate to the FAB, leaving both control room phones free.

The control room is seen at the mine as the focal point for information, sometimes the fact that mines rescue personnel were going underground had not been given to the CRO and he had to confirm that these personnel were to be allowed underground.

Two-way information from the pit bottom and the FAB was communicated very effectively and equipment was prepared as required.

Due to the lag between alarms the Safegas system had logged the CRO out and frustration was felt having to re-log in to accept alarms whilst briefing other personnel about the situation within the mine.

Some of the stages and actions to be carried out were not fully explained to the CRO. After the ventilation changes were initiated (breaching of the seal at 33-34 cut-through and alteration of the panel regulators), pressure was put on the CRO for gas monitoring information, which would only be available after the pollutants had been able to clear the tailgate. The longwall was approximately 3300 metres in and the effects of a velocity of 1.07 m/sec (resulting from the above ventilation changes) will only be seen some 51.4 minutes after the velocity change has been affected.

Too many people use the control room as a stopping-off point. Members of the IMT passed through the control room checking on gas readings. The Mine Ventilation Officer used the trending facility of Safegas to plot Ellicott diagrams and gas trends. This information was relayed to IMT. Print outs were developed from the mock-up system. These were checked periodically throughout the incident.

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On the whole, the CRO and the Gas Chromatograph Operator conducted the exercise in a very professional manner following due procedures and relaying information as they knew it. The fact that the Gas Chromatograph Operator was available enabled the CRO to maintain the control of the incident and was able to relay information as required.

Recommendations

1. IMT to ensure that CRO informed of intended actions so that he can confirm actions as required. This should be done by one of the duty card holders. This way the CRO only gets information from one person in contact with the IMT.

2. Limit access to the control room to stop people wandering in and out.

3. Extra phone point for personnel with duty cards so as not to use control room as a telephone room.

4. Modify Safegas so that login time lasts for the shift duration of the CRO. CRO to log out should he leave the control room. This will reduce frustration on accepting alarms.

5. Gas Chromatograph Operator was useful as backup to CRO although he was not required to take a large number of bag samples due to the scenario.

6. Ensure that duplicate tasks are not given to duty card holders and that duty card holders stick to their duties.

7. Consider increased and more regular use of the PED to send messages to trapped personnel. Short, accurate messages can often provide a moral boost and (perhaps) can also be used to provide advice/directions. NB. Some

messages sent by the Exercise Assessment Committee members to the underground assessors did NOT get through.

The impacts of the broken ground above the goaves adjacent to LW 204 and LW 205 need to be investigated in regard

to this.

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ASSESSMENT OF LONGWALL 205 FACE CREW ESCAPE

ASSESSORS: TIM JACKSON, PETER BAKER, WARREN PENDLEBURY, GREG DALLISTON AND JAMES MARSHALL

Commencement Time of Incident 2931.

The Longwall 205 face crew were given the following scenario –

“You have just felt a severe air blast / pressure change with a drop in the ventilation quantity and heard a major fall in the goaf. The air is thick with dust. You are experiencing increased respiration, severe headache and are feeling confused”

At the time of the incident, five members of the 205 crew were at 24 chock and the Deputy / Supervisor was at the tailgate of 205 longwall.

One of the crew was injured during the initial incident and suffered a fractured leg. The remainder of the crew became aware that a fall had occurred when they attempted to go out through the maingate. The crew administered first aid to the injured person from the first aid kit that is kept at the 205 tailgate. The fact there were trained first-aiders in the crew enabled a reasonable level of first aid to be carried out, including vital sign observations.

The initial donning of the fenzy units was carried out efficiently, but there was some confusion over whether the fenzy units should have had goggles (they do not). Four crew members were given trainer units and two were asked to don their belt-worn units. One trainer did not have a nose clip. All crew members, apart from the first casualty, changed over to real SSR90 units. On two of these units, the goggles were broken when they were pulled off the neck strap.

During the time the crew was evacuating the face, delays were experienced by the crew because of the need to communicate using pens and notebooks. Some members became frustrated with this and created the situation where the crew tried to talk through the mouthpieces. The decision to leave the first-aider with the casualty was a tough call and may have been influenced by the injured person going unconscious when the crew attempted to walk him out on the AFC. To leave a fit person with an injured person does contravene the self-escape philosophy set up by industry. The decision for that person to stay may have been influenced by the fact that the event was an exercise. This may have not been so conclusive in a real emergency.

The five fit crewmembers initially escaped to 30 cut-through (Tailgate 205) where the first-aider was given two SSR90’s to return to the injured person on the face. The crew were not exposed to any visibility restraints and made their second SSR90 change over at 20 cut-through 57 minutes after the initial donning. At 15 cut-through one team member was overcome by the conditions and a decision was made to leave him under a temporary air shower from the compressed air line. When the crew reached the cache at 10 cut-through they obtained the three SSR90’s and kept walking outbye. There were no SCSR’s left in 205 return after the crew had evacuated. The hot and humid environmental conditions in the 205 returns were extremely taxing on the crew during their evacuation.

The crew supervisor should be congratulated on the way he handled the situation. He gave clear direction to his crew and constantly checked on their condition. He also instructed the crew on the availability of compressed airlines as they crossed the tailgate, which was later used by the 2 men on the face.

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He was also instrumental in deciding to leave the heat stressed person at 15 cut-through and left clear instruction on what to do to keep himself as comfortable as possible until rescue returned. The supervisor had trouble contacting control once they had escaped because the phone 757 was not working other than by using the emergency dial. This was not part of the exercise and requires investigation by the mine. Once the supervisor was able to get through to the underground control room operator he gave a factual report on the situation and requested further instructions.

Recommendations

8. The mine re-investigates the escape time-lines and distances between cache locations in longwall returns – particularly where poor visibility may be experienced.

9. Investigate the number of SCSR in the longwall return caches. In this scenario there were sufficient numbers, but there were only six people on the face. If there had of been one more person on the face, there were no spare units in the caches. The escaping crew expressed concerns during the debrief of this point. Self-escape routes need to be planned and serviced by sufficient SCSRs for the maximum number of personal in the panel in both primary and alternate routes.

10. During the refresher training for SCSR, mines must ensure that duration times of at work and at rest are explained to wearers.

11. Communications using pens and notebooks, and not talking through mouthpieces, should be adopted as an industry standard.

12. Trial the use of walking sticks in areas of excessive rib spall. The trial to consider the appropriateness of using “candy cane” shaped curved handles, or the current right angled “elbow” shaped handles.

13. Treat any person who ‘escapes’ in the hot and humid conditions as a patient to ensure they recover from the experience – particularly in the rehydration of persons.

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ASSESSMENT OF FIRST AID RESPONSE – LONGWALL 205 FACE CREW

ASSESSOR: JAMES MARSHALL

The initiation of the exercise at the longwall face occurred smoothly. The casualty broke his leg at chock 24. After becoming aware that he was suffering the affects of CO2, the casualty correctly donned his Fenzy. The remainder of the crew came across the casualty after their investigation of the maingate end of the longwall face. The casualty was grasping his broken thigh and groaning through the mouthpiece of the self-rescuer. The first-aider took control of the situation. He use his notepad to find out what was wrong with the casualty and instructed the other crew to get the first aid kit from the tailgate.

The first-aider began inspecting the suspected broken leg. Firstly, he tried to feel the thigh, but the casualty groaned in pain and pushed his hands away. He then wrote a message to ask if the casualty could feel his toes, to which he indicated positively. He also confirmed that it was not an open fracture. He then pulled the pants leg out of the casualty’s boots to check the skin colour. The first-aider wrote to the Crew Supervisor that they need to support the leg and get a stretcher. He also queried the location of the first aid kit and when the SSR90’s were to arrive because 15 minutes had already elapsed. The Crew Supervisor wrote that another person had gone to retrieve it. He remembered that there was a first aid kit at chock 7 and quickly retrieved it. The Crew Supervisor and first-aider then opened the box. The first-aider looked at the first aid kit contents list and tried to find appropriate bandages to splint the leg.

At 2154 hours, the SSR90’s, 2 x blind man sticks and the tailgate first aid kit arrived at chock 24. The blind man sticks were too long to be used as a splint and one of them was broken to an appropriate length. The SSR90’s were donned completely by all crew by 2159 hours. The leg was then bandaged with the splint in place using 2 wide bandage with the ends taped off. These bandages were not appropriate for the situation and were not applied tight enough for actually splinting the leg. This would have increased the realism of the exercise.

The first-aider then checked that the casualty’s toes did not have pins and needles. This message was written ambiguously and first-aider had to confirm the answer. Thumbs up questions were asked from time to time of the casualty to check that he was okay. The second blind man stick was checked for its length to be used as a crutch. The first-aider then bandaged a couple of dressings to the top of the piping so that it wouldn’t cut into the armpit of the casualty.

The Crew Supervisor then checked the temperature of the casualty and had the casualty squeeze his fingers to check for strength. The crew then lifted the casualty over the spill plates onto the AFC. This was done with some rough handling. At 2206, the crew began moving the casualty out of the longwall face. He was being carried by two crew members.

It soon became apparent that the injured person was not going to be carried out the whole length of the tailgate (3.5kms). The casualty then became unconscious and the decision was made to leave the casualty at chock 53. The remaining 5 crew were to travel out the tailgate, however, the first-aider was to retrieve some more SSR90’s from the first cache in the tailgate and then return to the casualty on the longwall and wait for assistance.

During this part of the exercise, the first-aider and assisting crew need to be congratulated for their professional attitude and urgency to improvise and reduce the impact of the broken leg on the casualty. Their response was also effective in terms of the time taken to perform the first aid, attempt assisted escape and evacuate the area.

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Set up of Air Shower

On the return of the first-aider to the casualty at the longwall face (2050 hours), he brought two SSR90’s from the 30 cut-through cache. He also brought the tailgate stoneduster air hose down the face as a secondary air supply. The air hose extended to 61 chock, whilst the casualty was located at 53 chock. The first-aider had to drag the casualty along the AFC to the air hose.

At 0345, the first-aider and casualty were notified that they had 15 minutes of use left from their SSR90’s. Despite there being one last SSR90, that the first-aider planned to use to escape down the tailgate, leaving the casualty with the air hose. He had not considered that there would not be any SSR90’s at any of the caches as he moved down the tailgate because they were taken by the rest of the longwall crews on their escape.

The first-aider and casualty were prompted by the assessors to work out how both could use the air hose or SSR90 for fresh air. The first-aider removed two of the chock legs protective gaiters from the nearest chock and proceeded to velcro the two together to make an “air-tent”. The crutch that they had made earlier was used as a tent pole when they placed the leg gators over themselves, sitting on the AFC.

The use of a spanner to hit against the AFC pans to attract attention to their location was also good.

Recommendations

14. Mine personnel should spend some time brainstorming / training sessions to utilise available equipment innovatively to make air showers, barricades etc. This will improve the likelihood that panic won’t set in should some personnel be unfit to facilitate self-escape. It would be particularly beneficial where there is more than one person to use the airline.

15. Mine personnel need to consider taking more time to ensure that the correct message is written on notepad communication.

Page 18 of 101


ASSESSMENT OF INCIDENT MANAGEMENT AND EMERGENCY CONTROL

ASSESSORS: DAVID CLIFF AND MALCOLM SMITH

Introduction

Two assessors were assigned to witness and record the activities of the Incident Management Team (IMT). The assessors were charged with recording the techniques and emergency plans utilised during the emergency exercise at Kestrel Coal.

Formation and Structure of IMT

The IMT was formed shortly after the arrival of the mine manager (refer event log for time) who assumed the role of Incident Controller (IC) from the Control Room Operator (CRO). The mine manager arrived on site with Duty Card 4 – Rescue Coordinator. The IMT consisted of the seven principal duty cardholders. Other duty cardholders arrived shortly after this, except for Duty Cardholder 7 – who arrived approximately 30 minutes later. He brought with him a clerk to record the essential details for the event log.

There needs to be more control over access and movement into and out of the IIMT room. On a number of occasions the decision making process was suspended or interrupted due to the unexpected absence (or arrival) of individual members of the IMT.

First briefing of IMT was held at 0015. IMT function included external advisors – NR&M Mines Inspector and Industry Safety and Health Representative.

Internal Functioning of the Team

The IMT was led by the IC. The first issues outlines were the processes and protocols to be followed for decision-making. Risk Management and Change Management were the tools to be utilised.

The risk management process followed the basic flow: hazard identification, issues associated with hazards and controls. Later on this process was extended to include the proposed sequences of work. The risk management process was applied to each potential work sequence associated with the rescue process separately. No documented comparative analysis was undertaken of the benefits and costs, of the various rescue options. The disjointed flow of people (and information) into and out of the IMT made it difficult for any risk management assessments to actually reach their conclusions.

It was good to see that, on several occasions, members of the IMT, other than the IC, forced the decision-making process to be rigorous and not take short cuts. On several occasions a course of action was decided upon, only to be overturned by a late question, which then caused a shift in focus and initiation of a risk management on a different scenario.

The members of the IMT demonstrated thorough and accurate knowledge of the mine and its systems to deal with the situation. As previously stated, decision-making was impeded by the repeated movement in and out of the IMT by various members without being directed to do so by the IC. In addition, decision-making would have been improved with a stronger sense of urgency, direction and focus – best provided by a clearly stated (and written-up) set of Goals, Objectives and Priorities.

Page 19 of 101


There appeared to be little urgency for the limited oxygen supply available to the persons left underground. A number of suggestions for action were not recorded and thus could not be followed through and evaluated. They were not considered until repeated some time later.

The fatigue of the IMT became evident in the early hours of the morning and the ability to make decisions and carry out analysis was demonstrably slowed.

Overall, it is the opinions of the assessors, that IMT functioned well as a team and deserves high praise for their teamwork, thought process and clarity of instructions. In particular, the IC should be complimented on keeping the diverse group functioning for such an extended period of time given that most would have not had any sleep for over 24 hours.

The Emergency Response Procedures, including check lists were not referenced.

The IMT room was inadequate for its function, both in size and in the way it was equipped (see audit sheets for details). This hampered effective operation of the IMT and caused unnecessary delays to the decision-making process.

External Communications to the IMT

In general, the communications into and out of the IMT was adequate. The lack of direct computer connection to the mine environment monitoring system caused delays in updating key gas concentrations and on several occasions information became garbled in the transfer.

The IC carried out an effective debrief of key staff and acquired the necessary facts quickly. Thus he was able to brief the rest of the IMT appropriately and in a timely manner.

The IC ensured that surface personnel were kept informed of events.

The duty card system seemed to function effectively and the use of briefcases to contain all the relevant documents and support material was effective.

There was only one telephone into the IMT which was an internal phone. This had positive as well as negative impacts. No one individual was assigned the responsibility to monitor the phone. This became an issue when calls were being received by the IMT, where different individuals answered and passed messages to the IC. It limited the number of extraneous contacts that would cause the IMT to divert from its key function, but also meant that communications had to be verbally transferred to the control room or other key areas to be relayed to the desired target. The IC had a radio but there was no attempt to use it.

The reliance on verbal communications was a major concern to the assessors due to the probability of mis-information transfer. The capabilities of the IMT to cope with external agencies, in particular the media and miners families, was not evident.

Positive Points noted by the IMT Assessors

�� The positive attitude by all Kestrel personnel we dealt with. �� The quick establishment of the decision making protocols. �� The effective organisation of the relief IMT and implementation of the changeover.

Page 20 of 101


�� The provision of dedicated clerical support to the IMT freed up the IC and others to focus on the key issues rather than be bogged down in record keeping. However, it needs to be recognised that having clerical people taking records can lead to “over-recording” of information because they do not know what is important and what is not. It is often better to have the IC or another IMT member put the main information on a white board so everyone gets to see it and it is only this information that is recorded prior to being erased. An interesting check for Kestrel would be to go back and review the information recorded (through the sterling efforts of the person concerned) with this in mind.

�� The systematic approach of the IC to the IMT process. There were regular information updates. The IC tried to implement risk management and change management processes.

�� The instructions were issued clearly and the IC checked to make sure that they were understood. �� The absence of friction between IMT members. �� The degree and currency of knowledge, by all members of the IMT, of the layout and operation of the mine. �� The exercise was treated as though it were the real thing.

Recommendations

16. The decision making process needs more focus and each option needs to be driven to completion before allowing digression.

17. All IMT members need to be encouraged to actively participate in the decision making process.

18. Duty card holders need to recognise the need to remain with the IMT unless authorised to leave. This is especially true if there is an exchange of roles.

19. Computer access to the mine environment monitoring system in the IMT is essential. Ventilation simulation software should also be on this computer.

20. Communications between the IMT and CRO should be better documented.

21. A systematic process for evaluating fatigue should be implemented rather than rely on the individuals to notify the IC of their status.

22. Calculators should be included in the duty card briefcases.

23. A mine plan in the IMT should show monitoring locations.

24. There needs to be more white boards / areas to display key information for immediate reference.

25. Suitable techniques should be used to capture ideas, generate alternatives and evaluate the different options to allow for systematic comparison.

26. There needs to be more urgency in decision making when retrieving persons underground who are injured or have limited life support equipment available.

27. The environment conditions merit closer monitoring due to the impact of effective temperature on the effective duration time of rescue teams using BG174’s.

28. Ventilation flow sensors in key roadways would enable more accurate interpretation of makes and effects of changes in ventilation.

Page 21 of 101


ASSESSMENT OF INCIDENT MANAGEMENT TEAM CHANGE-OVER

ASSESSOR: GREG ROWAN

The need to establish a change-over mechanism was identified as early as 3.50am (6hrs 19mins into the exercise) by the original Incident Management Team - IMT1. It was determined that the change-over was to occur at 7.30am the following morning and all IMT1 members were to notify their designated replacements to be on site prior to that time for a formal briefing.

The change-over meeting for IMT2 commenced at 6.41am and consisted of the Incident Controller IMT1 providing a verbal overview of the circumstances that had occurred during the previous 9 hours. The meeting was held in the crowded IMT room with limited reference to a mine plan and little reference to any written record of previous events. In this instance, the IC’s recollection of events was substantially accurate, if not entirely so, however it would not be good practice to suggest that such would always be the case.

The lack of white-boards and/or notice sheets hindered the transfer of information, as did the lack of a set of Goals, Objectives, Priorities, Resources and Status board. The IMT2 had no Information Check Sheets to refer to in order for them to assess whether they had all the relevant information and the detailed status of each of the elements of the emergency response.

The change-over meeting concluded and IMT2 took charge at 7:15am. The underground exercise was terminated at 7:30am once Mines Rescue Team 3 returned to the FAB with the last of missing workers. A desktop exercise involving the IMT2 continued until 8:28am. During the desktop exercise, IMT2 were questioned on their understanding of previous events, the current status of the deployment and availability of current resources (personnel and equipment) and their proposed future courses of action. It is well recognised that information in the possession of IMT1 may have been interrupted in its passage to IMT2 by the termination of the underground exercise. Nevertheless, when questioned IMT2 was of the opinion that IMT1 had passed onto it all the information it required.

However, some of the information that was not passed on, or was incorrectly gathered, included: �� the time that the fall of ground occurred �� the exact locations of the missing / injured workers – were they in transit, on the surface, at the hospital etc �� the status of family notifications �� the exact location of the seal that had been breached – further confused by the lack of a mine plan �� the exact nature of the changes that had been made to the underground regulators �� the phone at the FAB (Tailgate 205) was not working and they were using a phone some 100 metres away �� the status of the SSR90 caches, first-aid kits and trauma kits in the panel where people were being deployed as well as

the status of non-working phones underground and the status of the mines rescue resources, suits, O2 bottles etc

The new IMT personnel need not only to gain the information from the previous team, they also need to maintain the momentum of the IMT and the group dynamic. This is often best achieved through a staggered change-over. This staggered change-over can commence as early as the 5 hour mark with the IC usually the last to change out. The IC cross over may take up to 2 hours as the IC is often very difficult to move on.

Page 22 of 101


The replacement IC needs to be aware to look for fatigue and monitor the decision making processes during the changeover – this should be included on the Duty Cards of the IC and the backup IC.

Recommendations

29. That the IMT members change-over be conducted on a staggered basis with no more than 2 persons being shifted at a time. This will provide for much more cohesion in the team and limit the possibility of loss of information

30. That there be a greater use of aids such as mine plans, whiteboards, flipcharts etc to display relevant information. A written record of the status of resources is vital to the change-over of any command structure.

31. A written chronological record of milestone events be kept, updated regularly and referred to 32. Consideration be given to allowing the display of this information (through windows) so that persons can update

themselves without having to constantly interrupt the IMT discussions with questions 33. A series of Check Sheets be developed for IMT2 to act as memory prompts in the same way as a Debriefing Officer

ensures capture of information. The prompt sheets could include such things as: �� options discussed and reasons for not doing and/or doing �� current goals / actions with expected outcomes, responsibilities and timeframes �� any alternative or secondary thrusts being investigated �� any limits established … time, gas levels, temperatures �� problems or difficulties experienced to date

Page 23 of 101


ASSESSMENT OF IN-SEAM INTERVENTION – QUEENSLAND MINES RESCUE

Assessors: Peter Baker, Warren Pendlebury and Greg Dalliston

The effort and commitment of the members of the QMRS (staff and volunteers) to respond to a simulated emergency at this time of night needs to be congratulated. Most had worked long shifts on the day of the incident and were called out after very little, if any, sleep and many traveled long distances to participate.

The problem with conducting simulated underground mines rescue events is, and always has been, creating the realism necessary to keep adrenaline high for all participants. Addressing these realities requires a balance in the practicalities of simulating an underground emergency environment, with the need to ensure realistic time frames are incorporated into the simulation.

The hot and humid conditions in the 205 panel return (31qC Dry and 30qC Wet) ensured that this exercise was conducted in close to actual conditions. Although the ventilation flow of 2.4 m/sec was six times that which would have been present if the scenario presented was real.

The purpose of this section of the Level 1 Emergency is to assess the practices and procedures adopted by the Mines Rescue teams in comparison to the mines rescue training provided – in order to assess the adequacy of the procedures and protocols themselves and the understanding of those procedures by the teams.

The first response from Kestrel rescue trainees was limited by the number of proficient trainees available and the number of persons who held senior positions (such as Ventilation Officer), and who were members of the IMT. Of the mines rescue trainees on site, only one team could be deployed, and hence, could not be deployed into the tailgate without a backup team. This slowed response to reach the first casualty located at 15 cut-through:

�� One member was out of oxygen time. �� Two members had worked the previous 12 hour shift, and it was decided that they were not fit to respond. �� One member was sick. �� Others members on site were part of IMT, the Ventilation Officer and FAB person. �� The mine geologist was deployed in MRT 1 when the known incident related to a major roof and goaf fall. This person

may have been valuable in IMT in evaluating the ground conditions around the fall.

While the response to call out by mines rescue members was timely, the deployment of teams from the surface to underground could have been improved. This was highlighted by the need to MRT 1 to be on standby for MRT 2 after directly being deployed in hot and humid conditions themselves.

The QMRS activities conducted and co-ordinated underground were done so in a professional manner. The use of QMRS Station Superintendent as the FAB Controller ensured that there was excellent control of operations:

�� All tasks assigned were achieved. �� Communication to Team Captain and team members was of a high standard. �� Use of flameproof diesel vehicle was delayed even when CH4 was at 1.25%.

Page 24 of 101


The set up of the fresh air base (FAB) was done efficiently, although the minimum equipment required was not met in total. Spare oxygen cylinders for the BG174’s were not available and this could have impacted on the exercise if MRT 1, who had previously been deployed in hot and humid conditions, were on standby for MRT 2. This left MRT 1 with suits which had oxygen cylinders less than full pressure.

The deployment time for hot and humid conditions as derived from the QMRS protocols is an important control to minimise effects on mines rescue team members. This was spelt out when MRT 1 went over their deployment time of 55 minutes by some 45% (24 minutes), and as a result had two team members visibly effected by the conditions.

The MRT’s knowledge and application of first aid displayed, including the level of information about pertinent conditions by teams at change-over was of a high quality. The MRT’s did not appear to be aware of the position and content of the mines first aid and trauma kits. One of these kits was at 205 tailgate double-doors crib room, some 20 metres from the FAB. This equipment including air splints could have been used on the casualty on longwall face, who was known to have a broken leg.

The distance from the FAB phone connected to the surface limited the ability to influence the IMT by the FAB Controller who was vastly experienced in rescue and was on the pointy end of the information chain.

The long distance to the casualty on the longwall through irrespirable atmosphere was identified and thus the fact that aided response on foot was impossible. The use of a diesel vehicle to reach this area was identified early but hesitation to use this once CH4 level reached 1.25%. (The requirements for use of flameproof diesels under legislation are 1% withdraw vehicle and 1.25% shut vehicle down.)

FAB Controller stressed that irrespirable atmosphere was anywhere that the gas levels are > the legislative limits. Ventilation station in 205 tailgate was not clearly marked on the plan used by QMRS and was poorly marked on the rib at the station.

Recommendations

As an outcome of these assessments, it is recommended that:

34. There be a review of the Kestrel Mines Rescue System in the early part of surface intervention (i.e. when minimum persons are available).

35. Mines rescue teams are to ensure all team protocols are adhered to – even in the absence of reality, it is good practice (e.g. communications and information left with the FAB Official, Captain / Team checks on equipment etc.)

36. An expert working party be established to research the use of flameproof vehicles in atmospheres containing levels of flammable gases in excess of the current legislative requirements, and guidelines be developed on how and when they may or may not be used in life threatening scenarios. The outcome of this research may result in changes in the wording of legislation.

37. The rescue efforts appeared hampered by a lack of effective communications between the FAB and the surface. The use of a phone some 100 metres away, while in direct line of site appeared to minimise communication from the FAB to

Page 25 of 101


IMT. The availability of phone and lines as part of the mines emergency equipment to allow a line to be run from permanent phones to FAB positions should be assessed as part of the mines emergency system. Mines should have a phone and line available to run from FAB to mine communication system to minimise the hazard of incorrect communication, information breakdown and ensure timely communication to surface for input to IMT.

38. Queensland Mines Rescue Service and mines through their mines rescue agreement should ensure that competencies are developed and persons trained for the key positions of Fresh Air Base Controller and Substation Mines Rescue Controller so that in the event of QMRS staff members not being available, competent persons will be available for these key roles.

39. While QMRS have developed controls to attempt to minimise the effects on mines rescue personnel deployed in hot and humid conditions these controls (administration controls) are low on the list of hierarchy of controls. It is recommended that QMRS investigate modern control methods to minimise this hazard. Some controls may include cooling vests, cooling of breathing tubes etc.

40. When developing Mines Rescue Team tasks, position, status and content of the mine’s emergency equipment which may be relevant to the task being undertaken should be marked on the plan and communicated to MRT teams and FAB Controller.

41. And perhaps most importantly, the exercise clearly showed that the better the escape systems (and therefore survival systems) in place at a mine, the more likely it is that mines rescue teams will be required to enter and search for survivors some of whom may be at distances not able to be covered on foot within the time constraints placed by use of self contained breathing apparatus– the industry as a whole needs to ensure we are ready for this.

Page 26 of 101


ASSESSMENT OF SURFACE AND MINES RESCUE CONTROL

ASSESSORS: MURRAY BIRD AND TONY DE SANTIS

From the outset, when the emergency exercise was first triggered the response of the mine site personnel was in line with the type of situation that was presented to them and was treated with the required level of urgency.

One of the problems that has been commonly identified in other simulated exercises is the lack of support available for the Control Room Operator when the emergency happens outside of “normal” working hours. On this occasion the night shift crew was starting work just as the emergency was starting to escalate and were therefore able to lend assistance.

One of the deputies on the oncoming shift was rescue trained and was the first to assume the role of Surface Controller. He was able to gather the necessary information and disseminate it to the nightshift crew.

The critical roles of Portal Sentries, and Gate Security were also allocated along with clear instructions to the Lamp Room Attendant to make sure he kept an accurate record of who was in the mine and names of anyone who came out of the mine.

The way that the callout procedure has been established at Kestrel allowed the Control Room Operator to focus on getting information to and from the underground, rather than being pre-occupied with making numerous external calls. The only external phone call he had to make was to the Mine Manager. It was then the Mine Manager who was responsible for making additional calls, including the mine-site Mines Rescue Co-ordinator. With the use of mobile phones, the Mine Manager and the mine-site Mines Rescue Co-ordinator were able to utilise their time whilst driving to the mine to contact other members of the IMT and to mobilise mines rescue teams and QMRS personnel.

It wasn’t long after the Mine Manager and the mine-site Mines Rescue Co-ordinator arrived that the mines rescue brigadesmen started to arrive. This ensured that an operational team was available by the time the IMT had decided to send them underground. Once the QMRS Assistant Superintendent arrived, the Mines Rescue Co-ordinator assumed a support role to the Superintendent. This may have been by design or based on the fact that the initial Mines Rescue Co-ordinator had to be replaced when he went into the mine with the first rescue team as an operational team member. Both the QMRS Assistant Superintendent and the Mines Rescue Co-ordinator spent time alternating between the IMT room and the rescue room.

Once the extent of the emergency became clear, the Mines Rescue Co-ordinator realised that he was going to need more than just the one Kestrel mines rescue team he had available. The decision was made to instigate the Mutual Assistance Scheme and mines rescue personnel from the neighbouring Crinum Mine were called out. The call out started at 1:10am with 16 team members on-site by 2:41am. Overall, the callout procedure and response of rescue team personnel was handled extremely well.

The overall response from QMRS was handled very well. The Blackwater Mines Rescue Superintendent and Assistant Superintendent and GAG Jet Co-ordinator (with GAG Jet) all arrived on-site within a short time of each other, approximately 2½ hours after the call to evacuate the mine had been initiated.

These roles are critical to ensure clear communication channels between the IMT, the rescue teams on the surface, the FAB and the operational teams. The purpose of this part of the assessment was to review the effectiveness of the surface response and liaison between mines rescue personnel, IMT and surface control.

Page 27 of 101


Observations

�� Initial response to incident was handled well by the mine site personnel. �� Deployment of QMRS personnel and mines rescue personnel was handled extremely well - although the briefings of the

first 2 teams was not handled as well as it could have been and appeared rather ad hoc �� The IC was regularly updating those on the surface, but not Mines Rescue Teams going underground. This seems at

odds with priorities �� The first 2 teams were briefed only by the Mines Rescue Coordinator – who, in turn, had not been fully briefed. Not all

the information was passed on and teams asked a number of background questions to which answers were not known. �� There was up to 90 minutes between the IMT determining that rescue teams were needed and the first team leaving the

surface. The first team was ready well before they were briefed �� Team equipment preparation was slow with only 1 brigadesman initially available. Once the QMRS arrived the process

became most efficient. However, only the minimum amount was prepared, for example, when the decision was made to send 8 man teams instead of 6 – more time was spent on readying the extra gear

�� The use of QMRS Superintendent at FAB assisted in communication flow between surface and rescue teams. �� The role of the QMRS in the IMT was not clearly defined - appeared to be part of the decision-making team within the

IMT but not formally part of IMT. �� Information flow from the Control Room, including gas alarms, appeared disjointed / ad hoc. �� Instructions to rescue teams were verbal and passed on from IMT to QMRS Superintendent to rescue teams.

Sometimes instructions can lose something in the translation. �� Some written instructions were issued (although somewhat vague) after the verbal instructions given. �� Mine plans not available for rescue teams. �� Cap lamps and rescuers not identified until the rescue teams were told that they were ready to go. �� The team from Crinum brought their own equipment, even though the Mutual Assistance protocols did not require it.

This worked well and saved time later on in the exercise

Recommendations

42. The IC, or senior IMT member, should brief Mines Rescue Teams or at least be present to ensure that all information is being passed on and that questions can be answered by somebody familiar with the mine.

43. Testing of Mines Rescue Equipment should be continued until all of it is completed.

44. Greater concentration on getting the first team off the surface properly briefed and equipped is needed as this is the hardest thing to do in reality. Once the actions and limits as set by the IMT, this must become the priority.

45. Basic mine and incident information should be written up on a white-board in the Mines Rescue Room. An enlarged Captains Information Sheet could suit the purpose.

46. Review Mutual Assistance protocols in relation to additional equipment being immediately dispatched from adjacent mines.

47. The role of the QMRS within the IMT should be clearly defined – for example, formally recognised as part of the decision-making team and / or advisory and / or implementation.

Page 28 of 101


48. It should be a consideration to set up a gas-monitoring terminal in the IMT room so that gas trends can be continually monitored.

49. Clearly defined instructions to be issued to rescue teams. One way of doing so could be writing the instructions on the electronic whiteboard in the IMT room and giving the printout to rescue teams.

50. The role of preparing and issuing plans during an incident should be clearly defined. Additional plans will always be required. This may be a role for the Mine Surveyor.

Page 29 of 101

TTHHEE TTIIMMEELLIINNEE
Page 30 of 101

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at ch

ock 5

3 with

a firs

t -aid

er an

d 4 S

SR90

s (to

be re

trieve

d fro

m Ta

il Ga

te ca

che a

t c/t 3

0)

0:54

2231

Co

ncer

n exp

ress

ed in

contr

ol ro

om ab

out s

till no

conta

ct fro

m 20

4 Dep

uty.

1:00

2232

20

4 Dep

uty no

-road

ed B

Hea

ding (

trans

port

road

) 205

main

gate

outby

e 0 cu

t-thr

ough

. 1:0

1 22

34

CRO

decla

red i

ncide

nt an

d com

menc

ed in

ciden

t log.

1:03

2235

20

4 Dep

uty co

ntacte

d CRO

from

204 t

ailga

te en

tranc

e. Ad

vised

��

roof

fall 5

– 6 m

etres

(whic

h was

impa

ssibl

e) in

belt r

oad 3

3 cut-

throu

gh, 2

05 m

ainga

te ��

all po

wer o

ff sec

tion

��no

sign

of m

en

��tw

o veh

icles

in 20

5 main

gate

pane

l ��

venti

lation

slow

due t

o fall

, fres

h air r

eadin

gs at

lip of

fall

��ch

ecke

d all s

toppin

gs al

ong 2

05 ho

motro

pal b

elt –

in tac

t ��

no D

AC co

mmun

icatio

ns al

ong 2

05 be

lt roa

d Fiv

e of th

e six

longw

all cr

ew le

aves

53 ch

ock.

Cas

ualty

left w

ith 3

x SSR

90’s

1:04

2240

CR

O ar

rang

es fo

r veh

icles

to go

to ta

ilgate

205 i

n cas

e cre

w wa

lk ou

t the 2

05 pa

nel v

ia the

tailg

ate

1:09

2241

Lo

ngwa

ll cre

w ar

rived

at S

SR ca

che,

30 cu

t-thr

ough

tailg

ate

1:10

2242

Lo

ngwa

ll cre

w de

parte

d cac

he w

ith 4

men h

eadin

g outb

ye (w

ith on

e SSR

90 an

d plan

) and

first

-aide

r retu

rned

to C

asua

lty #1

on th

e fac

e with

2 x S

SR90

’s 1:1

1 22

43

204 D

eputy

decid

ed to

enter

205 t

ailga

te in

vehic

le in

sear

ch of

miss

ing cr

ew. L

oade

d tra

uma k

it, firs

t aid

kit an

d stre

tcher

from

205 t

ailga

te cri

broo

m an

d too

k pa

nel fi

rst -a

ider a

nd ga

s dete

cting

equip

ment.

1:1

2

2246

Al

l per

sons

acco

unted

for e

xcep

t for 6

perso

ns m

issing

at lo

ngwa

ll 205

1:1

5 22

47

CRO

open

ed D

uty C

ard 1

brief

case

and a

ssum

ed th

e role

of In

ciden

t Con

trolle

r. 1:1

6 1:1

7 22

50

204 D

eputy

in co

mpan

y with

an ex

perie

nced

mine

wor

ker,

enter

ed ta

ilgate

retur

n thr

ough

doub

le do

ors.

Dep

uty ta

king C

O2 re

ading

s with

21/31

drag

er tu

bes

1:19

2256

20

4 Dep

uty an

d firs

t -aid

er re

ache

d 4 cu

t-tho

ugh,

205 t

ailga

te an

d we

re ad

vised

that

they w

ere s

uffer

ing fr

om re

spira

tory d

istre

ss (1

0.4%

CO 2

). Do

nned

self

resc

uers,

took

read

ings a

nd w

ithdr

ew.

1:25

2257

Lo

ngwa

ll cre

w (4

men

) arri

ved a

t 20 c

ut-thr

ough

cach

e. T

hree

SSR

90’s

at ca

che a

nd 1

carri

ed fr

om 30

cut-t

hrou

gh ca

che.

Cha

nge o

ver c

omple

ted an

d cre

w lef

t at 2

301

1:24

2301

��

204 D

eputy

calle

d fro

m ph

one 7

57 at

205 t

ailga

te cri

broo

m. N

orma

l pho

ne di

d not

work

– had

to us

ed em

erge

ncy l

ine (n

ot p

art o

f this

exe

rcise

). Ad

vised

the

CRO

of th

e foll

owing

read

ings:

4.1%

CH4

, 19.6

ppm

CO, 1

7.8%

O2,

10.4%

CO2

, ven

tilatio

n 0.4

m/s t

aken

from

the v

elome

ter –

need

to m

ake

corre

ction

s. Te

mper

ature

30qC

dry,

29qC

wet

��Su

gges

ted m

ines r

escu

e per

sonn

el re

quire

d to e

nter t

he ar

ea.

1:30

Page

32 o

f 101

Real

Tim

e Ac

tions

Sum

mar

y

2345

Mine

Man

ager

arriv

ed on

site.

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

Even

t Tim

e 23

02

First

gas a

larm

on C

ONSP

EC. T

ailga

te 20

5 sen

sor b

etwee

n 0 an

d 1 cu

t-thr

ough

: 8.7

ppm

CO, 2

.15%

CH4

1:3

1 23

05

Seco

nd C

ONSP

EC al

arm

at 20

5 tail

gate

: 19.6

ppm

CO, 4

.17%

CH4

1:3

4 23

08

��Me

mber

of lo

ngwa

ll cre

w sto

ps th

roug

h exh

austi

on (

Casu

alty #

2)

��De

cision

mad

e to l

eave

him

resti

ng un

der im

prov

ised a

ir-sh

ower

10 m

etres

outby

e 15 c

ut-thr

ough

, 205

tailg

ate

1:37

2309

��

CRO

conta

cted M

ine M

anag

er (in

tran

sit to

mine

site)

on m

obile

– up

date

of sit

uatio

n with

gas r

eadin

gs.

��CR

O ins

tructe

d to e

vacu

ate th

e mine

1:3

8

2310

��

CRO

infor

med O

utbye

Sup

ervis

or to

act a

s Pit B

ottom

Mar

shall

. 1:3

9 23

12

��20

4 Dep

uty an

d cre

w lef

t pan

el for

surfa

ce

��CR

O ha

s acc

ounte

d for

all p

erso

nnel

and s

ecur

ity es

tablis

hed o

n sur

face.

1:41

2320

��

Long

wall c

rew

arriv

ed at

10 cu

t-thr

ough

cach

e. Pi

cked

up al

l 3 S

SR90

’s to

carry

but d

id no

t don

. 1:4

9 23

33

��Lo

ngwa

ll cre

w ar

rive a

t fres

h-air

, dou

ble do

ors 2

05 ta

ilgate

. ��

Long

wall d

eputy

conta

cted C

RO us

ing em

erge

ncy p

hone

at 75

7. Pr

ovide

d deta

iled b

riefin

g of e

vents

up to

that

time

2:02

2341

QM

RS B

lackw

ater S

uper

inten

dent

phon

ed in

to C

RO re

ques

ting b

rief

2:10

2:14

0015

Un

derg

roun

d Mine

Man

ager

brief

ed IM

T of

incide

nt. D

ecisi

on m

aking

proc

ess d

eterm

ined,

meeti

ng pr

otoco

l dete

rmine

d, ris

k ass

essm

ents

/ cha

nge

mana

geme

nt pr

oced

ures

set in

plac

e. 2:4

4

0016

Ind

ustry

Site

Safe

ty an

d Hea

lth R

epre

senta

tive a

rrive

d on s

ite.

2:45

0024

Ins

pecto

r and

Mine

s Res

cue S

uper

inten

dents

arriv

e on-

site.

2:53

0025

Th

ree o

f the m

issing

long

wall c

rew

arriv

ed on

surfa

ce.

2:54

0026

Lo

ngwa

ll cre

w de

brief

ed on

surfa

ce –

no hy

drati

on ch

ecks

2:5

6 00

35

Incide

nt Co

ntroll

er de

brief

ing 20

4 Dep

uty in

IMT

– no p

lan w

as us

ed.

3:04

0041

Si

te Se

nior E

xecu

tive a

rrive

d on s

ite.

3:10

0043

IM

T re

conv

ened

. Ven

tilatio

n Offic

er pr

ovide

d ven

tilatio

n rea

dings

from

Con

spec

and t

ube b

undle

of ta

ilgate

retur

n. V

entila

tion O

fficer

advis

ed tu

be bu

ndle

read

ings h

ad be

en co

nfirm

ed by

the G

C an

d wer

e: 11

.8ppm

CO,

2.51

% C

H4, 1

9.11%

O2,

6.31%

CO2

. 3:1

2

0107

Mi

ne S

ite M

ines R

escu

e Co-

ordin

ator in

itiated

mutu

al as

sistan

ce ca

ll. 3:3

6 01

08

��IM

T de

tailed

disc

ussio

ns on

optio

ns fo

r rec

over

y of m

issing

perso

ns

Optio

n 1 –

Drive

vehic

le str

aight

down

tailg

ate no

w (C

H4 2.

6 %)

Optio

n 2 –

Reve

rse ai

rflow

in tai

l-gate

Op

tion 3

– Br

eech

seal

inbye

33C/

T 20

5 Main

gate

Optio

n 4 –

Load

out a

nd ex

tricate

over

fall

Optio

n 5 –

Bore

holes

3:37

Page

33 o

f 101

Real

Tim

e Ac

tions

Sum

mar

y

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

Even

t Tim

e ��

NR&M

Insp

ector

proh

ibited

the u

se of

dies

el ve

hicle

in the

retur

n at C

H4 co

ncen

tratio

ns of

2.5%

. 01

30

��IM

T dis

cuss

ions o

n risk

asse

ssme

nt to

reco

ver t

he ca

sualt

y fro

m 15

cut-t

hrou

gh ta

ilgate

. Trig

gers

for th

e bac

k-up t

eam

to as

sist a

nd es

tablis

hed

trans

port

avail

abilit

y. ��

NO S

ENSE

OF

URGE

NCY

desp

ite th

e fac

t that

the IM

T ha

d ide

ntifie

d SSR

90 ex

pirati

on tim

e app

roxim

ately

3:00a

m. E

xpira

tion t

ime f

or ca

sualt

ies on

lon

gwall

was

3:00

am, c

asua

lty at

15 cu

t-thr

ough

, tailg

ate w

as 12

:30am

.

3:59

0136

Ins

tructi

on gi

ven t

o pre

pare

2 x E

IMCO

’s an

d 3 x

PJB’

s to p

it bott

om.

4:05

0140

GA

G ar

rives

on si

te.

4:09

0145

Co

ntinu

ed di

scus

sions

in IM

T on

optio

ns fo

r rec

over

y. N

o dec

ision

s yet

made

. No t

eam

yet d

eploy

ed.

4:14

0152

Bl

ackw

ater S

tation

Sup

erint

ende

nt ar

rived

on si

te.

4:21

0155

IM

T dis

cuss

ion on

venti

lation

optio

ns. S

afe w

orkin

g per

iods f

or m

ines r

escu

e tea

ms, n

umbe

r of te

ams a

vaila

ble. M

ines I

nspe

ctor’s

comm

ent “

Gentl

emen

, tim

e is t

icking

, it’s

time t

o do s

ometh

ing’.

4:24

0205

IM

T tol

d to r

econ

sider

ALL

optio

ns by

asse

ssor

. 4:3

4 02

13

CRO

expr

esse

d con

cern

abou

t the m

en un

derg

roun

d who

se ai

r was

to ru

n out

at ap

prox

imate

ly 3:0

0am.

4:4

2 02

16

Confi

rmati

on of

EIM

CO’s

and P

JB’s

read

y. 4:4

5 02

18

��QM

RS T

eam

1 rea

dy to

go un

derg

roun

d. ��

Conti

nued

disc

ussio

n on O

ption

3 an

d ass

ociat

ed ha

zard

s. 4:4

7

0227

QM

RS T

eam

1 lea

ves s

urfac

e tas

ked w

ith re

cove

ry of

longw

all cr

ew m

embe

r at 1

5 cut-

throu

gh, 2

05 ta

ilgate

. 4:5

6 02

38

First

PED

mess

age s

ent to

trap

ped m

en –

‘Help

is on

it’s w

ay’.

5:07

0240

Fu

rther

IMT

discu

ssion

rega

rding

knoc

king o

ver t

he se

al in

maing

ate O

ption

3. D

iscus

sion i

s bog

ging d

own.

IMT

advis

ed by

asse

ssor

s “too

muc

h sub

jectiv

e op

inion

, not

enou

gh ob

jectiv

e pro

of”.

5:09

0241

Cr

inum

mine

s res

cue t

eam

memb

ers a

rrive

on-si

te.

5:10

0245

FA

B es

tablis

hed a

t 205

tailg

ate by

Mine

s Res

cue T

eam

1. 5:1

4 02

53

Mine

s Res

cue T

eam

1 (8 m

en) d

epar

ts FA

B. N

otifie

d by C

RO th

at MR

T 2 w

ere s

uiting

up on

surfa

ce.

5:22

0304

IM

T dis

cuss

ion on

sequ

ence

of w

ork r

equir

ed fo

r the

Opti

ons 2

and 3

iden

tified

. 5:3

3 03

05

CRO

advis

ed th

at Cr

inum

Mine

s Res

cue T

eam

2 rea

dy to

be de

ploye

d whe

n nee

ded.

5:34

0316

IM

T we

re ad

vised

that

QMRS

Tea

m 2 (

8 men

) wer

e rea

dy to

go.

5:45

0318

��

QMRS

Tea

m 2 l

eft su

rface

task

ed as

stan

dby f

or Q

MRS

Team

1.

��QM

RS T

eam

1 hav

e rea

ched

patie

nt at

15 cu

t-thr

ough

5:4

7

0322

IM

T se

ttle on

Opti

on 3

to br

each

the s

eal in

bye 3

3 cut-

throu

gh, M

ainga

te 20

5 B H

eadin

g and

turn

off th

e gas

drain

age p

oints

22 an

d 26.

5:51

0332

QM

RS T

eam

2 arri

ved a

t FAB

– 8 m

en

6:01

0343

QM

RS T

eam

1 rad

ioed F

AB as

ked f

or Q

MRS

Team

2 for

assis

tance

6:1

2

Page

34 o

f 101

Real

Tim

e Ac

tions

Sum

mar

y

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

Even

t Tim

e 03

50

��QM

RS T

eam

1 arri

ved a

t 9 cu

t-thr

ough

TG2

05, r

adioe

d FAB

and t

hat th

ey ha

d left

patie

nt wi

th SS

R90 a

nd un

der c

ompr

esse

d air f

low as

they

wer

e ru

nning

out o

f wor

king t

ime.

QMRS

Tea

m 1 w

ere r

eturn

ing to

FAB

. ��

Mine

Man

ager

dire

cted I

MT to

the c

hang

e-ov

er w

ith IM

T#2 a

t 7.30

am. E

stabli

shed

a 1 h

our t

imeli

ne to

pass

over

infor

matio

n to t

heir a

ltern

ate, a

nd th

e ch

ange

over

to be

comp

leted

by 7:

30am

.

6:19

0352

MR

T 2 p

repa

ring t

o lea

ve F

AB. D

iscus

sed l

eavin

g 2 te

am m

embe

rs to

carry

out a

ir rea

dings

. 6:2

1 03

57

CRO

was i

nform

ed th

at ca

sualt

y was

on hi

s way

out a

nd Q

MRS

Team

2 re

ques

ted as

sistan

ce.

6:26

0402

QM

RS A

/Sup

erint

ende

nt re

porte

d to I

MT th

at QM

RS T

eam

3 (8 m

en) w

ere o

n sur

face

6:31

0403

IM

T co

nven

ed –

risk a

nalys

is re

gard

ing re

versi

ng th

e ven

tilatio

n. 6:3

2 04

04

��QM

RS T

eam

1 and

QMR

S Te

am 2

met a

t 4 cu

t-thr

ough

TG2

05 an

d exc

hang

ed de

tailed

infor

matio

n con

cern

ing pa

tient.

��

One m

embe

r of Q

MRS

Team

1 su

fferin

g hea

t dist

ress

. 6:3

3

0411

20

4 Dep

uty an

d EIM

CO dr

ivers

desp

atche

d to b

reac

h sea

l at 2

05 m

ainga

te an

d clos

ing th

e reg

ulator

at 20

5 bloc

k I H

eadin

g. 6:4

0 04

14

QMRS

Tea

m 2 r

each

ed ca

sualt

y at 9

cut-t

hrou

gh.

6:43

0435

��

QMRS

Tea

m 2 p

atien

t con

dition

deter

iorate

s at 5

cut-t

hrou

gh –

beco

mes s

tretch

er ca

se.

��20

4 Dep

uty ar

rived

in 20

5 pan

el wi

th 2 x

EIM

CO’s

and o

pera

tors.

7:04

0455

QM

RS T

eam

2 arri

ves a

t FAB

with

patie

nt.

7:24

0457

��

QMRS

Tea

m 3 l

eavin

g sur

face t

aske

d with

cond

uctin

g ven

tilatio

n cha

nge,

close

regu

lator

in 20

4 pan

el re

turn a

nd op

en do

ors i

nbye

FAB

. ��

CRO

infor

med t

hat M

RT 2

patie

nt wa

s out

and o

kay.

7:26

0500

20

4 Dep

uty fin

ished

knoc

king d

own s

eal 3

3 C/T

205 M

ainga

te “B

” Hdg

7:2

9 05

02

QMRS

Tea

m 1 d

epar

t FAB

with

patie

nt he

ading

in ve

hicle

to su

rface

. 7:3

1 05

10

QMRS

Tea

m 3 a

rrive

at F

AB.

7:39

0516

20

4 Dep

uty in

forme

d CRO

that

seal

at 33

C/T

had b

een k

nock

ed do

wn at

0500

. 7:4

5 05

19

��IM

T ad

vised

that

seal

had b

een b

roke

n at 0

500.

��Se

cond

venti

lation

read

ing ta

ken i

n tail

gate

retur

n – ve

ntilat

ion ra

te do

ubled

. ��

Mine

Man

ager

brief

ed IM

T to

conta

ct alt

erna

tes fo

r man

agem

ent c

hang

e ove

r.

7:48

0520

QM

RS T

eam

1 rea

ched

the s

urfac

e with

casu

alty.

7:49

0532

Ve

ntilat

ion in

forma

tion r

elaye

d to C

RO th

at the

venti

lation

was

1.07

m/s

and q

uanti

ty 16

.9 m3 /s

. 8:0

1 05

35

IMT

deba

te on

diffe

renc

es of

infor

matio

n reg

ardin

g the

venti

lation

read

ings –

contr

adict

ory a

dvice

of ve

locity

1.70

m/s

or 1.

07 m

/s.

8:04

0540

Fu

rious

deba

te – f

atigu

e iss

ues b

ecom

ing ap

pare

nt. IM

T me

mber

s fru

strate

d. 8:0

9 05

47

Cons

pec i

nform

ation

at 20

5 tail

gate:

0.97

% C

H4, 5

.4ppm

CO.

8:1

6 05

49

IMT

infor

med o

f meth

ane l

evels

in ta

ilgate

205 n

ow be

low 1%

. 8:1

8

Page

35 o

f 101

Real

Tim

e Ac

tions

Sum

mar

y

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

Even

t Tim

e 05

50

Mine

Man

ager

disc

usse

d with

IMT

do w

e hav

e tea

ms av

ailab

le. M

ine M

anag

er as

ked A

/Sup

erint

ende

nt, Q

MRS,

on av

ailab

ility o

f mine

s res

cue t

eams

, whe

re

are t

hey.

IMT

discu

ssed

the u

se of

vehic

les fo

r the

resc

ue of

peop

le on

the l

ongw

all.

8:19

0555

20

4 Dep

uty no

tified

FAB

that

regu

lator

clos

ed in

I Hea

ding 2

05 bl

ock.

8:24

0558

��

Venti

lation

surve

y in 2

05 ta

ilgate

, airfl

ow of

1.07

m/s d

eterm

ined.

��FA

B Co

ntroll

er br

iefed

all p

erso

nnel

at FA

B ab

out p

lan. C

H4 no

w be

low 1%

, QMR

S Te

am 3

to be

desp

atche

d in a

vehic

le do

wn ta

ilgate

and r

etriev

e 2

perso

ns of

f the l

ongw

all.

��QM

RS T

eam

4 (6 m

en) r

eady

to go

unde

rgro

und.

8:27

0615

QM

RS T

eam

3 dep

arts

FAB

in Dr

iftrun

ner.

8:44

0622

IM

T inf

orme

d CO

on C

onsp

ec w

as 15

.4ppm

CO.

8:5

1 06

25

Tired

deba

te in

the IM

T on

the s

ource

of th

e inc

reas

ed C

O ma

ke

8:54

0641

IM

T co

mmen

ced c

hang

e ove

r mee

ting w

ith IM

T 2.

9:10

0651

IM

T de

bate

over

confu

sion r

egar

ding t

he tim

e of Q

MRS

Team

3 wa

s due

back

at th

e ribb

on ie

., 071

7 or 0

727

9:20

0657

QM

RS T

eam

3 arri

ved a

t the t

wo m

en (c

asua

lty +

first

-aide

r) on

long

wall f

ace.

9:26

0705

QM

RS T

eam

3 left

61 ch

ock w

ith ca

sualt

y and

first

-aide

r. 9:3

4 07

16

IMT

2 ass

umed

contr

ol.

9:45

0724

QM

RS T

eam

3 arri

ved a

t 9 cu

t-thr

ough

and i

nform

ed F

AB th

at the

y had

all m

embe

rs of

team

plus c

asua

lty an

d firs

t -aid

er.

9:53

0727

IM

T 2 d

ecide

d to d

eploy

QMR

S Te

am 4

in se

arch

of Q

MRS

Team

3.

9:56

0730

��

IMT

advis

ed by

CRO

that

QMRS

Tea

m 3 h

ad ar

rived

at F

AB in

PJB

– all

perso

ns ac

coun

ted fo

r. ��

Exer

cise t

ermi

nated

. 9:5

9

0747

IM

T 2 d

ebrie

fed by

asse

ssme

nt tea

m re

gard

ing de

sktop

exer

cise t

o con

tinue

mine

reco

very.

10

:16

0828

De

sktop

exer

cise t

ermi

nated

. 10

:57

Page

36 o

f 101


S
TTHHEE AAUUDDIITT TTOOOOLLS
Page 37 of 101

TIME

SUMM

ARY

OF A

CTIO

NS

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

LONG

WAL

L CR

EW E

SCAP

E AU

DIT

TOOL

ASSE

SSOR

S: P

ETER

BAK

ER, W

ARRE

N PE

NDLE

BURY

, GRE

G DA

LLIS

TON

AND

JAME

S MA

RSHA

LL

DETA

ILED

ACT

IONS

AND

COM

MENT

S 21

31

All L

ongw

all C

rew

(exc

ept D

eputy

) gath

ered

at ch

ock 2

4 and

expla

ined i

ncide

nt trig

ger.

Trigg

ers g

iven t

o cre

w wa

s a st

ateme

nt re

ad ou

t by t

he A

sses

sor “

You h

ave

just fe

lt a se

vere

air b

last a

nd he

ard a

majo

r fall

in th

e goa

f and

main

gate.

The

air

is th

ick w

ith du

st, ne

gligib

le ve

ntilat

ion”.

The

y wer

e also

told

they w

ere

expe

rienc

ing vi

olent

panti

ng an

d hea

dach

es (e

ffects

of C

O2)

2135

Cr

ew do

nned

Fen

zy’s

and b

egan

first

aid tr

eatm

ent o

f injur

ed em

ploye

e. As

part

of the

scen

ario,

the c

rew

were

infor

med t

hat d

ue to

the s

ever

ity of

the

wind

blas

t, one

of th

e cre

w ha

d bee

n kno

cked

over

and i

njure

d the

ir low

er le

g. 21

37

Caug

ht up

with

Dep

uty (d

oing i

nspe

ction

s nea

r tail

gate)

and g

ave h

im th

e sa

me in

forma

tion a

s the

crew

had r

eceiv

ed.

Depu

ty ha

d alre

ady r

eceiv

ed a

PED

mess

age f

rom

CRO

to co

ntact

him

urge

ntly.

He d

id so

BEF

ORE

he w

as aw

are t

hat th

e exe

rcise

had b

egun

, tho

ugh t

he co

nver

satio

n was

inter

rupte

d by i

ncide

nt as

sess

or.

2143

De

puty

and c

rew

now

togeth

er at

choc

k 24.

Two

men

disp

atche

d to t

he

tailga

te to

get fi

rst ai

d gea

r and

SSR

90’s.

Th

e com

munic

ation

diffic

ulty c

reate

d by w

earin

g self

resc

uers

was s

ubsta

ntiall

y re

duce

d by t

he us

e of n

ote pa

ds an

d pen

s. Co

mmun

icatio

ns be

twee

n cre

w an

d Dep

uty w

ere s

uffici

ent to

ensu

re th

at no

critic

al inf

orma

tion w

as ov

erloo

ked

– whil

e this

meth

od ta

kes t

ime,

it is v

ery t

horo

ugh a

nd cr

eates

a pe

rman

ent

reco

rd of

the d

iscus

sions

takin

g plac

e and

the d

ecisi

ons b

eing u

nder

taken

. 21

54

First

aid eq

uipme

nt an

d SSR

90’s

arriv

e at c

hock

24 an

d Dep

uty ex

plaine

d to

crew

that th

ey w

ere g

oing t

o do a

chan

geov

er fr

om F

enzy

units

to S

SR90

’s.

Long

wall D

eputy

was

very

awar

e of th

e lim

ited d

urati

on of

the b

elt w

orn f

enzy

un

it and

the a

moun

t of ti

me th

at wa

s req

uired

to ad

minis

ter fir

st aid

and

prep

are t

o eva

cuate

. 21

59

Chan

geov

er to

SSR

90 co

mplet

ed by

all m

embe

rs of

the lo

ngwa

ll cre

w (in

cludin

g cas

ualty

). Ch

ange

over

tech

nique

s wer

e con

ducte

d com

peten

tly. O

ne cr

ew m

embe

r ap

pear

ed un

sure

thou

gh di

d not

put h

imse

lf at r

isk –

he si

mply

watch

ed th

e cre

w me

mber

s. Tw

o SSR

90’s

had g

oggle

s whic

h fail

ed as

soon

as th

ey w

ere d

onne

d. It

appe

ared

that

the ru

bber

had d

eterio

rated

. 22

06

First

aid tr

eatm

ent c

omple

ted an

d cre

w be

gan e

xtrica

tion o

f injur

ed pa

tient

along

AFC

. At

this

point

it wa

s the

obvio

us in

tentio

n to t

ake t

he ca

sualt

y with

the c

rew.

Di

fficult

y and

redu

ced s

peed

of tr

avel

had n

ot ap

pear

ed to

be co

nside

red a

s ye

t.

Page

38 o

f 101

TIME

SUMM

ARY

OF A

CTIO

NS

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

DETA

ILED

ACT

IONS

AND

COM

MENT

S 22

25

Decis

ion m

ade t

o lea

ve ca

sualt

y on f

ace l

ine an

d lea

ve a

first a

id att

enda

nt wi

th him

. As

the c

asua

lty w

as tr

ansp

orted

alon

g the

AFC

, his

injur

ed le

g was

knoc

ked

time a

nd ag

ain on

the A

FC fli

ght b

ars.

This

wou

ld ha

ve al

most

certa

inly

rend

ered

the c

asua

lty un

cons

cious

due t

o sho

ck fr

om th

e pain

. No

stre

tcher

was

avail

able

as th

is wa

s loc

ated a

t the m

ainga

te.

Crew

had m

oved

appr

oxim

ately

30 ch

ocks

in 15

minu

tes (in

cludin

g init

ial lif

t on

to AF

C).

2235

Lo

ngwa

ll cre

w lea

ves c

asua

lty at

choc

k 53 (

with

three

spar

e SSR

90’s)

and

starts

mov

ing to

cach

e at 3

0 cut-

throu

gh.

It was

diffic

ult fo

r the

Dep

uty to

expla

in to

his cr

ew w

hat h

is int

entio

ns w

ere.

This

led to

a lon

g dela

y in d

epar

ting B

UT it

was i

mpor

tant th

at all

crew

me

mber

s (inc

luding

the c

asua

lty) h

ad a

good

unde

rstan

ding o

f wha

t the p

lan

was –

some

frus

tratio

n app

eare

d with

in the

crew

due t

o this

diffic

ulty i

n co

mmun

icatin

g. 22

41

Long

wall c

rew

(5 m

en) a

rrive

d at c

ache

at 30

cut-t

hrou

gh.

Ther

e wer

e thr

ee S

SR90

’s at

the ca

che a

t 30 c

ut-thr

ough

. The

first

aid

atten

dant

took t

wo of

thes

e and

retur

ned t

o the

casu

alty o

n the

long

wall f

ace.

The r

emain

ing fo

ur cr

ew m

embe

rs (in

cludin

g the

Dep

uty) t

ook t

he on

e re

maini

ng S

SR90

and t

he m

ine pl

an w

hich w

as al

so th

ere,

and c

ontin

ued

outby

e. 22

57

The l

ongw

all cr

ew (n

ow fo

ur m

en) a

rrive

d at 2

0 cut-

throu

gh ca

che.

The

re w

ere

three

SSR

90’s

at thi

s cac

he an

d the

crew

had c

arrie

d one

with

them

from

the

cach

e at 3

0 cut-

throu

gh.

Crew

chan

ged o

ver f

rom

SSR9

0 to S

SR90

.

On ro

ute to

this

cach

e, the

Dep

uty ha

d con

tinua

lly ch

ecke

d and

asse

ssed

the

cond

ition o

f the c

rew

memb

ers a

nd th

e atm

osph

eric

cond

itions

. Th

e num

ber o

f SSR

90’s

avail

able

had b

een c

alcula

ted.

The c

hang

eove

r was

cond

ucted

very

well a

nd ha

d bee

n well

prac

ticed

. 23

08

One c

rew

memb

er ph

ysica

lly di

stres

sed d

ue to

the s

tress

and h

umidi

ty. C

ould

not c

ontin

ue w

ith es

cape

. A

decis

ion w

as m

ade q

uickly

that

the ex

haus

ted cr

ew m

embe

r wou

ld ha

ve to

be

left w

here

they

wer

e. Th

e Dep

uty to

ok th

e cre

w me

mber

10 m

etres

furth

er ou

tbye t

o a co

mpre

ssed

air

outle

t and

expla

ined t

o him

(in w

riting

) to s

tay un

der t

he im

prov

ised ‘

air

show

er’ (w

ith ea

r plug

s in(

, kee

p his

SSR9

0 on a

nd st

ay in

an up

right

posit

ion.

Depu

ty the

n tur

ned t

he ai

r sho

wer o

n and

teste

d the

atmo

sphe

re to

deter

mine

the

effec

tiven

ess o

f the a

ir sho

wer.

2312

De

puty

and t

wo re

maini

ng cr

ew m

embe

rs lea

ve 15

cut-t

hrou

gh (le

aving

ex

haus

ted cr

ew m

embe

r) an

d con

tinue

outby

e.

Page

39 o

f 101

TIME

SUMM

ARY

OF A

CTIO

NS

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

DETA

ILED

ACT

IONS

AND

COM

MENT

S 23

20

Long

wall c

rew

arriv

ed at

10 cu

t-thr

ough

cach

e. Th

ree S

SR90

’s we

re av

ailab

le. T

he cr

ew pi

cked

up on

e eac

h to c

arry

but d

id no

t do a

chan

geov

er.

It was

not c

onsid

ered

nece

ssar

y to d

o a ch

ange

over

at ea

ch of

the c

ache

s be

caus

e at th

e spe

ed th

e cre

w we

re tr

avell

ing at

they

wer

e sur

e the

y wou

ld ma

ke it

back

to fr

esh a

ir in t

he tim

e the

y still

had i

n the

unit t

hey h

ad on

(tr

aining

was

to ch

ange

over

after

60 m

inutes

use)

. Th

is wa

s a va

lid de

cision

but a

sses

sors

were

not s

ure i

f the c

rew

memb

er at

15

cut-t

hrou

gh w

as co

nside

red w

hen a

ll thr

ee S

SR90

’s we

re ta

ken f

rom

the 10

cu

t-thr

ough

cach

e. 23

33

Long

wall c

rew

arriv

ed at

the d

ouble

door

s and

deter

mine

d the

y wer

e now

in

fresh

air.

Whe

n the

crew

arriv

ed at

the d

oors

the D

eputy

used

his g

as de

tector

to co

nfirm

fre

sh ai

r and

the c

rew

were

instr

ucted

that

it was

safe

to re

move

their

SSR

90’s

after

they

pass

ed th

roug

h the

door

s. 23

35

Depu

ty co

ntacte

d CRO

on th

e eme

rgen

cy nu

mber

from

phon

e 757

long

wall

tailga

te cri

broo

m.

Depu

ty inf

orme

d CRO

of hi

s nam

e, loc

ation

, who

was

with

him

and w

ho he

had

to lea

ve be

hind (

and w

here

they

wer

e). H

e the

n exp

laine

d wha

t had

occu

rred

in ch

rono

logica

l ord

er, d

iscus

sed s

ome o

ption

s and

aske

d wha

t they

wou

ld lik

e him

to do

. 23

45

Long

wall c

rew

left fo

r the

surfa

ce in

a PJ

B tha

t had

been

delib

erate

ly lef

t for

them

earlie

r. Th

ese m

en ca

me ou

t of th

e lon

gwall

tailg

ate in

a de

hydr

ated c

ondit

ion. T

he

thoug

ht of

leavin

g tra

nspo

rt for

them

was

an ex

celle

nt on

e – w

ater

shou

ld

also

be h

igh

on p

riorit

ies in

thes

e situ

atio

ns.

Page

40 o

f 101

TIME

ACTI

ONS

SUMM

ARY

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

205 M

AING

ATE

AUDI

T TO

OL

ASSE

SSOR

: TIM

JACK

SON

DETA

ILED

ACT

IONS

/ COM

MENT

S 21

31 –

2145

Fo

ur pe

rsons

at ch

ock 2

2 wer

e told

that

a goa

f fall h

ad oc

curre

d an

d tha

t they

wer

e suff

ering

from

rapid

pulse

, hea

dach

e and

we

re in

a co

nfuse

d men

tal st

ate.

One c

rew

memb

er w

as us

ing a

traini

ng un

it tha

t had

no no

se

piece

and g

oggle

s (co

ntinu

ed us

ing un

it). O

ne m

an w

as w

ith

asse

ssor

at m

ainga

te an

d the

Dep

uty w

as at

the t

ailga

te.

Ensu

re th

at tra

ining

units

are c

omple

te for

train

ee us

e.

2141

Cr

ew do

nned

units

and d

ecide

d to h

ead t

o main

gate.

Whe

n the

y rea

ched

the m

ainga

te the

y wer

e told

of an

impa

ssab

le ro

of fal

l and

that

venti

lation

was

slug

gish.

The

men

, usin

g note

taking

an

d talk

ing, d

ecide

d to h

ead t

o the

tailg

ate us

ing th

e bud

dy gr

ip sy

stem.

Reinf

orce

ment

of no

talki

ng w

hen e

scap

e app

aratu

s on n

eede

d.

2142

Cr

ew lo

cated

Sha

nnon

who

had a

n inju

red k

nee a

nd

comm

ence

d ass

essm

ent.

Perso

nnel

need

to be

mad

e awa

re th

at SS

R90’s

will

last lo

nger

than

90 m

inutes

if at

rest.

2146

Tw

o per

sons

wen

t with

Ass

esso

r tow

ards

the t

ailga

te, le

aving

tw

o per

sons

conti

nuing

asse

ssme

nt of

patie

nt.

2148

As

sess

or le

ft fac

e to p

repa

re ba

rrier

s in A

and B

Hea

ding.

2155

Ba

rrier

s com

pleted

. 22

05

Dies

el ma

n tra

nspo

rter s

toppe

d at 3

1 cut-

throu

gh, tr

ansfo

rmer

sit

e. De

puty

had s

toppe

d to c

heck

powe

r. H

e exp

laine

d tha

t he

had c

heck

ed al

l stop

pings

on th

e way

in. H

e was

advis

ed by

Co

ntrol

to inv

estig

ate th

e sam

e. 22

07

Depu

ty ch

ecke

d for

gas a

s he w

ent in

to 33

cut-t

hrou

gh B

to A

He

ading

: 20.9

% O

2, Ni

l CH 4

, 3pp

m CO

22

12

Depu

ty att

empte

d to r

ing co

ntrol

from

cribr

oom

in B

Head

ing.

He w

as ad

vised

that

there

wer

e no c

ommu

nicati

ons a

nd no

po

wer in

secti

on.

It is i

mpor

tant th

at PE

D re

liabil

ity is

inve

stiga

ted to

ensu

re w

orkin

g abil

ity.

2215

20

4 Dep

uty w

ent to

A H

eadin

g bar

rier,

Conv

eyor

Roa

d and

tried

ve

rbal

comm

unica

tion.

Verb

al co

mmun

icatio

n was

unsu

cces

sful.

Page

41 o

f 101

TIME

ACTI

ONS

SUMM

ARY

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

DETA

ILED

ACT

IONS

/ COM

MENT

S 22

16

204 D

eputy

chec

ked g

ener

al bo

dy in

A H

eadin

g and

obtai

ned:

20.9

% O

2, Ni

l CH 4

, Nil C

O an

d 0.2%

CO 2

. 22

19

204 D

eputy

chec

ked d

eputi

es st

atutor

y rep

ort b

ook i

n crib

room

an

d left

pane

l at 2

220.

2222

20

4 Dep

uty at

tempte

d to u

se ph

one a

t 205

Belt

Roa

d, A

Head

ing, 3

1 cut-

throu

gh an

d was

advis

ed th

at no

co

mmun

icatio

ns w

ere a

vaila

ble.

2230

20

4 Dep

uty at

tempte

d to u

se ph

one a

t 205

main

gate,

0 cu

t-thr

ough

, A H

eadin

g and

was

advis

ed th

at the

re w

ere n

o co

mmun

icatio

ns av

ailab

le.

2232

20

4 Dep

uty no

-road

ed at

205 m

ainga

te, B

Hea

ding a

nd fit

ted

infor

matio

n tag

. 22

35

204 D

eputy

rang

Con

trol fr

om 20

4 pan

el an

d adv

ised t

he

follow

ing in

forma

tion:

No co

ntact

has b

een m

ade.

Ther

e was

two v

ehicl

es in

the p

anel

and t

hat th

ere c

ould

be

quite

a few

men

in th

e pan

el.

Relay

ed th

e gas

read

ings h

e had

take

n. 22

44

204 D

eputy

gathe

red 2

04 cr

ew an

d exp

laine

d the

situa

tion.

Instru

cted t

he fir

st -a

ider t

o ass

ist th

e Dep

uty an

d ins

tructe

d the

re

st of

the cr

ew to

assis

t in ga

therin

g firs

t aid

equip

ment

and

then p

roce

ed to

the c

ribro

om an

d awa

it fur

ther in

struc

tions

. 22

52

PJB

left 2

04 cr

ibroo

m.

2250

20

5 tail

gate

– ven

tilatio

n dou

ble do

ors o

pene

d – D

eputy

ch

ecke

d gen

eral

body

: 0.6%

CH 4

and 0

.6%

CO 2

. 22

56

At 4

cut-t

hrou

gh, D

eputy

bega

n to f

eel e

ffects

of C

O2 po

isonin

g. Do

nned

self-r

escu

ers a

nd de

tected

17.8%

O2,

4.1%

CH4

, 19

.6ppm

CO

and 1

0.4%

CO 2

.

Depu

ty ha

d to b

e pro

mpted

to ta

ke C

O2 re

ading

– us

ing m

ulti-g

as de

tector

not c

ontin

uous

re

ading

s

2258

De

puty

took r

eadin

gs at

3 – 4

cut-t

hrou

gh, 2

05 ta

ilgate

: W

et bu

lb – 2

9qC

Dry b

ulb -

31qC

Ve

lomete

r – 2.

4 m/se

c (ad

vised

0.4 m

/sec)

2300

– 23

15

Depu

ty trie

d to p

hone

Con

trol –

enga

ged.

Use

d eme

rgen

cy lin

e to

conta

ct an

d adv

ised C

RO of

gas r

eadin

gs an

d obs

erva

tions

.

Page

42 o

f 101

TIME

ACTI

ONS

SUMM

ARY

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

DETA

ILED

ACT

IONS

/ COM

MENT

S 04

35

204 D

eputy

arriv

ed in

pane

l with

2 EI

MCO’

s and

two o

pera

tors.

He ex

plaine

d the

plan

to br

each

the s

toppin

gs in

A H

eadin

g. Ch

eck t

o see

if se

al wa

s bre

athing

in /o

ut.

3 x S

SR90

’s for

use b

y per

sonn

el.

Fork

tyne o

f EIM

CO to

brea

ch st

oppin

g – sm

all ho

le.

Depu

ty to

monit

or at

mosp

here

at st

oppin

g and

third

perso

n to a

ct as

spott

er ou

tbye E

IMCO

. De

puty

to gr

adua

lly op

en up

stop

ping.

Depu

ty to

take v

entila

tion r

eadin

g. 04

50

Initia

l hole

knoc

ked i

n stop

ping.

0500

Co

mplet

e stop

ping d

own a

nd ve

ntilat

ion re

ading

take

n. Ex

ercis

e ter

mina

ted.

0505

De

puty

and t

wo op

erato

rs lef

t pan

el.

Depu

ty to

be co

mmen

ded o

n his

effor

ts an

d eva

luatio

n of th

e situ

ation

.

Page

43 o

f 101

ELEM

ENT

PERF

ORMA

NCE

CRIT

ERIA

OBJE

CTIV

E EV

IDEN

CE S

OUGH

TOB

SERV

ATIO

N

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

INCI

DENT

MAN

AGEM

ENT

TEAM

AUD

IT T

OOL

ASSE

SSOR

S: M

ALCO

LM S

MITH

AND

DAV

ID C

LIFF

Emer

genc

yCo

ntro

l Fo

rmati

on of

Incid

ent

Mana

geme

nt Te

am

��Tim

e tak

en to

form

the I

ncide

nt Ma

nage

ment

Team

��W

ho fo

rmed

the I

ncide

nt Ma

nage

ment

Team

(duty

card

)

��Ma

ke up

of te

am (E

EHMP

)

��Re

lief p

erso

nnel

identi

fied

��Le

ader

ship

estab

lishe

d

��De

fined

role

of Inc

ident

Mana

geme

nt Te

am

��De

fined

role

of Inc

ident

Mana

geme

nt Te

am m

embe

rs

��De

fined

role

of Inc

ident

Mana

geme

nt Te

am su

ppor

t pe

rsonn

el

Incide

nt Co

ntroll

er (D

uty C

ard 1

) –

Statu

tory M

ine M

anag

er (

SMM)

Incide

nt trig

gere

d at 2

2:35 C

RO

Confi

rmed

at 22

:45 by

inter

im IC

SM

M on

site

23:49

IM

T br

iefing

00:15

Duty

Card

1 – 7

not s

ub ca

rds +

Ind

ustry

Safe

ty an

d Hea

lth

Repr

esen

tative

+ D

NRM

Inspe

ctor,

last

memb

er ar

rived

00:49

on si

te wi

th ste

nogr

aphe

r.

Relie

f per

sonn

el ide

ntifie

d on w

all pl

ans

Mine

Man

ager

clea

rly in

char

ge

Incide

nt Co

ntrol

Grou

p fun

ction

defin

ed

by H

azar

d Mgt

Plan

for E

merg

ency

Mgt

Roles

of IM

T de

fined

by du

ty ca

rds

Roles

defin

ed by

sub d

uty ca

rds

COMM

ENT

IMT

forma

tion p

roce

ss sm

oothl

y ex

ecute

d with

Duty

Car

d sys

tem be

ing

activ

ated a

nd im

pleme

nted.

Duty

Card

4 h

ad di

fficult

y in l

ocati

ng so

me su

b du

ty ca

rds –

duty

card

s in b

riefca

ses i

n sp

ecial

cabin

et. S

ub du

ty ca

rds i

n gr

een m

anilla

folde

rs in

filing

cabin

et in

contr

ol ro

om.

Duty

card

s use

d wer

e las

t upd

ated o

n 19

Nov

embe

r 200

1.

Chan

ge ov

er pl

an ex

ecute

d well

and

trans

ition s

mooth

– inf

o tra

nsfer

inc

omple

te.

Page

44 o

f 101

ELEM

ENT

PERF

ORMA

NCE

CRIT

ERIA

OBJE

CTIV

E EV

IDEN

CE S

OUGH

TOB

SERV

ATIO

N

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

The E

merg

ency

Con

trol

Room

��Ad

visor

y Com

mitte

e esta

blish

ed

��Inc

ident

Mana

geme

nt Te

am

memb

ers r

epor

t to E

merg

ency

Co

ntrol

Room

��

The E

merg

ency

Con

trol R

oom

is su

itably

loca

ted

��En

try in

to the

Eme

rgen

cy C

ontro

l Ro

om is

contr

olled

��Th

e lay

out o

f the E

merg

ency

Co

ntrol

Room

: -

Size

, sea

ting

-Lig

hting

and e

merg

ency

ba

ckup

lighti

ng

-En

viron

menta

l mon

itorin

g fac

ilities

-

Disp

lay bo

ards

��Ad

equa

te su

itable

stati

oner

y is

avail

able:

-

Incide

nt log

book

-

Writi

ng pe

ns an

d pen

cils

-Er

aser

s and

corre

ction

fluid

-W

riting

pads

-

Flip c

harts

-

High

lighti

ng pe

ns

-St

ick-it-

page

s -

Suita

ble sc

ale ru

les

Not e

viden

t. Ye

s

Yes,

adjac

ent to

Con

trol ro

om an

d oth

er ke

y fac

ilities

Contr

ol wa

s init

ially

estab

lishe

d, on

a nu

mber

of oc

casio

ns pe

rsons

enter

ed

and l

eft w

ithou

t bein

g auth

orise

d to,

and t

here

was

one c

hang

e of r

ole th

at wa

s not

autho

rised

or no

tified

(Duty

Ca

rd 4)

. Th

e EC

room

was

too s

mall f

or du

ty ca

rd m

embe

rs to

fit.

Ther

e wer

e ins

uffici

ent s

eats

(5) f

or

memb

ers o

f the I

MT.

Only

one d

isplay

boar

d ava

ilable

. No

elec

tronic

acce

ss to

mon

itorin

g da

ta.

Duty

card

syste

m pr

ovide

d brie

f cas

es

which

conta

ined e

merg

ency

perso

nal

vest

for du

ty ide

ntific

ation

, stat

ioner

y inc

luding

incid

ent lo

g boo

ks, p

ens a

nd

penc

ils. N

o rule

rs ob

vious

nor s

tick i

t pa

ges,

highli

ght p

ens,

flip ch

arts,

er

aser

s or c

orre

ction

fluid.

No c

ases

co

ntaine

d calc

ulator

s whic

h did

caus

e so

me m

inor p

roble

ms la

ter in

the n

ight

– CO

make

calcs

.

COMM

ENT

IMT

would

have

bene

fited f

rom

electr

onic

acce

ss to

gas m

onito

ring

syste

m.

Secu

rity m

ust b

e esta

blish

ed an

d ma

intain

ed fo

r entr

y and

depa

rture

from

em

erge

ncy c

ontro

l room

.

Infor

matio

n pre

vious

ly de

velop

ed fr

om

Risk

Ass

essm

ent c

ould

not b

e re

feren

ced b

y all I

MT m

embe

rs, th

is is

impo

rtant

for th

e con

trol o

f acti

vities

, as

signm

ents

and c

ontin

gent

plann

ing.

Addit

ional

wall m

ounte

d flip

char

ts an

d wh

ite bo

ards

wou

ld ha

ve as

sisted

the

IMT

in re

feren

cing p

revio

usly

discu

ssed

inf

orma

tion a

nd de

cision

s mad

e.

Read

y acc

ess t

o a ph

otoco

pier w

ould

also e

nhan

ce th

e abil

ity to

diss

emina

te inf

o to I

MT m

embe

rs.

Page

45 o

f 101

ELEM

ENT

PERF

ORMA

NCE

CRIT

ERIA

OBJE

CTIV

E EV

IDEN

CE S

OUGH

TOB

SERV

ATIO

N

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

Incid

ent

Mana

gem

ent

Team

The I

ncide

nt Ma

nage

ment

Team

is pr

ovide

d with

su

fficien

t infor

matio

n to

adeq

uatel

y car

ry ou

t its

dutie

s both

unde

rgro

und a

nd

on th

e sur

face

-Ma

rker p

ens a

nd er

aser

s -

Calcu

lator

s Th

e Inc

ident

Mana

geme

nt Te

am is

pr

ovide

d with

: ��

Incide

nt ba

ckgr

ound

��

Unde

rgro

und p

erso

nnel

and

locati

on

-Ty

pical

mine

gas t

ypes

-

Typic

al ma

kes

��Co

pies o

f Safe

ty Ma

nage

ment

Syste

m ��

Copie

s of E

EHMP

��Up

-to-d

ate un

derg

roun

d plan

s inc

luding

: -

Venti

lation

distr

ibutio

n -

Gas m

onito

ring p

oints

-Es

cape

route

s -

SCSR

chan

geov

er lo

catio

ns

-El

ectric

al ins

tallat

ions

��Up

-to-d

ate su

rface

plan

s sho

wing

: -

Build

ing lo

catio

ns

-Ro

ad sy

stems

and g

ates

-Lo

catio

n of m

ain se

rvice

s iso

lation

contr

ol eq

uipme

nt -

Loca

tion o

f fire

fighti

ng

equip

ment

-Lo

catio

n of r

escu

e equ

ipmen

t -

Loca

tion o

f haz

ardo

us

mater

ials,

includ

ing ex

plosiv

es

IC co

llecte

d info

from

CRO

and u

/g cre

ws an

d brie

fed IM

T 00

:15. B

riefin

g inc

luded

incid

ent d

etails

, loca

tions

of

perso

nnel

and p

roce

ss to

be fo

llowe

d by

IMT.

A co

py of

HMP

s was

avail

able

in the

IM

T an

d the

CR.

Not

acce

ssed

exce

pt TA

RPS

by C

RO.

Wall

s of IM

T co

ntaine

d up t

o date

pla

ns. G

as m

onito

ring p

oints

not

evide

nt.

No su

rface

plan

s evid

ent.

COMM

ENT

Adeq

uate

infor

matio

n ava

ilable

.

Surfa

ce pl

ans m

ust b

e ava

ilable

for

use,

espe

cially

whe

re m

utual

assis

tance

has b

een i

nitiat

ed. Pa

ge 46

of 1

01

ELEM

ENT

PERF

ORMA

NCE

CRIT

ERIA

OBJE

CTIV

E EV

IDEN

CE S

OUGH

TOB

SERV

ATIO

N

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

The I

ncide

nt Ma

nage

ment

Team

are p

rovid

ed w

ith

suita

ble an

d suff

icien

t co

mmun

icatio

ns eq

uipme

nt.

The I

ncide

nt Co

ntroll

er

suffic

iently

brief

s the

Incid

ent

Mana

geme

nt Te

am to

allow

the

m to

functi

on

imme

diatel

y.

��Th

e Inc

ident

Contr

ol Ro

om is

pr

ovide

d with

at le

ast tw

o (2)

ex

terna

l and

two (

2) in

terna

l tel

epho

nes o

n sep

arate

lines

.

��Tw

o-wa

y rad

ios or

alter

nativ

e me

ans a

re pr

ovide

d as s

uppo

rt be

twee

n the

Incid

ent M

anag

emen

t Te

am an

d Inc

ident

Contr

ol loc

ation

s ��

The I

ncide

nt Co

ntroll

er br

iefs t

he

Incide

nt Ma

nage

ment

Team

��Th

e Inc

ident

Mana

geme

nt Te

am

deve

lops a

ction

plan

s

��Th

e Inc

ident

Mana

geme

nt Te

am

revie

ws av

ailab

le ex

isting

inf

orma

tion o

n: -

Miss

ing an

d una

ccou

nted f

or

perso

ns

-Em

erge

ncy i

ncide

nt wi

tness

ac

coun

ts -

Envir

onme

ntal in

forma

tion

includ

ing ga

s mon

itorin

g and

ve

ntilat

ion di

stribu

tion

��Th

e Inc

ident

Mana

geme

nt Te

am

deter

mine

s the

prep

ared

ness

of

the E

merg

ency

Res

pons

e Tea

ms

One e

merg

ency

phon

e con

necte

d –

seem

ed to

only

have

inter

nal a

cces

s.

A ra

dio w

as pa

rt of

Duty

Card

1 kit

, not

turne

d on.

00:15

initia

l brie

fing b

y IC,

thor

ough

wi

thout

being

verb

ose.

A pr

oces

s of r

isk m

anag

emen

t and

ch

ange

man

agem

ent w

as in

stiga

ted –

see c

omme

nts.

Vario

us D

uty C

ard m

embe

rs ca

rried

out

these

func

tions

and r

epor

ted ba

ck to

IM

T re

gular

ly.

Duty

Card

4 co

ntroll

ed th

is in

conju

nctio

n with

MRS

coor

dinato

r, an

d re

porte

d bac

k to I

MT

COMM

ENT

Exter

nal a

cces

s via

mobil

e pho

ne in

co

ntrol

room

. Extr

a staf

f coo

pted a

s ne

cess

ary t

o sup

port

CRO.

Not

forma

lised

in D

uty C

ard s

ystem

or

emer

genc

y plan

s.

IC en

sure

d tha

t he w

as fu

lly br

iefed

dir

ectly

by ke

y per

sonn

el. R

egula

r sy

stema

tic up

dates

by IC

of IM

T.

Page

47 o

f 101

ELEM

ENT

PERF

ORMA

NCE

CRIT

ERIA

OBJE

CTIV

E EV

IDEN

CE S

OUGH

TOB

SERV

ATIO

N

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

Data

Col

latio

n Th

e Inc

ident

Mana

geme

nt Te

am en

sure

s tha

t all d

ata is

co

llecte

d and

man

ipulat

ed to

be

come

usefu

l infor

matio

n inc

luding

the b

riefin

g and

de

brief

ing of

perso

nnel.

��Da

ta ga

therin

g pro

cess

is

estab

lishe

d to e

nsur

e tha

t all

gene

rated

data

is ma

de av

ailab

le,

includ

ing:

-Ga

s ana

lysis

-Ve

ntilat

ion di

stribu

tion

-Re

ports

-

Obse

rvatio

ns

��Pr

oces

ses a

re es

tablis

hed t

o ma

nage

distr

ibutio

n of in

forma

tion

��Da

ta is

proc

esse

d whe

neve

r and

wh

erev

er re

quire

d to e

nsur

e tha

t it

beco

mes u

seab

le

��Inf

orma

tion c

ritica

l for d

ecisi

on

makin

g is g

iven t

he hi

ghes

t prio

rity

��Inf

orma

tion a

nd de

cision

s are

ca

pture

d in a

n ope

ratio

ns lo

g, wi

th pa

rticula

r refe

renc

e to:

-Da

te an

d tim

e -

Decis

ions a

nd re

ason

s -

Perso

ns or

perso

ns ta

king

actio

n -

Perso

n or p

erso

ns to

who

m ac

tion i

s dire

cted

No fo

rmal

proc

ess w

as es

tablis

hed.

Reco

rds k

ept in

indiv

idual

Duty

Card

inc

ident

log bo

oks.

Occ

asion

ally

tabula

ted on

whit

e boa

rd –

lost w

hen

page

scro

lled t

hrou

gh.

No pr

oces

s to r

ecov

er pr

eviou

sly

docu

mente

d disc

ussio

ns.

No fo

rmal

proc

ess e

viden

t.

On a

numb

er of

occa

sions

CO

make

wa

s not

calcu

lated

until

aske

d for

nor

effec

tive t

empe

ratur

e – vi

tal fo

r eff

ectiv

e ope

ratio

nal ti

me of

resc

ue

teams

.

Yes.

Sten

ogra

pher

kept

detai

ls of

all

decis

ions a

nd ris

k man

agem

ent d

etails

. De

tails

of wh

o is t

o tak

e acti

on no

t re

cord

ed, n

or w

ho di

recte

d it.

COMM

ENT

Infor

mal d

ata co

llecti

on pr

oces

s cau

sed

some

prob

lems i

n acc

urac

y of d

ata –

lack o

f eas

y disp

lay re

quire

d re

confi

rmati

on of

some

data

and a

nu

mber

of m

iscon

cepti

ons w

ere

prom

ulgate

d – fo

r exa

mple:

CO

in %

ra

ther t

han p

pm. I

ncide

nt qu

oted a

s oc

curin

g at 2

2:45 r

ather

than

21:31

. 22

:45 be

ing th

e tim

e the

incid

ent w

as

decli

ned a

s an e

merg

ency

.

Ther

e was

no fa

cility

to ke

ep ke

y data

on

open

disp

lay as

only

white

boar

d wa

s ded

icated

to de

cision

mak

ing

proc

ess.

IMT

room

need

ed m

ore w

hite

boar

ds an

d othe

r rec

ordin

g dev

ices t

o all

ow fo

r imme

diate

refer

ence

. Page

48 o

f 101

ELEM

ENT

PERF

ORMA

NCE

CRIT

ERIA

OBJE

CTIV

E EV

IDEN

CE S

OUGH

TOB

SERV

ATIO

N

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

Data

Ver

ifica

tion

The I

ncide

nt Ma

nage

ment

Team

verifi

es, a

s far

as

poss

ible,

all da

ta co

llecte

d be

fore p

roce

ssing

and u

se.

��Th

e Inc

ident

Mana

geme

nt Te

am

ensu

re in

tegrity

of al

l gas

samp

ling

point

s

��Th

e Inc

ident

Mana

geme

nt Te

am

ensu

re th

e inte

grity

and c

alibr

ation

of

gas a

nalys

ers u

sed

��Th

e Inc

ident

Mana

geme

nt Te

am

ensu

re th

e vali

dity o

f gas

read

ings

by ch

eckin

g both

perce

ntage

and

rang

e

��Th

e Inc

ident

Mana

geme

nt Te

am

make

s use

of ga

s rati

os be

fore a

nd

in sc

enar

io mo

dellin

g

��Th

e Inc

ident

Mana

geme

nt Te

am

estab

lishe

s add

itiona

l stra

tegica

lly

locate

d sam

pling

point

s whe

re

poss

ible

��Th

e Inc

ident

Mana

geme

nt Te

am

cross

refer

ence

s obs

erva

tions

and

repo

rts to

valid

ate he

arsa

y inf

orma

tion

Whe

re po

ssibl

e gas

conc

entra

tions

fro

m CO

NSPE

C ch

ecke

d aga

inst T

ube

bund

le an

d GC.

No c

heck

mad

e tha

t se

nsor

s wer

e whe

re th

ey w

ere

supp

osed

to be

or if

dama

ged.

No

reas

on to

susp

ect th

at the

y wou

ld be

da

mage

d.

GC w

ould

be ca

libra

ted pr

ior to

use.

Othe

rs ca

libra

ted as

per p

olicie

s. Se

e abo

ve.

Not p

artic

ularly

relev

ant e

xcep

t at e

nd

when

CO

make

used

. Ellic

ott di

agra

ms

cons

tructe

d to e

valua

te ex

plosib

ility.

Not r

eally

relev

ant, r

elied

on ha

nd he

ld me

asur

emen

ts to

monit

or pr

ogre

ssion

of

venti

lation

impr

ovem

ents.

As ap

prop

riate.

COMM

ENT

This

was g

ener

ally w

ell do

ne. S

ever

ity

of inj

ury n

ot cla

rified

nor r

ecog

nised

in

decis

ion m

aking

proc

ess.

Relia

nce o

n ver

bal d

ata tr

ansfe

r ca

used

seve

ral tr

ansc

riptio

n erro

rs.

Page

49 o

f 101

ELEM

ENT

PERF

ORMA

NCE

CRIT

ERIA

OBJE

CTIV

E EV

IDEN

CE S

OUGH

TOB

SERV

ATIO

N

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

Cont

inge

ncy

Plan

s Th

e Inc

ident

Mana

geme

nt Te

am ef

ficien

tly de

velop

co

nting

ency

plan

s tha

t ide

ntify

the em

erge

ncy

situa

tion a

nd re

spon

se

requ

ireme

nts.

��Th

e Inc

ident

Mana

geme

nt Te

am

asse

mble

relev

ant d

ata in

a tim

ely

mann

er

��Th

e data

is ch

ecke

d by t

he

Advis

ory T

eam

��Th

e Inc

ident

Mana

geme

nt Te

am

deve

lops t

he m

ost li

kely

emer

genc

y situ

ation

exist

ing

��Th

e Adv

isory

Team

is co

nsult

ed

and a

dvise

s the

Incid

ent C

ontro

ller

of the

emer

genc

y situ

ation

exist

ing

��Th

e Inc

ident

Mana

geme

nt Te

am

make

use o

f all a

vaila

ble ex

perts

an

d res

ource

s

��Th

e Inc

ident

Mana

geme

nt Te

am

deve

lop co

nting

ency

plan

s and

up

date

as of

ten as

nece

ssar

y

IMT

used

regu

lar br

eak o

uts to

upda

te re

levan

t data

.

IC us

ed IM

T as

advis

ory t

eam.

IC de

fined

likely

situa

tion.

No d

issen

t.

Not o

bser

ved.

IMT

utilis

ed by

IC as

ad

visor

y tea

m.

IMT

has r

ange

of ex

pertis

e plus

Ind

ustry

Safe

ty an

d Hea

lth

Repr

esen

tative

and N

R&M

perso

nnel.

Conti

ngen

cy pl

ans d

evelo

ped a

nd

chan

ged –

see c

omme

nts.

COMM

ENT

Refer

to os

cillat

ing de

cision

mak

ing

proc

ess.

Back

up of

IMT

imple

mente

d and

well

or

ganis

ed.

Fatig

ue m

anag

emen

t of IM

T su

bjecti

ve

and n

ot we

ll man

aged

. Sev

eral

adve

rse im

pacts

of tir

ed pe

rsonn

el oc

curre

d – eg

unab

le to

reso

lve hi

gh

CO.

Page

50 o

f 101

ELEM

ENT

PERF

ORMA

NCE

CRIT

ERIA

OBJE

CTIV

E EV

IDEN

CE S

OUGH

TOB

SERV

ATIO

N

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

Incid

ent

Mana

gem

ent

Team

Dec

ision

Ma

king

The I

ncide

nt Ma

nage

ment

Team

is ef

fectiv

e in d

ecisi

on

makin

g

��Th

e Inc

ident

Mana

geme

nt Te

am

make

s dec

ision

s as a

team

��Th

e Inc

ident

Mana

geme

nt Te

am

follow

a de

fined

proc

ess i

n de

cision

mak

ing

��Th

e Inc

ident

Mana

geme

nt Te

am

actua

lly us

es co

nting

ency

plan

ning

��Th

e Inc

ident

Mana

geme

nt Te

am

takes

into

acco

unt a

ll opti

ons w

hen

makin

g dec

ision

s

��Th

e Inc

ident

Mana

geme

nt Te

am

identi

fies a

ll haz

ards

asso

ciated

wi

th the

emer

genc

y

Guide

d dec

ision

mak

ing by

IC,

inade

quate

invo

lve m

embe

rs of

IMT

in the

actua

l dec

ision

mak

ing w

as ev

ident.

Infor

mal d

iscus

sions

occu

rring

outsi

de

IMT

betw

een s

mall g

roup

s of D

uty C

ard

holde

rs.

Attem

pted t

o foll

ow ris

k man

agem

ent

and c

hang

e man

agem

ent.

Cons

idere

d ven

tilatio

n con

trols

– wha

t ifs

. Cre

ated p

lans t

o cop

e with

vario

us

situa

tions

e.g.

air flo

w thr

ough

seal

inspe

ction

port

tested

prior

to kn

ockin

g do

wn se

al to

ensu

re th

at it w

ould

incre

ase f

low no

t dec

reas

e it.

IMT

memb

ers c

anva

ssed

for is

sues

an

d haz

ards

.

Risk

man

agem

ent p

roce

ss us

ed to

de

fine h

azar

ds –

no fo

rmal

chec

k list

s re

lied o

n per

sona

l exp

erien

ce –

subje

ctive

asse

ssme

nts on

ly.

COMM

ENT

Decis

ion

mak

ing

not c

ompl

etely

effe

ctive

too

muc

h po

st co

nclu

sion

varia

tion

and

revis

iting

of l

ogic.

Seem

ingl

y unw

illing

to co

mm

it to

an

actio

n pa

th. O

n a n

umbe

r of

occa

sions

a co

nclu

sion

appe

ared

to

be re

ache

d an

d wa

s onl

y the

n ch

allen

ged,

this

initi

ated

a ne

w tra

in

of d

iscus

sion.

Disc

ussio

n os

cillat

ed

betw

een

reve

rsin

g ve

ntila

tion

and

impr

ovin

g ex

istin

g ve

ntila

tion

thro

ugh

closin

g re

gulat

or an

dkn

ockin

g do

wn st

oppi

ng in

m

ainga

te.

On a

num

ber o

f occ

asio

ns R

M no

t co

mpl

eted

. Haz

ards

iden

tified

and

issue

s but

did

not

pro

gres

s to

cont

rols.

No sy

stem

atic

atte

mpt

to d

o co

mpa

rativ

e ana

lysis

of o

ptio

ns.

Alwa

ys w

orke

d on

one

at a

time.

Com

para

tive a

nalys

is ca

rried

out

on

ly ve

rball

y.

Page

51 o

f 101

ELEM

ENT

PERF

ORMA

NCE

CRIT

ERIA

OBJE

CTIV

E EV

IDEN

CE S

OUGH

TOB

SERV

ATIO

N

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

The I

ncide

nt Ma

nage

ment

Team

uses

risk m

anag

emen

t tec

hniqu

es in

arriv

ing at

de

cision

s

��Th

e Inc

ident

Mana

geme

nt Te

am

identi

fies t

he ap

prop

riate

contr

ols

for ea

ch ha

zard

��Th

e Inc

ident

Mana

geme

nt Te

am

incor

pora

tes ap

prop

riate

haza

rd

contr

ols an

d con

strain

ts in

all

oper

ation

al de

cision

s

��Th

e Inc

ident

Mana

geme

nt Te

am

does

not in

voke

any a

ction

that

enda

nger

s life

��Th

e Inc

ident

Mana

geme

nt Te

am

takes

all re

ason

able

actio

n to

resc

ue pe

rsons

rema

ining

un

derg

roun

d

��Th

e Inc

ident

Mana

geme

nt Te

am

cons

iders

the sa

fety o

f all p

erso

ns

in an

y dec

ision

to de

ploy s

uch

perso

ns in

unde

rgro

und r

escu

e an

d / or

reco

very

��Th

e Inc

ident

Mana

geme

nt Te

am

take i

nto ac

coun

t the f

ate of

any

miss

ing pe

rsons

in an

y dec

ision

to

seal

the m

ine

��Th

e Inc

ident

Mana

geme

nt Te

am

make

prov

ision

s for

reco

very

of the

de

ceas

ed pe

rsons

after

seali

ng

Risk

man

agem

ent p

roce

ss us

ed.

Relie

d on s

kills

of IM

T to

identi

fy co

ntrols

. No a

ttemp

t to co

nsult

outsi

de

this g

roup

or an

y refe

renc

es –

exce

pt in

attem

pt to

valid

ate us

e of d

iesel

vehic

le in

2.5 %

CH 4

.

Part

of ris

k man

agem

ent a

nd ch

ange

ma

nage

ment

proc

ess.

IMT

agre

ed on

all a

ction

s and

follo

wed

risk m

anag

emen

t and

chan

ge

mana

geme

nt pr

oces

s. Fo

llowe

d MRS

em

erge

ncy g

uideli

nes.

See c

omme

nts, fo

cus o

f IMT

was t

o re

trieve

perso

nnel.

Yes.

Not r

eleva

nt.

Not e

viden

t – no

t rele

vant

– no

dece

ased

perso

ns id

entifi

ed.

COMM

ENT

Risk

man

agem

ent p

roce

ss n

ot fu

lly

follo

wed

too

ofte

n di

gres

sions

allow

ed an

d de

cisio

n pa

ths n

otfo

llowe

d th

roug

h. C

onclu

sions

not

co

nfirm

ed an

d va

cillat

ion

occu

rred.

Page

52 o

f 101

ELEM

ENT

PERF

ORMA

NCE

CRIT

ERIA

OBJE

CTIV

E EV

IDEN

CE S

OUGH

TOB

SERV

ATIO

N

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

Incid

ent

Mana

gem

ent

Team

Mon

itorin

g

Incid

ent

Mana

gem

ent

Team

Co

mm

unica

tion

The I

ncide

nt Ma

nage

ment

Team

mon

itor e

merg

ency

co

nditio

ns an

d tre

nds

conti

nuall

y dur

ing th

e em

erge

ncy.

The I

ncide

nt Ma

nage

ment

Team

estab

lish a

nd m

aintai

n eff

ectiv

e com

munic

ation

with

all

nece

ssar

y inte

rnal

emer

genc

y per

sonn

el.

��Th

e Inc

ident

Mana

geme

nt Te

am

ensu

res t

hat it

rece

ives a

ll inf

orma

tion l

ikely

to eff

ect th

e de

cision

mak

ing pr

oces

s.

��Th

e Inc

ident

Mana

geme

nt Te

am

regu

larly

upda

tes th

e acti

on an

d co

nting

ency

plan

s

��Th

e Inc

ident

Mana

geme

nt Te

am

revie

ws op

erati

onal

optio

ns an

d de

cision

s in l

ine w

ith em

erge

ncy

resp

onse

requ

ireme

nts

��Th

e Inc

ident

Mana

geme

nt Te

am

cons

ults w

ith th

e Adv

isory

Comm

ittee w

hen c

hang

es in

op

erati

onal

decis

ions a

re re

quire

d ��

The I

ncide

nt Ma

nage

ment

Team

pr

ohibi

ts ex

terna

l una

uthor

ised

conta

ct or

comm

unica

tions

with

all

emer

genc

y per

sonn

el

��Th

e Inc

ident

Mana

geme

nt Te

am

maint

ains e

ffecti

ve

comm

unica

tions

with

all

emer

genc

y res

pons

e gro

ups b

y: -

On-lin

e com

puter

, if av

ailab

le -

Telep

hone

-

Back

-up f

acilit

y (me

ssag

e)

-Ra

dio (t

wo-w

ay)

Duty

Card

proc

ess f

ollow

ed. I

C ins

tructe

d reg

ular u

pdate

s of k

ey ga

s an

d othe

r infor

matio

n.

The I

MT w

as re

gular

ly up

dated

on th

e inf

orma

tion h

owev

er, p

revio

us

infor

matio

n was

not r

eadil

y acc

essib

le an

d this

caus

ed so

me co

nfusio

n e.g.

no

. of m

ines r

escu

e per

sonn

el av

ailab

le.

Yes,

but n

eeds

impr

ovem

ent.

Vacil

lation

in de

cision

mak

ing.

IMT

memb

ers u

tilise

d as A

dviso

ry Co

mmitte

e.

Acce

ss to

area

restr

icted

. How

ever

en

try to

IMT

not c

ontro

lled.

No co

mpute

r acc

ess a

vaila

ble

Sing

le int

erna

l telep

hone

Pa

per m

essa

ges u

sed t

o com

munic

ate

with

indivi

dual

memb

ers o

f IMT

Comm

unica

tions

betw

een t

he va

rious

gr

oups

man

aged

by th

e rele

vant

Duty

Card

holde

r. Op

erati

ons l

og

maint

ained

by st

enog

raph

er. I

C an

d Du

t y Ca

rd 3

carri

ed ou

t brie

fings

of

COMM

ENT

IC ca

lled f

or re

gular

upda

te an

d Duty

Ca

rd 5

regu

larly

chec

ked g

as

conc

entra

tions

. CRO

regu

larly

rang

inf

o thr

ough

to IM

T.

IC ex

pres

sed f

rustr

ation

at

unau

thoris

ed eg

ress

of ke

y Duty

Car

d ho

lders

– los

t integ

rity of

IMT

and

asso

ciated

decis

ion m

aking

proc

ess.

Infor

matio

n exc

hang

e betw

een I

MT an

d re

place

ment

IMT

impe

rfect.

Qu

estio

ning o

f rep

lacem

ent IM

T re

veale

d inc

omple

te inf

orma

tion

exch

ange

d and

data

in re

cord

book

s inc

omple

te – e

g natu

re of

injur

ies of

pe

rsonn

el etc

.

Page

53 o

f 101

ELEM

ENT

PERF

ORMA

NCE

CRIT

ERIA

OBJE

CTIV

E EV

IDEN

CE S

OUGH

TOB

SERV

ATIO

N

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

Emer

genc

yTe

rmin

atio

n Th

e Inc

ident

Mana

geme

nt Te

am w

ill eff

ectiv

ely

termi

nate

emer

genc

y ma

nage

ment

requ

ireme

nts

at co

nclus

ion of

emer

genc

y.

��Th

e Inc

ident

Mana

geme

nt Te

am

maint

ains e

ffecti

ve co

mmun

icatio

n by

: -

Regu

lar fa

ce-to

-face

conta

ct -

Telep

hone

-

Writt

en m

essa

ge

-W

ith M

ines R

escu

e -

Reco

rding

infor

matio

n flow

by

an op

erati

on lo

g inc

luding

da

te an

d tim

e of in

ciden

t, tim

e of

all su

bseq

uent

deve

lopme

nts, ti

me of

all

decis

ions a

nd tim

e of a

ll co

nfere

nces

and o

utcom

e ��

The I

ncide

nt Ma

nage

ment

Team

de

brief

s all e

merg

ency

perso

nnel

befor

e ter

mina

tion

��Th

e Inc

ident

Mana

geme

nt Te

am

relie

ves M

ines R

escu

e Tea

ms

from

oper

ation

al du

ty

��Th

e Inc

ident

Mana

geme

nt Te

am

relie

ves a

ll othe

r eme

rgen

cy

oper

ation

perso

nnel

from

duty

as

soon

as th

ey ar

e no l

onge

r re

quire

d

��Th

e Inc

ident

Mana

geme

nt Te

am

prep

ares

a sta

temen

t for r

eleas

e to

the pu

blic

��Th

e Inc

ident

Mana

geme

nt Te

am

arra

nges

for s

ecur

ity of

all

docu

menta

tion b

efore

term

inatio

n

surfa

ce w

ork f

orce

.

Left t

o Duty

Car

d 4.

Yes.

Left t

o Duty

Car

d hold

ers t

o adv

ise su

b Du

ty Ca

rd ho

lders

etc.

Not e

viden

t.

Not e

viden

t.

COMM

ENT

Page

54 o

f 101

ELEM

ENT

PERF

ORMA

NCE

CRIT

ERIA

OBJE

CTIV

E EV

IDEN

CE S

OUGH

TOB

SERV

ATIO

N

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

��Th

e Inc

ident

Mana

geme

nt Te

am

arra

nges

an ea

rly m

eetin

g date

to

comm

ence

prep

arati

on of

the

Emer

genc

y Inc

ident

Repo

rt

��Th

e Inc

ident

Mana

geme

nt Te

am is

re

lieve

d fro

m du

ty

Not e

viden

t.

Yes I

C sto

od pe

rsonn

el do

wn.

COMM

ENT

Page

55 o

f 101

TIME

SUMM

ARY

OF A

CTIO

NS

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

MINE

S RE

SCUE

AUD

IT T

OOL

ASSE

SSOR

S: P

ETER

BAK

ER, W

ARRE

N PE

NDLE

BURY

, GRE

G DA

LLIS

TON

(UND

ERGR

OUND

)MU

RRAY

BIR

D AN

D TO

NY D

E SA

NTIS

(SUR

FACE

)

DETA

ILED

ACT

IONS

AND

COM

MENT

S 21

31

Scen

ario

comm

ence

s – ro

of fal

l main

gate

205 l

ongw

all.

Powe

r off t

o lon

gwall

.

No co

mpute

r com

munic

ation

s to c

ontro

l room

.

Venti

lation

redu

ced t

o 6.53

m3 /s

.

DAC’

s out

and t

eleph

ones

out.

At th

is sta

ge se

lf esc

ape w

as th

e only

optio

n for

the l

ongw

all cr

ew –

see

‘esca

pe’ a

udit s

heets

and s

umma

ry.

2341

A/

Supe

rinten

dent,

QMR

S, co

ntacte

d CRO

requ

estin

g brie

f whic

h he w

as

prov

ided.

Also

told

will n

eed a

ssist

ance

from

QMR

S.

As pa

rt of

the K

estre

l Eme

rgen

cy R

espo

nse P

lan, th

e Mine

Man

ager

had

conta

cted Q

MRS

(this

was d

one b

efore

Mine

Man

ager

arriv

ed on

site)

.

2405

Re

scue

suits

being

teste

d. Fir

st mi

nes r

escu

e brig

ades

man t

o arri

ve on

site

starte

d to t

est B

G174

’s for

use

by M

RT 1.

2420

Mi

ne M

anag

er de

termi

ned t

o set

up F

AB at

205 t

ailga

te do

uble

door

s. Th

is wa

s a go

od de

cision

– the

area

s at th

e dou

ble do

ors w

as ea

sily

acce

ssibl

e with

tran

spor

t, the

re w

as en

sure

d fre

sh ai

r and

telep

hone

co

mmun

icatio

ns w

ere a

vaila

ble on

site

(alth

ough

telep

hone

at ta

ilgate

door

s sto

pped

wor

king d

uring

the s

hift, t

here

was

anoth

er w

ithin

100 m

etres

).

2424

Ins

pecto

r and

A/S

uper

inten

dent,

QMR

S, ar

rived

on si

te.

2448

QM

RS no

t yet

in att

enda

nce i

n IMT

. Mine

s Res

cue t

eam

memb

ers w

ere

identi

fied –

8 on

site,

2 in

trans

it and

3 un

derg

roun

d in p

it bott

om.

Two o

f the t

eam

memb

ers u

nder

grou

nd h

ad be

en on

after

noon

shift

and w

ere

there

fore n

ot us

ed, o

ne w

as ill

and a

nothe

r was

out o

f ‘oxy

time’.

This

left

enou

gh cu

rrent

team

memb

ers t

o hav

e one

at F

AB, o

ne re

scue

coor

dinato

r (on

su

rface

) and

one t

eam

of eig

ht. If

it we

re no

t for t

he qu

ick re

spon

se of

the

Crinu

m tea

m, th

e fac

t ther

e wer

e only

8 tea

m me

mber

s cou

ld ha

ve le

ad to

a de

lay in

initia

ting r

espo

nse.

Page

56 o

f 101

TIME

SUMM

ARY

OF A

CTIO

NS

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

DETA

ILED

ACT

IONS

AND

COM

MENT

S 01

07

Kestr

el Mi

nes R

escu

e Co-

ordin

ator in

itiated

mutu

al as

sistan

ce ca

ll. Th

is wa

s in r

ecog

nition

that

there

wou

ld pr

obab

ly be

insu

fficien

t brig

ades

on

site.

0116

Mi

ne M

anag

er br

iefed

A/S

uper

inten

dent,

QMR

S.

A/Su

perin

tende

nt the

n bec

ame a

mem

ber o

f the I

MT an

d was

heav

ily in

volve

d in

the de

cision

mak

ing pr

oces

s for

the r

ecov

ery o

f the p

erso

ns in

the l

ongw

all.

0140

GA

G ar

rives

on si

te.

This

incide

nt wa

s nev

er go

ing to

requ

ire th

e use

of th

e GAG

and i

t app

ears

to be

a wa

ste of

reso

urce

s to h

ave i

t call

ed ou

t eve

ry tim

e QMR

S ar

e call

ed –

this

shou

ld be

on an

‘as n

eeds

’ bas

is.

0152

QM

RS ar

rived

on si

te.

0210

Mi

nes R

escu

e tea

m br

iefing

by A

/Sup

erint

ende

nt, Q

MRS.

Br

iefing

was

verb

al an

d bac

ked u

p with

a wr

itten s

heet.

The

main

aim

of thi

s tea

m wa

s to t

rave

l to 15

cut-t

hrou

gh an

d rec

over

the p

erso

n cur

rentl

y tak

ing

refug

e the

re.

0218

A/

Supe

rinten

dent,

QMR

S, ad

vised

IMT

that te

am re

ady t

o go u

nder

grou

nd

now.

Disc

ussio

n too

k plac

e reg

ardin

g kno

cking

down

of st

oppin

g and

asso

ciated

ha

zard

s.

This

is 90

minu

tes fr

om w

hen t

he m

ajority

of th

e tea

m we

re on

site

(12:4

8am)

. Th

is tim

e mus

t be a

ble to

be re

duce

d in a

‘life

at ris

k’ sit

uatio

n.

0227

Mi

nes R

escu

e Tea

m 1 l

eave

s sur

face t

aske

d with

reco

very

of lon

gwall

crew

me

mber

at 15

cut-t

hrou

gh, 2

05 ta

ilgate

. Al

l team

mem

bers

knew

their

task

and t

he ur

genc

y req

uired

.

0241

Cr

inum

mine

s res

cue t

eam

arriv

es on

site.

Mu

tual a

ssist

ance

was

activ

ated a

t 1:07

am, w

hich m

eans

a de

lay of

90

minu

tes sh

ould

be fa

ctore

d in t

o any

futur

e plan

s. T

his w

as an

exce

llent

effor

t fro

m Cr

inum

cons

iderin

g the

y bro

ught

equip

ment

with

them.

0245

FA

B es

tablis

hed a

t 205

tailg

ate by

Mine

s Res

cue T

eam

1. Be

caus

e the

phon

e at th

e tail

gate

door

s was

U/S

, the F

AB w

as es

tablis

hed j

ust

arou

nd th

e cor

ner t

o ena

ble vi

sual

conta

ct wi

th an

other

phon

e.

It app

eare

d tha

t not

all th

e equ

ipmen

t req

uired

at F

AB un

der P

roce

dure

8.3 o

f the

Guid

eline

s was

in pl

ace.

Page

57 o

f 101

TIME

SUMM

ARY

OF A

CTIO

NS

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

DETA

ILED

ACT

IONS

AND

COM

MENT

S 02

53

Mine

s Res

cue T

eam

1 (8 m

en) d

epar

ts FA

B. N

otifie

d by C

RO th

at MR

T 2

were

suitin

g up o

n the

surfa

ce.

As so

on as

FAB

wer

e told

the C

rinum

team

was

read

y, the

y wer

e rea

dy to

go

activ

e.

This

team

worke

d well

toge

ther –

good

Cap

tains

contr

ol, go

od ro

tation

of

stretc

her c

arry,

teste

d rad

io aft

er jo

ining

ribbo

n and

ensu

ring t

eam

memb

ers

were

copin

g with

the h

umid

cond

itions

.

0305

CR

O ad

vised

that

Crinu

m Mi

nes R

escu

e Tea

m 2 r

eady

to be

deplo

yed w

hen

need

ed.

As op

pose

d to M

RT 1,

MRT

2 we

re re

ady t

o go a

ctive

in le

ss th

an 30

minu

tes

after

arriv

ing. T

he re

ason

s for

the d

iscre

panc

y nee

d to b

e inv

estig

ated f

urthe

r.

0311

MR

T 1 o

ff com

munic

ation

ribbo

n at 9

– 10

cut-t

hrou

gh, ta

ilgate

205.

This

was p

re-p

lanne

d with

FAB

. The

team

took

1000

metr

es of

radio

ribbo

n on

two 5

00 m

etre s

pools

. It w

ould

have

been

diffic

ult fo

r a te

am of

5 me

n to r

un

the rib

bon o

ut us

ing th

is me

thod.

The Q

MRS

Guide

lines

state

s und

er P

roce

dure

8.2 ‘

If rad

io co

mmun

icatio

n is

not m

aintai

ned t

he te

am sh

ould

not tr

avel

beyo

nd 30

minu

tes fr

om th

e FAB

” –

this n

eeds

revie

w.

0316

IM

T we

re ad

vised

that

MRT

2 (8 m

en) w

ere r

eady

to go

. Co

mmun

icatio

ns be

twee

n IMT

and F

AB w

ere r

easo

nably

good

but w

ould

have

be

en m

uch i

mpro

ved i

f the p

hone

at th

e doo

rs wa

s ope

ratio

nal.

0318

MR

T 2 l

eft su

rface

task

ed as

stan

dby f

or M

RT 1.

MRT

1 hav

e rea

ched

patie

nt at

15 cu

t-thr

ough

.

Upon

arriv

al at

15 cu

t-thr

ough

, the t

eam

found

the p

atien

t in re

ason

ably

good

co

nditio

n. Th

ey pl

aced

a MA

RS un

it on h

im be

fore t

urnin

g off t

he ai

r sho

wer

and w

ere t

hen t

old by

the p

atien

t that

he ha

d see

n a lig

ht inb

ye –

this w

as no

t pa

rt of

the sc

enar

io an

d dela

yed t

he re

turn d

epar

ture t

ime o

f the t

eam

(unin

tentio

nally

).

Team

had t

aken

wate

r in fo

r the

patie

nt an

d use

d it w

ell fo

r the

patie

nt an

d for

the

mselv

es.

0332

MR

T 2 a

rrive

d at F

AB (8

men

).

0333

A/

Supe

rinten

dent,

QMR

S, re

ques

ted tw

o mine

s res

cue p

erso

nnel

to tak

e ve

ntilat

ion re

ading

outby

e of 1

cut-t

hrou

gh, 2

05 ta

ilgate

. Th

is re

ques

t was

delay

ed du

e to t

he fa

ct the

re w

as no

anam

omete

r ava

ilable

(it

is no

t par

t of F

AB eq

uipme

nt).

Page

58 o

f 101

TIME

SUMM

ARY

OF A

CTIO

NS

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

DETA

ILED

ACT

IONS

AND

COM

MENT

S 03

34

MRT

1 left

15 cu

t-thr

ough

with

casu

alty.

The c

asua

lty w

as ab

le to

walk

with

assis

tance

and h

e was

well

trea

ted an

d re

sted r

egula

rly on

the w

ay ou

t.

0343

MR

T 1 r

adioe

d FAB

and a

sked

for M

RT 2

for as

sistan

ce du

e to l

imita

tion o

f wo

rking

time.

At th

is po

int th

e Cap

tain r

ealis

ed th

e tea

m wa

s not

going

to be

able

to ge

t the

patie

nt ou

t in th

e wor

king t

ime a

llowe

d und

er th

e guid

eline

s in h

ot an

d hum

id co

nditio

ns.

0350

MR

T 1 a

rrive

d at 9

cut-t

hrou

gh, r

adioe

d FAB

and l

eft pa

tient

with

SSR9

0 and

un

der c

ompr

esse

d air f

low as

they

wer

e run

ning o

ut of

worki

ng tim

e. M

RT 1

were

retur

ning t

o FAB

.

This

was n

eces

sary

for te

am sa

fety,

thoug

h it w

as no

t com

munic

ated w

ell to

the

patie

nt.

Some

of th

e tea

m me

mber

s in M

RT 1

were

reall

y stru

gglin

g in t

he hu

midit

y and

thi

s high

lighte

d the

need

for s

trict c

ontro

ls on

the w

orkin

g tim

e of te

ams i

n the

se co

nditio

ns.

0352

MR

T 2 p

repa

ring t

o lea

ve F

AB. D

iscus

sed l

eavin

g two

team

mem

bers

to ca

rry

out a

ir rea

dings

. It w

as de

cided

that

an ei

ght m

an te

am w

ould

be re

quire

d and

this

was a

good

de

cision

.

0355

20

4 Dep

uty re

porte

d to F

AB –

can’t

brea

ch se

al un

til air

quan

tity ta

ken a

nd no

co

mmun

icatio

ns in

205.

Instru

cted b

y FAB

Con

trolle

r to w

ait at

FAB

.

MRT

2 dep

art F

AB w

ith re

turn t

ime o

f 044

5.

If the

venti

lation

mon

itorin

g at th

e lon

gwall

tailg

ate w

as w

orkin

g cor

rectl

y, thi

s tas

k wou

ld no

t hav

e bee

n req

uired

and w

ould

have

resu

lted i

n the

stop

ping

brea

ch be

ing do

ne ea

rlier.

Team

wor

king t

ime r

educ

ed du

e to a

tmos

pher

ic re

ading

s tha

t had

been

ra

dioed

thro

ugh.

At th

is po

int th

ere w

ere t

wo te

ams o

pera

tiona

l with

the t

hird t

eam

still o

n the

su

rface

. In t

he Q

MRS

Guide

lines

this

was a

ccep

table

if ano

ther t

eam

is im

media

tely m

obilis

ed.

Was

MRT

3 im

media

tely m

obilis

ed?

0402

A/

Supe

rinten

dent,

QMR

S, re

porte

d to I

MT th

at MR

T 3 (

8 men

) wer

e on s

urfac

e an

d exp

laine

d why

assis

tance

was

need

ed by

MRT

1.

This

was t

he lin

k fro

m the

oper

ation

al tea

ms to

FAB

to IM

T an

d is a

nece

ssity

in

an em

erge

ncy.

0404

MR

T 1 a

nd M

RT 2

met a

t 4 cu

t-thr

ough

and e

xcha

nged

detai

led in

forma

tion

conc

ernin

g pati

ent.

One m

embe

r of M

RT 1

suffe

ring h

eat d

istre

ss.

The d

etail i

n this

comm

unica

tion w

as ex

celle

nt an

d wor

ked w

ell fo

r the

two f

irst

Aide

rs to

conv

erse

.

Again

the n

eces

sity o

f adh

ering

to th

e red

uced

wor

king t

imes

in hu

mid

diti

id t

Page

59 o

f 101

TIME

SUMM

ARY

OF A

CTIO

NS

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

DETA

ILED

ACT

IONS

AND

COM

MENT

S co

nditio

ns w

as ev

ident.

0412

MR

T 1 r

each

ed F

AB.

MRT

1 had

been

activ

e for

79 m

inutes

(guid

eline

s sug

gest

50 m

inute

worki

ng

time i

n the

se co

nditio

ns).

Two t

eam

memb

ers w

ere o

bviou

sly ef

fected

by th

e co

nditio

ns an

d wate

r was

avail

able

at FA

B for

trea

tmen

t.

Exce

eding

thes

e guid

eline

s is n

ot pu

tting t

eam

safet

y as t

he to

p prio

rity.

0414

MR

T 2 r

each

ed ca

sualt

y at 9

cut-t

hrou

gh.

MRT

2 fou

nd th

e cas

ualty

unde

r the

air s

howe

r wea

ring a

SSR

90 (M

RT 1

had

put th

is on

after

MAR

S ha

d run

out).

They

wer

e the

first

team

(or p

erso

n) to

men

tion t

he po

ssibi

lity of

using

the

gogg

les.

The t

eam

move

d swi

ftly du

e to t

ime c

onstr

aints.

0415

A/

Supe

rinten

dent,

QMR

S, br

iefed

IMT

rega

rding

MRT

1 an

d MRT

2 ac

tivitie

s. Ag

ain th

is lin

k was

evide

nt be

twee

n FAB

and I

MT.

0417

Tw

o mem

bers

of MR

T 1 t

ook v

entila

tion r

eadin

g in t

ailga

te do

gleg.

Whil

e it w

as ne

cess

ary t

o go o

nly a

shor

t dist

ance

and t

he ta

sk w

as ce

rtainl

y no

t one

rous

, the u

se of

team

mem

bers

after

they

have

been

expo

sed t

o hot

and h

umid

cond

itions

.

0421

MR

T 2 l

eft 9

cut-t

hrou

gh w

ith pa

tient.

Th

e tea

m mo

ved a

t a go

od pa

ce fo

r the

patie

nt.

0424

A/

Supe

rinten

dent,

QMR

S, co

ntacte

d add

itiona

l mine

s res

cue p

erso

nnel

from

Oaky

Cre

ek.

It had

beco

me ev

ident

that a

furth

er ex

tensio

n of th

e Mutu

al As

sistan

ce

Sche

me w

as re

quire

d.

0435

MR

T 2’s

patie

nts co

nditio

n dete

riora

tes at

5 cu

t-thr

ough

– be

come

s stre

tcher

ca

se.

A/Su

perin

tende

nt, Q

MRS,

bega

n brie

fing M

RT 3.

Team

radio

ed F

AB an

d upd

ated s

ituati

on.

Put M

ARS

unit o

n pati

ent, p

repa

red s

tretch

er an

d the

n set

up fo

r a si

x man

ca

rry on

the s

tretch

er (e

xcell

ent id

ea).

MRT

3 wer

e orig

inally

brief

ed to

mak

e som

e ven

tilatio

n cha

nges

but th

is ch

ange

d in t

rans

it.

0445

Mi

ne M

anag

er re

ques

ted M

RT 3

to be

brief

ed in

IMT

room

.

Page

60 o

f 101

TIME

SUMM

ARY

OF A

CTIO

NS

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

DETA

ILED

ACT

IONS

AND

COM

MENT

S 04

55

MRT

3 brie

fing c

omple

te in

IMT

room

. Ass

ignme

nt ide

ntifie

d.

MRT

2 retu

rns t

o FAB

with

patie

nt.

MRT

2 retu

rned

to F

AB af

ter be

ing ac

tive f

or 60

minu

tes, th

ough

had i

denti

fied

that th

ey w

ould

be up

to 10

minu

tes ov

ertim

e with

contr

ol.

The t

eam

had c

arrie

d a la

rge p

erso

n ove

r 500

metr

es, th

ough

had d

one s

o re

lative

ly ea

sily d

ue to

the 6

man

carry

– thi

s was

a ve

ry go

od ef

fort.

0457

MR

T 3 l

eavin

g sur

face t

aske

d with

cond

uctin

g ven

tilatio

n cha

nge,

close

re

gulat

or in

204 p

anel

retur

n and

open

door

s inb

ye F

AB.

CRO

infor

med t

hat M

RT 2

patie

nt wa

s out

and o

kay.

This

task c

hang

ed on

route

.

0502

MR

T 1 l

eft F

AB w

ith pa

tient

head

ing in

vehic

le to

surfa

ce.

MRT

1 was

being

used

as a

stand

by te

am fo

r MRT

2. M

RT 3

could

have

been

us

ed fo

r this

task

after

the c

ondit

ions t

hat M

RT 1

had b

een t

hrou

gh.

0510

MR

T 3 a

rrive

d at F

AB.

0516

FA

B no

tified

IMT

(via I

MT em

erge

ncy p

hone

) tha

t MRT

1 pr

ocee

ding t

o su

rface

.

204 D

eputy

infor

med C

RO th

at sto

pping

had b

een k

nock

ed do

wn at

0500

.

This

was t

he on

ly wa

y tha

t they

could

get h

old of

them

.

0520

MR

T 1 r

each

ed th

e sur

face w

ith ca

sualt

y.

0601

A/

Supe

rinten

dent,

QMR

S, br

iefed

IMT

on M

RT 3

tasks

– to

mobil

ise fr

om F

AB

to lon

gwall

. It w

as no

t evid

ent w

here

this

instru

ction

was

initia

ted. T

he F

AB C

ontro

ller w

as

in a g

ood p

ositio

n to a

t leas

t ‘adv

ise’ in

this

situa

tion.

0615

MR

T 3 d

epar

ts FA

B dr

iftrun

ner.

At th

is sta

ge th

e CH4

leve

l was

runn

ing at

0.93

%, th

erefo

re w

ithin

the le

gal

limits

for r

unnin

g a m

achin

e.

The d

riftru

nner

was

nece

ssar

y to t

rave

l the r

equir

ed 3.

2km

to the

long

wall f

ace

and b

ack t

o get

the tw

o rem

aining

men

.

Page

61 o

f 101

TIME

SUMM

ARY

OF A

CTIO

NS

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

DETA

ILED

ACT

IONS

AND

COM

MENT

S 06

26

MRT

3 at e

nd of

ribbo

n con

tacted

FAB

. Th

is wa

s pre

-arra

nged

with

the F

AB C

ontro

ller a

nd th

e tea

m ha

d bee

n inf

orme

d tha

t if th

ey ha

d not

conta

cted F

AB a

gain

withi

n one

hour

– a s

econ

d tea

m wo

uld be

mob

ilised

.

Again

the s

tandb

y tea

m wa

s MRT

2 wh

o had

alre

ady h

ad a

worko

ut in

the ho

t an

d hum

id atm

osph

ere.

0657

MR

T 3 a

rrive

d at th

e two

men

on lo

ngwa

ll fac

e. MR

T 3 f

ound

the t

wo m

en on

the l

ongw

all fa

ce at

choc

k 61.

The

y had

run a

co

mpre

ssed

air li

ne fr

om th

e tail

gate

and h

ad ta

ken r

efuge

unde

r an

impr

ovise

d can

vas d

one.

The t

eam

pass

ed an

SSR

90 to

each

of th

e men

and t

hen p

roce

eded

to lo

ad

the in

jured

man

in th

e stre

tcher

.

0700

A/

Supe

rinten

dent,

QMR

S, in

forme

d IMT

that

MRT

4 and

5 ha

d arri

ved o

n site

.

0705

MR

T 3 l

eft ch

ock 6

1 with

casu

alty a

nd fir

st -a

ider.

MRT

3 did

not w

aste

any v

aluab

le tim

e gett

ing m

obile

from

the A

FC ba

ck to

FA

B.

They

had t

o car

ry the

casu

alty a

long t

he A

FC (it

was

posit

ively

isolat

ed),

which

wa

s a di

fficult

task

but h

andle

d well

.

0714

A/

Supe

rinten

dent,

QMR

S, br

iefed

the I

MT on

the M

RT 1

repo

rt.

0724

MR

T 3 a

rrive

d at 9

cut-t

hrou

gh an

d info

rmed

FAB

that

they h

ad al

l mem

bers

of tea

m, ca

sualt

y and

first

-aide

r. Th

e rad

io me

ssag

e was

rece

ived a

nd un

derst

ood b

y FAB

, yet

the IM

T we

re

discu

ssing

the n

eed t

o dep

loy M

RT 4

three

minu

tes la

ter. T

he m

essa

ge ha

d ob

vious

ly no

t bee

n pas

sed o

n.

0727

IM

T 2 d

ecide

d to d

eploy

MRT

4 in

sear

ch of

MRT

3.

Had I

MT co

ntacte

d FAB

rece

ntly f

or an

upda

te?

0730

MR

T 3 o

ut of

tailga

te in

PJB

– all p

erso

ns ac

coun

ted fo

r.

Exer

cise t

ermi

nated

.

The u

se of

the v

ehicl

e mea

nt tha

t MRT

3 re

turne

d in v

ery g

ood c

ondit

ion an

d the

men

wer

e extr

icated

rapid

ly. C

ould

this h

ave b

een d

eploy

ed ea

rlier?

Page

62 o

f 101

ELEM

ENT

PERF

ORMA

NCE

CRIT

ERIA

OBJE

CTIV

E EV

IDEN

CE S

OUGH

TOB

SERV

ATIO

N

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

QUEE

NSLA

ND M

INES

RES

CUE

SERV

ICE

– PER

FORM

ANCE

CRI

TERI

A AU

DIT

TOOL

ASSE

SSOR

S: M

URRA

Y BI

RD A

ND T

ONY

DE S

ANTI

S

COMM

ENT

QMRS

Pe

rform

ance

Cr

iteria

Writt

en M

ines R

escu

e Agr

eeme

nt Ex

isten

ce

Curre

nt mi

ne re

scue

perso

nnel

listed

on no

tice b

oard

. Di

d not

perso

nally

see M

ines

Resc

ue A

gree

ment.

Did c

orpo

ratio

n mee

t its o

bliga

tions

un

der t

he A

gree

ment

Mutua

l Ass

istan

ce

��Su

perin

tende

nt ��

14 T

eam

Memb

ers

��3 G

AG O

pera

tors

��Eq

uipme

nt

Duty

Card

s St

ation

Acti

on S

heets

/ Tim

e Log

s

Yes.

Annu

al Ex

ercis

e Pa

rticipa

tion

Emer

genc

y Exe

rcise

Com

mitte

e Ass

essm

ent

Yes.

CEO

part

of Em

erge

ncy E

xerci

se

Comm

ittee.

Appr

opria

te Tr

aining

Di

d Tra

inees

and G

AG op

erato

rs ��

demo

nstra

te ab

ility t

o use

BA

/ GAG

��

demo

nstra

te ab

ility t

o use

resc

ue eq

uip

��de

mons

trate

familia

rity w

ith re

scue

Pr

oced

ures

and p

rotoc

ols

Demo

nstra

te co

nfide

nce i

n abil

ity to

rend

er

aid de

mons

trate

profe

ssion

al co

nduc

t

Yes.

All te

ams a

ppea

red t

o be

conv

ersa

nt wi

th eq

uipme

nt an

d pr

otoco

ls.

Equip

ment

Maint

ained

Av

ailab

le Te

sted

Certif

ied

Yes.

Yes.

Yes.

Logg

ed in

to bo

ok.

Suffic

ient e

quipm

ent m

ade

avail

able.

Page

63 o

f 101

ELEM

ENT

PERF

ORMA

NCE

CRIT

ERIA

OBJE

CTIV

E EV

IDEN

CE S

OUGH

TOB

SERV

ATIO

N

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

COMM

ENT

Mutua

l Ass

istan

ce

MR C

all O

ut Pr

oced

ure -

��Ef

fectiv

e ��

Deplo

ymen

t of p

erso

nnel

��Ar

rived

in sp

ecifie

d tim

e fra

mes

Yes –

resp

onse

time w

as go

od.

Oper

atio

nal

Effic

iency

Op

erati

onal

Mine

Iner

tisati

on

��Ar

rival

of GA

G ��

Arriv

al of

supp

ort v

ehicl

es / s

ervic

es

��Fa

brica

tion o

f GAG

��

Hook

up of

GAG

��

Oper

ation

of em

erge

ncy s

eals

��Co

ntrol

/ Mon

itorin

g of A

tmos

pher

es

��Pr

edict

ive an

alysis

��

Contr

ol of

Fans

/ Ven

t Qua

ntitie

s /

Veloc

ity

��Op

erati

on of

GAG

��

On-g

oing c

ontin

uous

oper

ation

–

oper

ators

– su

ppor

t ser

vices

GAG

arriv

ed on

site,

but w

as no

t re

quire

d.

Duty

Card

Hold

ers

Mine

s Res

cue S

uper

inten

dent

��Re

ceive

s call

from

non-

affec

ted m

ine

��Iss

ues D

uty C

ards

��

Partic

ipates

in In

ciden

t Con

trol

Fres

h Air B

ase C

ontro

ller

��Lin

ks F

AB to

Sup

erint

ende

nt

MR S

urfac

e Con

trolle

r ��

Surfa

ce fa

cilitie

s

Yes.

Yes.

Good

.

��Ap

pear

ed th

at Mi

nes

Resc

ue A

ssist

ant

Supe

rinten

dant

assu

med r

ole as

part

of IM

T.

��W

ith Q

MRS

perso

n at

FAB,

comm

unica

tion

with

surfa

ce an

d res

cue

team

impr

oved

. ��

Initia

l Sur

face C

ontro

ller

went

in wi

th MR

T 1

team.

Res

pons

ibility

ha

nded

over

to

alter

nate.

Un

derg

roun

d Dep

loyme

nt As

per a

sses

smen

t –

Page

64 o

f 101

ELEM

ENT

PERF

ORMA

NCE

CRIT

ERIA

OBJE

CTIV

E EV

IDEN

CE S

OUGH

TOB

SERV

ATIO

N

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

QUEE

NSLA

ND M

INES

RES

CUE

SERV

ICE

RESP

ONSE

AUD

IT T

OOL

ASSE

SSOR

S: M

URRA

Y BI

RD A

ND T

ONY

DE S

ANTI

S

COMM

ENT

Mine

site

(Pre

pare

for a

ctive

te

am d

eploy

men

t)

x�

Offic

ial in

char

ge is

iden

tified

.

x�

Resc

ue te

am pr

epar

ation

area

is

identi

fied.

x�

Posit

ive an

d tim

ely id

entifi

catio

n of

offici

al in

char

ge (m

ay be

QMR

S or

Co

mpan

y) an

d des

ignate

d op

erati

ng ar

eas.

Resc

ue te

ams r

epor

ted to

resc

ue ro

om

wher

e the

y wer

e brie

fed.

x�

Equip

ment

is un

loade

d at

desig

nated

area

. x�

Du

e car

e of e

quipm

ent w

hen

unloa

ding.

Emer

genc

y veh

icle p

arke

d in c

ar pa

rk.

Addit

ional

gear

that

was r

equir

ed w

as

carri

ed by

hand

to E

merg

ency

Res

cue

Room

. x�

Pr

escri

bed c

heck

s and

tests

on

equip

ment

are c

arrie

d out

and

resu

lts re

cord

ed.

x�

Pres

cribe

d che

cks a

nd te

sts ar

e co

mplet

ely an

d con

fiden

tly ca

rried

ou

t and

reco

rded

.

Test

carri

ed ou

t and

reco

rded

on lo

g bo

oks.

At fir

st, te

sts w

ere s

low w

ith

only

one o

pera

tor. H

owev

er,

as m

ore t

eam

memb

ers

arriv

ed th

e 2nd

RZ2

5 was

us

ed.

x�

Team

s of r

equir

ed nu

mber

s are

for

med.

x�

In an

d abs

ence

of a

Resc

ue

Stati

on O

fficial

, con

trol a

nd

autho

rity is

exer

cised

.

Mine

Res

cue C

o-or

dinato

r ass

umed

thi

s role

well

.

x�

Team

capta

ins an

d vice

capta

ins

are a

ppoin

ted.

x�

Team

proc

edur

es ar

e de

mons

trated

comp

etentl

y. Ye

s.

x�

Team

brief

ings a

re re

ceive

d and

un

derst

ood.

x�

Input

and r

eceip

t of in

forma

tion a

t the

team

brief

ing is

relev

ant a

nd

posit

ive.

Relev

ant q

uesti

ons a

lso as

ked b

y the

tea

ms.

x�

Extra

equip

ment,

if re

quire

d, is

identi

fied a

nd pr

epar

ed fo

r use

. x�

Tim

e man

agem

ent is

effic

ient.

Once

they

wer

e info

rmed

that

they

were

going

oper

ation

al ur

genc

y im

prov

ed.

Lamp

s and

resc

uers

were

not

identi

fied u

ntil te

am w

as to

ld to

get r

eady

to go

.

Page

65 o

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ELEM

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E EV

IDEN

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OUGH

TOB

SERV

ATIO

N

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

SURF

ACE

COMM

UNIC

ATIO

NS A

UDIT

TOO

L

ASSE

SSOR

S: M

URRA

Y BI

RD A

ND T

ONY

DE S

ANTI

S

COMM

ENT

Data

gat

here

d an

ddi

ssem

inat

ed

IMT

Does

ever

ybod

y in t

he In

ciden

t Ma

nage

ment

Team

know

wha

t ha

ppen

ed an

d wha

t is no

w oc

curri

ng?

��Inf

orma

tion f

rom

initia

l incid

ent.

��Ad

dition

al da

ta wa

nted /

requ

ested

��

Witn

esse

s inte

rview

ed

Initia

l brie

fing o

f IMT

was g

ood.

Had

to

be re

peate

d a nu

mber

of tim

es as

pe

ople

arriv

ed la

ter.

Could

have

utilis

ed w

hiteb

oard

to

list s

eque

nce o

f eve

nts.

Tech

nica

l Sup

port

Team

Do

they

know

basic

ally w

hat

happ

ened

, wha

t infor

matio

n is n

ow

requ

ired,

what

to loo

k for

and w

hy

��Inf

orma

tion f

rom

initia

l incid

ent.

��Ad

dition

al da

ta wa

nted /

requ

ested

��

Freq

uenc

y of u

pdate

s ��

Appr

opria

te pe

rsonn

el an

d eq

uipme

nt pr

epar

ed

Yes –

gene

rally

hand

led w

ell.

Mine

s Res

cue T

eam

s Do

they

know

basic

ally w

hat

happ

ened

, wha

t infor

matio

n is n

ow

requ

ired a

nd pr

epar

ing fo

r wha

t the

y may

need

to do

.

��Inf

orma

tion f

rom

initia

l incid

ent

��Ad

dition

al da

ta wa

nted /

requ

ested

��

Freq

uenc

y of u

pdate

s ��

Appr

opria

te pe

rsonn

el an

d eq

uipme

nt pr

epar

ed

��Mi

nes R

escu

e Sup

erint

ende

nt pa

ssed

infor

matio

n onto

team

s. ��

Only

basic

infor

matio

n and

at

times

lack

ing in

detai

l.

Did n

ot kn

ow w

hen t

eam

went

oper

ation

al, w

here

they

wer

e, no

plan

s and

limite

d writt

en

instru

ction

s.

Prio

rities

es

tabl

ished

IM

T Do

es ev

eryb

ody i

n the

Incid

ent

Mana

geme

nt kn

ow w

hat th

e gro

up’s

prior

ities a

re an

d clea

r on w

hy?

��Di

scus

sions

of pr

ioritie

s ��

Docu

mente

d or o

n whit

eboa

rd

��Pl

annin

g don

e inli

ne w

ith th

em

��Pe

riodic

revie

w of

them

to de

termi

ne

that th

ey ar

e still

appr

opria

te an

d are

be

ing ac

hieve

d.

��Me

eting

proto

cols

estab

lishe

d at

the st

art.

Prior

ities /

objec

tives

not

writte

n up.

Could

have

utilis

ed th

e wh

itebo

ard t

o list

out w

hat th

e ob

jectiv

es an

d prio

rities

wer

e.

Tech

nica

l Sup

port

Team

Do

es ev

eryb

ody i

n the

Tec

hnica

l Su

ppor

t Tea

m kn

ow w

hat th

e gr

oup’s

prior

ities a

re?

��Di

scus

sions

on pr

ioritie

s ��

Infor

matio

n disp

atche

d and

reac

ted

too in

line w

ith th

em.

��Pe

riodic

revie

w of

them

to de

termi

ne

that th

ey ar

e bein

g ach

ieved

.

Tech

nical

Supp

ort te

am w

ere m

embe

rs of

IMT.

Page

66 o

f 101

ELEM

ENT

PERF

ORMA

NCE

CRIT

ERIA

OBJE

CTIV

E EV

IDEN

CE S

OUGH

TOB

SERV

ATIO

N

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

COMM

ENT

Mine

s Res

cue T

eam

Do

es ev

eryb

ody i

n the

resc

ue

teams

know

wha

t Incid

ent

Mana

geme

nt Te

am’s

and t

he m

ines

resc

ue pr

ioritie

s are

and c

lear o

n wh

y?

��Di

scus

sions

on pr

ioritie

s ��

Docu

mente

d or o

n whit

eboa

rd

��Pl

aning

done

inlin

e with

them

��

Perio

dic re

view

of the

m to

deter

mine

tha

t they

are s

till ap

prop

riate

and

they a

re be

ing ac

hieve

d.

Gene

ral u

nder

stand

ing of

incid

ent w

as

okay

. The

y wer

e give

n ver

bal

instru

ction

s whic

h wer

e the

n foll

owed

up

by w

ritten

notes

whic

h gen

erall

y lac

ked d

etail.

Instru

ction

s sho

uld ha

ve be

en

agre

ed in

IMT

and w

ritten

up

prior

to is

suing

to M

RT.

Grou

p Dy

nam

ics

IMT

How

does

the I

MT fu

nctio

n as a

gr

oup?

��Int

erpr

etatio

n of n

ew or

ongo

ing

infor

matio

n and

how

it is u

sed?

��

Decis

ion m

aking

meth

ods u

sed i

n de

termi

ning a

ction

plan

s. ��

How

is co

nsen

sus a

chiev

ed?

��Int

erac

tion o

f team

mem

bers?

Unde

rgro

und M

ine M

anag

er le

d all

discu

ssion

s. G

ood c

ontrib

ution

from

oth

er m

embe

rs. A

ltern

ative

s dis

cuss

ed, p

ath ch

osen

and d

ecisi

on

made

- if t

here

wer

e no o

bjecti

ons.

No re

al for

mal d

ecisi

on

makin

g.

Tech

nica

l Sup

port

Team

Ho

w do

es th

e Tec

hnica

l Tea

m fun

ction

as a

grou

p?

��Int

erpr

etatio

n of n

ew or

ongo

ing

infor

matio

n and

how

it is u

sed?

��

Decis

ion m

aking

meth

ods u

sed i

n de

termi

ning h

ow, w

ho, w

hat a

nd

when

infor

matio

n is r

equir

ed an

d dis

patch

ed.

��Ho

w is

cons

ensu

s ach

ieved

? ��

Inter

actio

n of te

am m

embe

rs?

Infor

matio

n pre

sente

d to I

MT fo

r de

cision

s.

Succ

essio

n Pl

ans

and

Chan

g-ov

er

IMT

How

does

the I

MT pr

epar

e for

a ch

ange

-ove

r of p

artic

ipants

?

��Pl

annin

g in a

dvan

ce

��Ap

prop

riate

perso

nnel

identi

fied

��Cr

oss–

over

perio

ds

��Inf

orma

tion e

xcha

nged

��

Docu

menta

tion

��Ha

nd ov

er w

as pl

anne

d well

in

adva

nce a

nd de

cision

mad

e as t

o wh

en pe

ople

would

call t

heir

repla

ceme

nts.

��Ex

chan

ge of

infor

matio

n don

e on

e-on

e rath

er th

an as

a tea

m.

Tech

nica

l Sup

port

Team

Ho

w do

es th

e Tec

h Sup

port

perso

nnel

prep

are f

or a

chan

ge

over

of pa

rticipa

nts?

��Pl

annin

g in a

dvan

ce

��Ap

prop

riate

perso

nnel

identi

fied

��Cr

oss–

over

perio

ds

��Inf

orma

tion e

xcha

nged

��

Docu

menta

tion

��Ha

nd ov

er w

as pl

anne

d well

in

adva

nce a

nd de

cision

mad

e as t

o wh

en pe

ople

would

call t

heir

repla

ceme

nts.

��Ex

chan

ge of

infor

matio

n don

e on

e-on

e rath

er th

an as

a tea

m.

Page

67 o

f 101

ELEM

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ORMA

NCE

CRIT

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OBJE

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E EV

IDEN

CE S

OUGH

TOB

SERV

ATIO

N

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

COMM

ENT

Mine

s Res

cue P

erso

nnel

How

does

the R

escu

e per

sonn

el pr

epar

e for

a ch

ange

-ove

r of

partic

ipants

?

��Pl

annin

g in a

dvan

ce

��Ap

prop

riate

perso

nnel

identi

fied

��Cr

oss–

over

perio

ds

��Inf

orma

tion e

xcha

nged

��

Docu

menta

tion

��Pl

anne

d as p

er IM

T.

��Di

d not

actua

lly ta

ke pl

ace.

Othe

r Su

ppor

t gr

oups

(Se

curit

y et

c)

How

does

the g

roup

s pre

pare

for a

ch

ange

-ove

r of p

artic

ipants

?

��Pl

annin

g in a

dvan

ce

��Ap

prop

riate

perso

nnel

identi

fied

��Cr

oss–

over

perio

ds

��Inf

orma

tion e

xcha

nged

��

Docu

menta

tion

Orga

nised

by S

urfac

e Con

trolle

r. Ch

ange

over

did n

ot tak

e plac

e.

Mine

s Res

cue T

eam

Ho

w do

es th

e Mine

s Res

cue T

eam

functi

on as

a gr

oup?

��Me

thod o

f upd

ating

perso

nnel

��Int

erpr

etatio

n of n

ew or

ongo

ing

infor

matio

n and

how

it cha

nges

cu

rrent

arra

ngem

ent

��De

cision

mak

ing m

ethod

s use

d in

deter

minin

g how

, who

, wha

t and

wh

en te

ams a

nd eq

uipme

nt ar

e re

quire

d and

disp

atche

d. ��

How

is thi

s con

sens

us ac

hieve

d?

��Int

erac

tion o

f team

mem

bers

from

total

grou

p, no

t just

a sing

le mi

nes

resc

ue te

am.

��Te

ams w

ere b

riefed

as a

grou

p. ��

Upda

ted in

forma

tion n

ot re

layed

to

oper

ation

al tea

ms.

��Di

d not

witne

ss an

y deta

iled

plann

ing or

decis

ion m

aking

.

Inte

ract

ion

betw

een

Grou

ps

How

well d

o the

thre

e gro

ups

inter

act a

nd co

mmun

icate

with

each

oth

er?

��Me

thod o

f com

munic

ation

– ve

rbal,

wr

itten e

tc.

��Fr

eque

ncy o

f com

munic

ation

��

Are c

ommu

nicati

ons o

ne w

ay or

two-

three

way

? ��

Is the

critic

al inf

orma

tion b

eing

clear

ly co

mmun

icated

? ��

Is the

re to

o muc

h ‘nic

e to k

now’

inf

orma

tion b

eing c

ommu

nicate

d?

��Ve

rbal

comm

unica

tion o

n a ne

eds

basis

. ��

Critic

al inf

orma

tion w

as re

layed

, ho

weve

r as m

entio

ned a

bove

, ch

ange

s in c

ondit

ion no

t co

mmun

icated

to op

erati

onal

team.

Need

to en

sure

that

infor

matio

n is r

elaye

d to

oper

ation

al tea

m.

Reco

rdin

g of

Info

rmat

ion

How

well d

o the

grou

ps re

cord

cri

tical

data

and e

vents

? ��

Who

reco

rded

infor

matio

n?

��Me

thod o

f rec

ordin

g?

��Is

it eas

ily re

viewe

d by g

roup

me

mber

s?

��Al

l Duty

Car

d hold

ers h

ad a

book

wh

ich th

ey re

cord

ed in

forma

tion

on.

Page

68 o

f 101

ELEM

ENT

PERF

ORMA

NCE

CRIT

ERIA

OBJE

CTIV

E EV

IDEN

CE S

OUGH

TOB

SERV

ATIO

N

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

COMM

ENT

��Do

es it

fulfil

the ne

eds o

f the

exer

cise?

��

Wou

ld it f

ulfil t

he ne

eds o

f an

inque

st?

��Sc

ribe a

lloca

ted to

IMT.

��Ta

pe re

cord

er al

so us

ed in

IMT.

Reali

ty o

f Exe

rcise

and

Roles

fille

d IM

T Do

partic

ipants

reac

t to th

e exe

rcise

the

same

way

that

they w

ould

in re

ality?

��Do

partic

ipants

clea

rly un

derst

and

the da

nger

s and

prior

ities?

��

Are p

artic

ipants

just

follow

ing pr

ompt

card

s?

��Ar

e dec

ision

s and

actio

ns be

ing

imple

mente

d in a

timely

man

ner?

��

Are p

artic

ipants

mor

e wor

ried a

bout

makin

g a m

istak

e rath

er th

an so

lving

the

prob

lem?

��Da

nger

s and

prior

ities c

learly

un

derst

ood.

��No

.

��Th

e tea

m cle

arly

wante

d to c

ome

up w

ith a

worka

ble so

lution

whic

h wo

uld no

t end

ange

r othe

rs.

��Al

thoug

h the

y rea

lised

tha

t SSR

90’s

would

run

out a

t 3:00

am. T

he le

vel

of ur

genc

y in g

etting

a re

scue

team

in to

retrie

ve

emplo

yees

was

lack

ing.

Tech

nica

l Sup

port

Team

Do

partic

ipants

reac

t to th

e exe

rcise

the

same

way

that

they w

ould

in re

ality?

��Do

partic

ipants

clea

rly un

derst

and

the da

nger

s and

prior

ities?

��

Are p

artic

ipants

just

follow

ing pr

ompt

card

s?

��Ar

e dec

ision

s and

actio

ns be

ing

imple

mente

d in a

timely

man

ner?

��

Are p

artic

ipants

mor

e wor

ried a

bout

makin

g a m

istak

e rath

er th

an so

lving

the

prob

lem?

Tech

nical

Mana

ger a

nd V

entila

tion

Offic

er w

ere p

art o

f IMT.

Di

d not

obse

rve a

sepa

rate

techn

ical te

am

Mine

s Res

cue T

eam

s Do

partic

ipants

reac

t to th

e exe

rcise

the

same

way

that

they w

ould

in re

ality?

��Do

partic

ipants

clea

rly un

derst

and

the da

nger

s and

prior

ities?

��

Are p

artic

ipants

just

follow

ing pr

ompt

card

s?

��Ar

e dec

ision

s and

actio

ns be

ing

imple

mente

d in a

timely

man

ner?

��

Are p

artic

ipants

mor

e wor

ried a

bout

makin

g a m

istak

e rath

er th

an so

lving

the

prob

lem?

Yes.

No.

Yes.

No.

Page

69 o

f 101

ELEM

ENT

PERF

ORMA

NCE

CRIT

ERIA

OBJE

CTIV

E EV

IDEN

CE S

OUGH

TOB

SERV

ATIO

N

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

SITE

RES

CUE

CO-O

RDIN

ATOR

S EF

FECT

IVEN

ESS

AUDI

T TO

OL

ASSE

SSOR

S: M

URRA

Y BI

RD A

ND T

ONY

DE S

ANTI

S

Prot

ectin

g an

das

sistin

g pe

rson

sin

volve

d in

Firs

t Re

spon

se fi

rst a

id

Prot

ectin

g an

das

sistin

g pe

rson

sin

volve

d in

aide

d es

cape

Prov

ision

of t

he

nece

ssar

y em

erge

ncy

equi

pmen

t and

serv

ices

Plan

ning

to

prov

ide f

or an

yes

calat

ion

of th

e em

erge

ncy

The S

ite R

escu

e Coo

rdina

tor

maxim

ises t

he sa

fety o

f per

sonn

el in

coor

dinati

ng an

y firs

t aid

resp

onse

The S

ite R

escu

e Coo

rdina

tor

maxim

ises t

he sa

fety o

f per

sonn

el in

coor

dinati

ng an

y aide

d esc

ape

resp

onse

.

The S

ite R

escu

e Coo

rdina

tor

ensu

res t

hat s

uffici

ent r

escu

e eq

uipme

nt an

d med

ical s

ervic

es is

av

ailab

le an

d in r

eadin

ess o

n site

du

ring a

n eme

rgen

cy.

The S

ite R

escu

e Coo

rdina

tor

ensu

res t

hat a

suita

ble re

spon

se

can b

e imp

lemen

ted fo

r any

es

calat

ion of

the e

merg

ency

thro

ugh

prop

er pl

annin

g.

��Mi

nimise

expo

sure

to ris

k

��Ini

tiates

QMR

S ca

ll out

if nec

essa

ry.

��In

conju

nctio

n with

Site

Eme

rgen

cy

Contr

oller

and Q

MRS

asse

ss ris

k of

any r

escu

e tea

m de

ploym

ent.

��Su

fficien

t ser

vicea

ble re

scue

eq

uipme

nt is

avail

able

on si

te.

��Su

fficien

t eme

rgen

cy m

edica

l tre

atmen

t cap

abilit

y is a

vaila

ble on

sit

e.

��Lia

ises w

ith In

ciden

t Con

trol

Comm

ittee

��Lia

ises w

ith Q

MRS

��Lia

ises w

ith ex

terna

l ass

istan

ce

agen

cies

��As

sess

any r

isk in

any f

irst r

espo

nse.

Site

Co-o

rdina

tor to

ok a

seco

ndar

y role

on

ce th

e QMR

S Su

perin

tende

nt too

k ov

er.

��Tr

avell

ed to

the m

ine w

ith M

ine

Mana

ger.

��Ca

lls m

ade f

orm

the ca

r

��W

ell do

ne, h

owev

er, it

appe

ared

to

be sl

ow.

��Em

erge

ncy a

mbula

nce o

n-sit

e.

��W

ell do

ne –

part

of IM

T.

��Ye

s. ��

N/A.

COMM

ENT

Site

Resc

ue C

o-or

dinato

r Role

wa

s han

ded o

ver t

o an

alter

nate

as fir

st on

e wen

t in

with

MRT

1.

Risk

asse

ssme

nt for

resc

ue

team

deplo

ymen

t was

part

of the

disc

ussio

ns he

ld in

IMT.

Page

70 o

f 101

ELEM

ENT

PERF

ORMA

NCE

CRIT

ERIA

OBJE

CTIV

E EV

IDEN

CE S

OUGH

TOB

SERV

ATIO

N

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

TECH

NICA

L SU

PPOR

T TE

AM A

UDIT

TOO

L

ASSE

SSOR

S: M

URRA

Y BI

RD A

ND T

ONY

DE S

ANTI

S

COMM

ENT

Leve

l and

det

ail o

f te

chni

cal in

form

atio

n co

llate

d, co

ordi

nate

d an

d co

mm

unica

ted

by

the T

echn

ical T

eam

to

the I

ncid

ent

Mana

gem

ent T

eam

Once

brief

ed by

Incid

ent C

ontro

ller,

what

level

of su

ppor

t was

co-o

pted?

��

Numb

er of

perso

ns co

-opte

d?

��Te

chnic

al ex

pertis

e of p

erso

ns?

��Kn

owled

ge le

vel o

f Kes

trel –

lay

out, p

erso

nnel

and s

ystem

s?

��A

numb

er of

perso

ns w

ere c

o-op

ted to

assis

t the I

MT.

��Kn

owled

ge le

vel w

as go

od.

Tech

nical

Team

not o

fficial

ly es

tablis

hed d

ue to

natur

e of

incide

nt. G

as C

hrom

atogr

aph

Oper

ator n

omina

ted.

Venti

lation

Offic

er an

d Te

chnic

al Ma

nage

r wer

e par

t of

IMT.

Was

the t

echn

ical s

uppo

rt tea

m as

semb

led ap

prop

riatel

y to a

ddre

ss

the le

vel o

f eme

rgen

cy an

d the

type

of

emer

genc

y?

��Te

chnic

al ex

pertis

e of p

erso

ns

co-o

pted i

n the

type

of

emer

genc

y bein

g fac

ed.

Yes.

Tech

nical

expe

rtise

appr

opria

te for

the e

merg

ency

.

Stan

dard

of in

forma

tion p

repa

red

for In

ciden

t Tea

m?

��Di

d the

detai

l and

form

at all

ow

the In

ciden

t Tea

m to

formu

late

decis

ions o

r was

mor

e deta

il re

quire

d?

Infor

matio

n on g

as co

ncen

tratio

ns an

d mo

veme

nts re

layed

to IM

T as

even

ts un

folde

d.

All in

forma

tion t

rans

fer w

as

verb

al.

Tran

sfer o

f infor

matio

n to I

ncide

nt Ma

nage

ment

Team

��

Verb

al, w

ritten

or a

comb

inatio

n of

both.

��

Was

the t

ime i

nterva

l betw

een

infor

matio

n tra

nsfer

adeq

uate?

��

Wer

e all r

espo

nses

from

the

Incide

nt Co

ntroll

er fo

r infor

matio

n me

t and

in a

timely

man

ner?

Tran

sfer o

f infor

matio

n was

verb

al.

Time i

nterva

l was

adeq

uate

but n

ot alw

ays a

ll enc

ompa

ssing

.

IMT

memb

ers r

egula

rly se

nt ou

t of IM

T ro

om to

gathe

r mo

re de

tails,

partic

ularly

gas

levels

.

Wer

e the

type

and s

tanda

rd of

ou

tside

servi

ces a

ppro

priat

e for

the

emer

genc

y?

��W

hat o

utside

servi

ces w

ere

activ

ated?

��

Did t

he le

vel o

f exp

ertis

e call

ed

dd

th i

t f th

QMRS

, Amb

ulanc

e and

hosp

ital w

ere

conta

cted.

The l

evel

of ex

pertis

e call

ed w

as

d t

Polic

e wer

e not

conta

cted.

Page

71 o

f 101

ELEM

ENT

PERF

ORMA

NCE

CRIT

ERIA

OBJE

CTIV

E EV

IDEN

CE S

OUGH

TOB

SERV

ATIO

N

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

COMM

ENT

addr

ess t

he re

quire

ments

of th

e em

erge

ncy?

ad

equa

te.

How

were

the o

utside

servi

ces

brief

ed?

��W

ritten

, ver

bal o

r a co

mbina

tion?

��

Was

this

infor

matio

n rec

orde

d?

This

was d

one v

erba

lly ov

er th

e pho

ne.

Apar

t from

QMR

S, ot

her

emer

genc

y ser

vices

wer

e not

mobil

ised.

Was

the b

riefin

g to t

he ou

tside

se

rvice

s app

ropr

iate?

��

Was

the b

riefin

g acc

urate

? ��

Did t

he le

vel o

f infor

matio

n pr

ovide

d per

mit th

e ser

vice

conc

erne

d to a

ct in

an

appr

opria

te an

d effe

ctive

ma

nner

?

Gene

rally

. Ye

s.

Wha

t was

the s

tanda

rd of

tech

nical

detai

l requ

ired?

��

Thro

ugho

ut the

exer

cise w

as th

e inf

orma

tion a

ccur

ate an

d su

fficien

t for t

he In

ciden

t Ma

nage

ment

Team

Gene

rally

. Co

mmun

icatio

n flow

appe

ared

to

falter

as th

e exe

rcise

dr

agge

d on.

How

was t

hat te

chnic

al de

tail

acqu

ired?

��

Wha

t sou

rces w

ere u

tilise

d for

inf

orma

tion?

��

Wer

e mor

e acc

urate

sour

ces

avail

able?

��

Wer

e the

sour

ces o

f infor

matio

n ve

rified

and a

uthor

ised p

rior t

o iss

ue?

Good

use o

f all a

vaila

ble re

sour

ces.

Cons

pec a

nd tu

be bu

ndle

gas

read

ings v

erifie

d by G

as

Chro

matog

raph

Ope

rator

.

Was

the s

tanda

rd an

d for

mat o

f de

tail p

repa

red a

dequ

ate fo

r the

Inc

ident

Mana

geme

nt Te

am?

��Di

d the

Incid

ent M

anag

emen

t Te

am qu

estio

n the

infor

matio

n or

metho

d in w

hich i

t was

pr

esen

ted?

Clar

ified a

nd di

scus

sed b

ut did

not

reall

y que

stion

. Ge

nera

lly w

ell do

ne.

How

was t

he ac

cura

cy of

the

infor

matio

n pre

pare

d for

the i

ncide

nt tea

m ch

ecke

d and

autho

rised

prior

to

issue

?

��Di

d the

Tec

hnica

l Offic

er ve

rify

and a

uthor

ise al

l infor

matio

n prio

r to

it bein

g iss

ued?

No. T

echn

ical M

anag

er w

as a

memb

er

of IM

T.

How

were

docu

ments

contr

olled

an

d info

rmati

on re

cord

ed an

d file

d?

��Vi

ew ev

idenc

e of d

ocum

ents

being

prep

ared

and f

iled.

A sc

ribe a

lloca

ted to

take

notes

in th

e IM

T.

Tape

reco

rder

was

also

used

.

No ev

idenc

e of a

ny ot

her

writte

n for

m of

comm

unica

tion.

Page

72 o

f 101

ELEM

ENT

PERF

ORMA

NCE

CRIT

ERIA

OBJE

CTIV

E EV

IDEN

CE S

OUGH

TOB

SERV

ATIO

N

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

COMM

ENT

Wha

t was

the l

evel

of int

erfac

e with

oth

er ar

eas i

n the

colla

tion a

nd

disse

mina

tion o

f infor

matio

n?

��Vi

ew ho

w tea

m int

erfac

ed w

ith

other

indiv

iduals

durin

g the

ex

ercis

e.

Team

brok

e up o

n a nu

mber

of

occa

sions

to di

ssem

inate

infor

matio

n.

Was

venti

lation

detai

l acc

urate

and

curre

nt?

��Me

thod b

y whic

h Ven

tilatio

n Of

ficer

colle

cted a

n coll

ated h

is inf

orma

tion.

��Us

e of g

as ch

roma

togra

ph

��Us

e of S

afeGa

s ��

Use o

f SIM

TARS

perso

nnel

��Int

erva

l betw

een c

heck

ing

SafeG

as fo

r exp

losive

atm

osph

eres

and t

he tr

endin

g the

reof.

Infor

matio

n flow

ed fr

om C

ontro

l Roo

m to

Venti

lation

Offic

er lo

cated

in th

e IMT

Ro

om.

Inter

val a

ppea

red t

o be s

uitab

le.

Good

use o

f ava

ilable

inf

orma

tion.

How

was v

entila

tion d

ata re

cord

ed

and d

issem

inated

? ��

Was

the i

nform

ation

reco

rded

an

d pre

sente

d in s

uch a

man

ner

that it

was

easil

y refe

renc

ed in

to tre

nds?

��

Did t

he V

entila

tion O

fficer

cros

s re

feren

ce w

ith “V

entsi

m” or

an

other

prog

ram?

��

Did t

he V

entila

tion O

fficer

cros

s re

feren

ce ac

tual c

ondit

ions

unde

rgro

und w

ith D

e-br

iefing

Of

ficer

? ��

Was

venti

lation

detai

l read

ily

autho

rised

by th

e Ven

tilatio

n Of

ficer

or th

e Tec

hnica

l Offic

er?

No, b

ut no

t nee

ded.

Yes.

Yes.

Not a

lway

s.

Venti

lation

simu

lation

carri

ed

out to

deter

mine

effec

ts of

prop

osed

venti

lation

chan

ge.

Infor

matio

n flow

dire

ctly f

rom

Contr

ol.

Page

73 o

f 101

ELEM

ENT

PERF

ORMA

NCE

CRIT

ERIA

OBJE

CTIV

E EV

IDEN

CE S

OUGH

TOB

SERV

ATIO

N

Emer

genc

y Exe

rcise

: Kes

trel C

oal M

ine

Tues

day,

27 N

ovem

ber 2

001

COMM

ENT

Was

the v

entila

tion i

nform

ation

in a

forma

t, and

of su

fficien

t deta

il, for

the

Incid

ent M

anag

emen

t Tea

m to

make

infor

med d

ecisi

ons?

��W

as th

e Inc

ident

Mana

geme

nt Te

am ab

le to

diges

t the

infor

matio

n with

out c

onsta

nt re

feren

ce to

the V

entila

tion

Offic

er?

��W

as cu

rrent

infor

matio

n eas

ily

refer

ence

d by t

he In

ciden

t Ma

nage

ment

Team

into

prev

ious

infor

matio

n pro

vided

?

Yes.

Yes.

Was

the s

trata

detai

l inclu

ding

locati

on of

bore

holes

avail

able

and

accu

rate?

��W

hat s

trata

plans

and g

eolog

ical

infor

matio

n wer

e ava

ilable

? ��

Wer

e bor

ehole

s clea

rly an

d ac

cura

tely m

arke

d?

Not u

tilise

d.

Was

the t

ype a

nd nu

mber

of m

ine

plans

avail

able

curre

nt an

d con

tain

the le

vel o

f deta

il req

uired

?

��Cu

rrenc

y of p

lans t

o be c

heck

ed.

��Di

d all p

lans p

rovid

e the

leve

l of

detai

l and

infor

matio

n req

uired

?

The p

lans i

n the

IMT

room

wer

e up-

toda

te. P

ositio

n of m

ine pl

an on

the w

all

made

it dif

ficult

for a

ll to v

iew w

hen

talkin

g abo

ut ar

ea ar

ound

long

wall f

ace

(300

mm of

f the f

loor)

Mine

s Res

cue T

eam

plans

not

read

ily av

ailab

le.

Page

74 o

f 101


SUMMARY OF RECOMMENDATIONS

These recommendations have been compiled from the assessment, audit tools and summaries of the Emergency Exercise Management Team.

CONTROL ROOM OPERATIONS

1. IMT to ensure that CRO informed of intended actions so that he can confirm actions as required. This should be done by one of the duty card holders. This way the CRO only gets information from one person in contact with the IMT.

2. Limit access to the control room to stop people wandering in and out.

3. Extra phone point for personnel with duty cards so as not to use control room as a telephone room.

4. Modify Safegas so that login time lasts for the shift duration of the CRO. CRO to log out should he leave the control room. This will reduce frustration on accepting alarms.

5. Gas Chromatograph Operator was useful as backup to CRO although he was not required to take a large number of bag samples due to the scenario.

6. Ensure that duplicate tasks are not given to duty card holders and that duty card holders stick to their duties.

7. Consider increased and more regular use of the PED to send messages to trapped personnel. Short, accurate messages can often provide a moral boost and (perhaps) can also be used to provide advice/directions. NB. Some

messages sent by the Exercise Assessment Committee members to the underground assessors did NOT get

through. The impacts of the broken ground above the goaves adjacent to LW 204 and LW 205 need to be

investigated in regard to this.

LONGWALL 205 FACE CREW ESCAPE

8. The mine re-investigates the escape time-lines and distances between cache locations in longwall returns – particularly where poor visibility may be experienced.

9. Investigate the number of SCSR in the longwall return caches. In this scenario there were sufficient numbers, but there were only six people on the face. If there had of been one more person on the face, there were no spare units in the caches. The escaping crew expressed concerns during the debrief of this point. Self-escape routes need to be planned and serviced by sufficient SCSRs for the maximum number of personal in the panel in both primary and alternate routes.

10. During the refresher training for SCSR, mines must ensure that duration times of at work and at rest are explained to wearers.

11. Communications using pens and notebooks, and not talking through mouthpieces, should be adopted as an industry standard.

Page 75 of 101


12. Trial the use of walking sticks in areas of excessive rib spall. The trial to consider the appropriateness of using “candy cane” shaped curved handles, or the current right angled “elbow” shaped handles.

13. Treat any person who ‘escapes’ in the hot and humid conditions as a patient to ensure they recover from the experience – particularly in the rehydration of persons.

FIRST AID RESPONSE – LONGWALL 205 FACE CREW

14. Mine personnel should spend some time brainstorming / training sessions to utilise available equipment innovatively to make air showers, barricades etc. This will improve the likelihood that panic won’t set in should some personnel be unfit to facilitate self-escape. It would be particularly beneficial where there is more than one person to use the airline.

15. Mine personnel need to consider taking more time to ensure that the correct message is written on notepad communication.

INCIDENT MANAGEMENT TEAM

16. The decision making process needs more focus and each option needs to be driven to completion before allowing digression.

17. All IMT members need to be encouraged to actively participate in the decision making process.

18. Duty card holders need to recognise the need to remain with the IMT unless authorised to leave. This is especially true if there is an exchange of roles.

19. Computer access to the mine environment monitoring system in the IMT is essential. Ventilation simulation software should also be on this computer.

20. Communications between the IMT and CRO should be better documented.

21. A systematic process for evaluating fatigue should be implemented rather than rely on the individuals to notify the IC of their status.

22. Calculators should be included in the duty card briefcases.

23. A mine plan in the IMT should show monitoring locations.

24. There needs to be more white boards / areas to display key information for immediate reference.

25. Suitable techniques should be used to capture ideas, generate alternatives and evaluate the different options to allow for systematic comparison.

26. There needs to be more urgency in decision making when retrieving persons underground who are injured or have limited life support equipment available.

27. The environment conditions merit closer monitoring due to the impact of effective temperature on the effective duration time of rescue teams using BG174’s.

Page 76 of 101


28. Ventilation flow sensors in key roadways would enable more accurate interpretation of makes and effects of changes in ventilation.

INCIDENT MANAGEMENT TEAM CHANGE-OVER

29. That the IMT members change-over be conducted on a staggered basis with no more than 2 persons being shifted at a time. This will provide for much more cohesion in the team and limit the possibility of loss of information

30. That there be a greater use of aids such as mine plans, whiteboards, flipcharts etc to display relevant information. A written record of the status of resources is vital to the change-over of any command structure.

31. A written chronological record of milestone events be kept, updated regularly and referred to 32. Consideration be given to allowing the display of this information (through windows) so that persons can update

themselves without having to constantly interrupt the IMT discussions with questions 33. A series of Check Sheets be developed for IMT2 to act as memory prompts in the same way as a Debriefing Officer

ensures capture of information. The prompt sheets could include such things as: �� options discussed and reasons for not doing and/or doing �� current goals / actions with expected outcomes, responsibilities and timeframes �� any alternative or secondary thrusts being investigated �� any limits established … time, gas levels, temperatures �� problems or difficulties experienced to date

IN-SEAM INTERVENTION – QUEENSLAND MINES RESCUE

34. There be a review of the Kestrel Mines Rescue System in the early part of surface intervention (i.e. when minimum persons are available).

35. Mines rescue teams are to ensure all team protocols are adhered to – even in the absence of reality, it is good practice (e.g. communications and information left with the FAB Official, Captain / Team checks on equipment etc.)

36. An expert working party be established to research the use of flameproof vehicles in atmospheres containing levels of flammable gases in excess of the current legislative requirements, and guidelines be developed on how and when they may or may not be used in life threatening scenarios. The outcome of this research may result in changes in the wording of legislation.

37. The rescue efforts appeared hampered by a lack of effective communications between the FAB and the surface. The use of a phone some 100 metres away, while in direct line of site appeared to minimise communication from the FAB to IMT. The availability of phone and lines as part of the mines emergency equipment to allow a line to be run from permanent phones to FAB positions should be assessed as part of the mines emergency system. Mines should have a phone and line available to run from FAB to mine communication system to minimise the hazard of incorrect communication, information breakdown and ensure timely communication to surface for input to IMT.

38. Queensland Mines Rescue Service and mines through their mines rescue agreement should ensure that competencies are developed and persons trained for the key positions of Fresh Air Base Controller and Substation

Page 77 of 101


Mines Rescue Controller so that in the event of QMRS staff members not being available, competent persons will be available for these key roles.

39. While QMRS have developed controls to attempt to minimise the effects on mines rescue personnel deployed in hot and humid conditions these controls (administration controls) are low on the list of hierarchy of controls. It is recommended that QMRS investigate modern control methods to minimise this hazard. Some controls may include cooling vests, cooling of breathing tubes etc.

40. When developing Mines Rescue Team tasks, position, status and content of the mine’s emergency equipment which may be relevant to the task being undertaken should be marked on the plan and communicated to MRT teams and FAB Controller.

41. And perhaps most importantly, the exercise clearly showed that the better the escape systems (and therefore survival systems) in place at a mine, the more likely it is that mines rescue teams will be required to enter and search for survivors some of whom may be at distances not able to be covered on foot within the time constraints placed by use of self contained breathing apparatus– the industry as a whole needs to ensure we are ready for this.

SURFACE AND MINES RESCUE CONTROL

42. The IC, or senior IMT member, should brief Mines Rescue Teams or at least be present to ensure that all information is being passed on and that questions can be answered by somebody familiar with the mine.

43. Testing of Mines Rescue Equipment should be continued until all of it is completed.

44. Greater concentration on getting the first team off the surface properly briefed and equipped is needed as this is the hardest thing to do in reality. Once the actions and limits as set by the IMT, this must become the priority.

45. Basic mine and incident information should be written up on a white-board in the Mines Rescue Room. An enlarged Captains Information Sheet could suit the purpose.

46. Review Mutual Assistance protocols in relation to additional equipment being immediately dispatched from adjacent mines.

47. The role of the QMRS within the IMT should be clearly defined – for example, formally recognised as part of the decision-making team and / or advisory and / or implementation.

48. It should be a consideration to set up a gas-monitoring terminal in the IMT room so that gas trends can be continually monitored.

49. Clearly defined instructions to be issued to rescue teams. One way of doing so could be writing the instructions on the electronic whiteboard in the IMT room and giving the printout to rescue teams.

50. The role of preparing and issuing plans during an incident should be clearly defined. Additional plans will always be required. This may be a role for the Mine Surveyor.

Page 78 of 101


S
AAPPPPEENNDDIICCEES
Page 79 of 101

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EVENT TIME

TOTAL Q % CO2 % CH4

6.3 6.312048 2.514556


APPENDIX 2 - VENTILATION AND GAS READINGS

GAS LOCATIONS

Event – Velocity 0.4 m/s, Gas inundation = 1100 metres Tailgate alarm / velocity sensor HIGH then LOW / gas inundation to 19 cut-through. 1316 metres 1556 metres (240 metres / 10 minutes) 1796 metres 2036 metres 2276 metres (cut-through names at time intervals are yet to be determined) 2516 metres 2756 metres 2996 metres 3300 metres (gas reaches mains / Conspec alarm / gas starts moving up tube bundle) Survivors reach mains / one group continues to walk out – others do as they would in the emergency ie. contact help Tailgate tube bundle alarm

9:31pm 9:31pm 9:40pm 9:50pm 10:00pm 10:10pm 10:20pm 10:30pm 10:40pm 10:50pm 11:04pm 11:16pm

11:44pm

GAS MAKE

Make CH4 m3/s – 0.158417

VELOCITY 5.7 6.976474 2.779246 0.390411 5.8 6.85619 2.731328 0.39726 5.9 6.739983 2.685034 0.40411 6.0 6.62765 2.640283 0.410959 6.1 6.519 2.597 0.417808 6.2 6.413855 2.555113 0.424658

0.431507 6.4 6.213422 2.475266 0.438256 6.5 6.117831 2.437185 0.445205 6.6 6.025136 2.400258 0.452055 6.7 5.935209 2.364433 0.458904 6.8 5.847926 2.329662 0.465753 6.9 5.763174 2.295899 0.472603 7.0 5.680843 2.2631 0.479452 7.1 5.600831 2.231225 0.486301 7.2 5.523042 2.200236 0.493151 7.3 5.447384 2.170096 0.5

Page 92 of 101

TOTAL Q % CO2 % CH4


7.4 7.5 7.6 7.7 7.8 7.9 8.0 8.1 8.2 8.3 8.4 8.5 8.6 8.7 8.8

5.37377 5.30212

5.232355 5.164403 5.098192 5.033658 4.970738 1.90937 4.8495

4.791072 4.734036 4.678341 4.623942 4.570793 4.518852

2.14077 2.112227 2.084434 2.057364 2.03987

2.005278 1.980213 1.955765 1.931915 1.908639 1.885917 1.863729 1.842058 1.820885 1.800193

VELOCITY 0.506849 0.513699 0.520548 0.527397 0.534247 0.541096 0.547945 0.554795 0.561644 0.568493 0.575342 0.582192 0.589041 0.59589 0.60274

8.9 4.468079 1.779966 0.609589 9.0 4.418433 1.760189 0.616438 9.1 4.369879 1.740846 0.623288 9.2 4.32238 1.721924 0.630137 9.3 4.275903 1.703409 0.636986 9.4 4.230415 1.685287 0.643836 9.5 4.185884 1.667547 0.650685 9.6 4.142281 1.650177 0.657534 9.7 4.099577 1.633165 0.664384 9.8 4.057745 1.6165 0.671233 9.9 4.016758 1.600172 0.678082

10.0 3.97659 1.58417 0.684932 10.1 3.937218 1.568485 0.691781 10.2 3.898618 1.553108 0.69863 10.3 3.860767 1.538029 1.705479 10.4 3.823644 1.52324 0.712329 10.5 3.787229 1.508733 0.719178 10.6 3.7515 1.4945 0.726027 10.7 3.716439 1.480533 0.732877 10.8 3.692028 1.466824 0.739726 10.9 3.648248 1.453367 0.746575 11.0 3.615082 1.440155 0.753425

Page 93 of 101

LOCATION


GAS PROFILE ACROSS FACE

GAS PROFILE ACROSS FACE LOCATION CO2 CH4

Maingate 3 0.5 50 4 0.7

100 4.5 1.1 150 5.5 1.6 200 6 2.1

Tailgate 6.31 2.51

Q 32.33 %CH4 0.0049 % CO2 0.0123

Make CH4 0.158417 Make CO2 0.397659

CH4

0

0.5

1

1.5

2

2.5

3

1 2 3 4 5 6

Series1

CO2

0

1

2

3

4

5

6

7

1 2 3 4 5 6

Series1

DISTANCE CALCULATIONS

Longwall 3300 metres (inundation = 20016 m3) Walking Speed 2000 m/hr (goaf cave distance = 20 metres) Air Speed 0.4 – 1440 m/hr Walk to Mains 1.65 hr Air to Mains 2.29 hr Difference 0.64 = 38.50 minutes Gas Inundation 924 metres Let Inundation 1100 metres Gas time to Mains 1.53 – 1hr 27 min Walk time to F/A 1.65 – 1 hr 36 min

Page 94 of 101


APPENDIX 3 – EXTRACT FROM INERTISATION ANNUAL INSPECTION REPORT

5 July 2001

The Mine Manager Kestrel Mine

Inertisation Annual Inspection Report

The scheduled Inertisation training for June was conducted at Kestrel Mine with the view of testing systems already in place at the mine.

A two page summary is attached to this letter for your reference.

The results are as follows:

Day 1:- Incoporated unpacking the flexible connection and attach to all available GAG docking facilities to check sizes, ease of connection and interface of connection surfaces.

Day 2:- Involved pressurising the water system, connecting the GAG ready for use and running the engine for some 25 minutes. (Time taken 2.9 hours)

Day 3:- Was the reverse of Day 1 with the exception that once again the engine was operated for a period of 32 minutes.(Time taken 2.5 hours)

The average of the training days would indicate a set up time in the order of 2.71 hours at Kestrel Mine. This would reasonably indicate a time frame of approximately time of 2.5 hours from arrival at Kestrel operating under the present conditions. This coupled with a 2 hour travel time would give a time frame well under the (10 hour window) from call to ready to operate at Kestrel Mine. It is envisaged that this would considerably reduce as the works discussed are completed.

During the course of the training conducted and inspections carried out during the time at Kestrel the issues highlighted below were identified:-

DOCKING FACILITY No. 2 (BELT DRIFT)

MRA SCHEDULE 3 SECTION 6

(a) Emergency Seals and Air Locks:Similarly the existing seal arrangements would appear to be adequate under normal mine conditions. However, the 12,000 pa exerted on them by the GAG system with 83qC temperature at 100% humidity is the unknown and would need to be assessed to ascertain whether the GAG in full operational status would perform to expectations.

(b) Docking facilities:The facilities did match to the GAG connection with the exception that an elbow to change direction will need to be fitted prior to GAG arrival on site:-

1/ The mutual assistance group and group leader for your mine are aware of this and will ensure that the elbow is fitted.

2/ The recommendation is that a set of securing bolts should live with the elbow to permit efficient utilisation of time to effect this connection.

Page 95 of 101


MRA SCHEDULE 3 SECTION 7

(c) Water supply:The existing water pressure and flow arrangements from the raw water supply is adequate for safe utilistation of the GAG unit at Kestrel. However, the same condition as with portal one would water supply would be preferable, ie a 6” Vitaulic coupling point to the main fire line with an isolation valve would be ideal (also see Annexure 3 MRA Section 2).

Waste Water:Controlled waste will be in the order of approximately 50qC. (Does this impact on the drain system in place?). The nuisance water loss should run away without any foreseeable problems as was found on the days of training.

Page 96 of 101


APPENDIX 4 – DECISION MAKING TECHNIQUES

Decision making is at the center of our very being. A thousand times each day we make decisions, sometimes casually, almost without thought, responding to long-established routine. Who we are as decision makers is no more or less complex than who we are as people……Now place five or six, or ten or twenty such complex individuals together, attempt to develop an agreed decision, and the potential differences seem almost beyond comprehension.(Napier & Gershenfeld. 1999:318)

With this in mind, it is any wonder that decision-makers have (for centuries) been searching for tools, aids or processes to help them make the “correct” decision.

Listed below are a number of short descriptions for different techniques commonly used as decision-making tools - each with their own benefits and shortcomings. Also listed are a couple of techniques that maybe useful in the generation of ideas and/or solutions to issues.

The Stepladder Approach. Two people begin a problem-solving task by exploring the nature of the issue and possible alternatives. After some time, the two are joined by a third person, with the notion of educating the new participate about the issue - but intentionally holding back any specific solutions. The new participant explores their own viewpoint and puts their solutions. Then the solutions of the first two people are thrown in and discussed. After a further period of time, the three are joined by a fourth person and the process continues.

Rational Problem Solving. A linear, six stage process:

1. Problem Identification 2. Diagnosis 3. Generation of Alternatives 4. Selection of Solution 5. Implementation 6. Evaluation and Adjustment

Pareto Analysis, also known as the 80/20 Rule - named after the Italian economist Alfredo Fredrico Damaso Pareto (1848-1923). In the course of his study on unequal distribution, Pareto discovered that 80% of the wealth was controlled by 20% of the population. The essence of the Pareto method is identifying that vital few to which corrective action can be applied where it will do the most good, the most quickly.

Intuitive Problem Solving. The most creative decisions often result from some unexpected thought, an aside tossed off in jest, a moment when the defenses were down or at a point of exhaustion, frustration or exasperation that could never have been programmed or anticipated. There are several techniques which can allow a new perspective and the freedom for people to consider alternatives not yet accessible. For example:

1. Brainstorming. Most people are familiar with the concept of brainstorming but - there are a number of critical rules to be applied if it is to work effectively

2. Inverse Brainstorming. What would increase hazards, endanger the workers 3. Attribute Brainstorming. How would this process operate if, the people-customer-worker-supervisor etc were

stronger-weaker / female-male / taller-shorter / stronger-weaker / younger-older / trapped-mobile etc, or if there were no money constraints or if we had perfect knowledge?

4. Vary the Entry Point. In trying to untangle fishing lines, it is often better to start at the fish rather than the reel 5. Draw Analogies. A previous solution to an old problem 6. Change Perspective. Think like a customer, victim, expert, novice 7. Chain Forward. Think as far as possible into the future – if I solve this problem, what is the next problem?

Page 97 of 101


Nominal Group Technique. A 2-stage process most often used to generate goals and choose among alternatives. Individuals work separately in the first or elicitation stage, then work as an interactive group on evaluating (choosing) stage.

Computer-Interactive Groups. What happens when we are able to remove the social inhibitors that often accompany interactive groups?

Round Robin Groups. Each individual writes 3 or 4 problems they face on separate cards which are then circulated to the others in the group - who each have to propose a solution to each of the problems.

Wildest Idea. When bogged down, often a competition on who can come up with the craziest, wildest idea not only injects fun, energy and new interest – sometimes, buried in the crazy ideas, lie the seeds to a creative new approach.

Synectics. William Gordon (1961) saw the ability to speculate as the key to removing normal resistances and the stereotypical and predictable traps we often fall into. The word synectics, means the joining together of different and apparently irrelevant elements.

Delphi Technique. A procedure to acquire informed judgements and opinions from knowledgeable individuals. The process uses a series of questions to develop a consensus forecast (by experts) about what will happen in the future.

References

Napier, Rodney W. & Matti K. Gershenfeld. 1999. Groups: Theory and Experience. Sixth Edition. Boston: Houghton Mifflin Company.

Russell, Robert S., & Taylor, Bernard W. 2000. Operations Management. New Jersey. Prentice-Hall Inc.

Page 98 of 101


APPENDIX 5 – LETTER TO QMRS FROM KESTREL COAL

Page 99 of 101


APPENDIX 6 - THE EXERCISE MANAGEMENT COMMITTEE

GREG ROWAN

Starting in the mining industry in 1978 and joining the Queensland Mines Rescue Service in 1979, Greg has worked as a miner, undermanager, mine manager, project manager and in private consultancy at different operations in Queensland and Western Australia. Recruited to the Queensland Department of Mines and Energy in 1997, Greg currently holds the position of Senior Inspector of Mines and has been Chairman of the Queensland Emergency Exercise Management Committee since its formation in 1998.

Greg holds a First Class Coal Mine Managers Certificate, has post-graduate qualifications in management (GCM), holds a Masters in Business Administration from the University of Queensland and is a certified Management System Lead Auditor.

Greg is the Queensland Chief Examiner for coal mine manager’s certificates, sits on the Australian National Coal Sector Review Committee, was awarded the 1999 International NEDO sponsorship, won the Boston Consulting Group Strategic Challenge in 2001 and is a Fellow of the Australasian Institute of Mining and Metallurgy.

MURRAY BIRD

Murray joined the underground coal mining industry in 1974 as a Trainee Mining Engineer in the BHP Southern NSW Coal Division. After obtaining Statutory Underground Coal Mining Certificates, he was appointed as a Deputy at Corrimal Colliery, Undermanager and Undermanager-In-Charge at Nebo Colliery, Deputy Manager at Old Bulli Colliery and Group Relieving Manager for the BHP Southern Coal Division.

Murray was appointed as Superintendent at Hunter Valley Mines Rescue Station in 1986 and was appointed Manager of the Newcastle Mines Rescue Station in 1994. Currently he holds the position of Chief Executive, NSW Mines Rescue Service which he has held since 1998.

Rescue based qualifications include Underground Mines Rescue, Open-cut Mines Rescue, Coal Mine Fire Officer, Police Rescue Operator, Vertical Rope Instructor, PADI Open Water Instructor, Class 3 Commercial Diver and NATA Auditor.

GREG DALLISTON

Greg has been involved in the mining industry for 26 years, and has gained experience in numerous areas. He started his career as a Cadet Mine Manager with the Queensland Coal Association, before working in a variety of positions within the industry, including 8 years as a mine Deputy.

Greg is employed as an Industry Safety and Health Representative, a position which he has held for the last 8 years.

Some of the roles pertaining to this position have included:

�� Participating in tripartite industry committees to develop new Safety and Health legislation for the Queensland Coal Industry; Member of State and National training committees for the mining industry;

�� Perform safety audits and inspections at mines throughout Queensland; �� Investigating serious and fatal mining accidents, assisting the Mining Warden as a reviewer into mining accidents; �� Member of Incident Management Teams at significant incidents, including the 1994 Moura No. 2 disaster;

Performing debriefs after incidents and providing critical incident management services; and �� Development of Manager, Undermanager and Deputy Statutory National Competency Standards, including Risk

Management and Emergency Response.

Page 100 of 101


MALCOLM SMITH

Malcolm was born and educated in Yorkshire, England. Malcolm commenced his mining career with the National Coal Board, Great Britain on completion of mining courses at Manvers Training Centre and Mexbro Technical College.

Malcolm became an active volunteer mine rescue team member attached to the Rotherham Central Mines Rescue Station of the National Coal Board, South Yorkshire and was appointed as a full-time Mines Rescue Brigadesman, Rotherham Central Mines Rescue Station.

After emigrating to Canada, he began working with McIntyre Mines in Alberta where he initiated the McIntyre Mines, Coal Division district mine rescue competitions for surface and underground mines and trained four Alberta Provincial winning teams. In March 1987, he accepted the appointment of Manager Mine Rescue with the Ontario Ministry of Labour, Ontario Mine Rescue Organisation in Canada and in August 1999, accepted the appointment of Chief Executive Officer, with the Queensland Mines Rescue Service Ltd.

PETER BAKER

Peter is currently employed by the Mines Rescue Service NSW as Manager – Southern Mines Rescue Station. He commenced working in the mining industry in 1980 and has held various positions, including Undermanager in Charge and Relief Manager. He assisted in the development of emergency procedures at Appin and Tahmoor Collieries and audits minesite emergency plans in his current role.

He has been in Mines Rescue since 1986 and was appointed Captain in 1988. Whilst a trainee, he represented the station as Competition Team Captain at the Australian Underground Championships. Peter holds a Master of Business and Technology Degree, a Mining Engineering Degree, Coal Mining Third, Second and First Class Ticket, Underground Mines Rescue Certificate, Train the Trainer Certificate and has completed the CMQB Emergency Preparedness Course.

TIM JACKSON

Tim has 30 years experience in the coal mining industry, which includes mines rescue service and holding the position of Statutory Mine Mechanical Engineer in NSW. He holds a First, Second and Third Class Certificate of Competency, an Associate Diploma in Coal Mining Engineering (Booval) and a Master in Business and Technology from the University of New South Wales.

At the time of the exercise Tim held the position of Inspector of Mines with the Department of Natural Resources and Mines.

TONY DE SANTIS

Tony is currently employed at Moranbah North Coal as the Underground Mine Manager. Prior to that he has held the position of Mine Manager at both Appin and Elouera Collieries in the Southern Coalfields of New South Wales.

Tony started in the mining industry in 1982 and has held a number of underground supervisory roles. He was also an active member of the mines rescue service between 1984 and 1997. Tony holds a Master of Business Administration, an Associate Diploma in Coal Mining, and First, Second and Third Class Certificates of Competency.

Page 101 of 101


JAMES MARSHALL

James is a recent graduate mining engineer who is currently employed by SIMTARS. James’ experience has included emergency exercise ventilation modelling, frictional ignition investigations, ventilation structure and seal competency investigations, risk assessment and management systems.

James has also been a significant contributor to the Bray Park Fireworks Accident Investigation. He is a qualified shotfirer and a graduate member of the AusIMM and IEAust.

WARREN PENDLEBURY

Warren is employed as the Senior Safety Advisor for Kestrel Coal, a position which he has held for the past 14 months, and was previously employed in various safety positions in both metalliferous mining and smelting.

Warren holds a Diploma in Workplace Health and Safety and is mines rescue trained for both metalliferous and coal mining.

DAVID CLIFF

Associate Professor David Cliff is currently Director of Research for the Minerals Industry Safety and Health Centre. Prior to that he spent eighteen months as Health and Safety Advisor to the Queensland Mining Council and over 10 years at SIMTARS, the last three as Manager, Mining Research Centre where he was responsible for directing the research effort of SIMTARS. He is actively involved in promoting the awareness of hazards in the mining industry, principally focussing on the prevention of fires and explosions and health and safety promotion. He has been actively involved in spontaneous combustion research since 1989 and has investigated a number of mine fires and spontaneous combustion episodes.

David’s qualifications include: a Bachelor of Science Degree (Honours) from the Monash University, a Doctor of Philosophy in Physical Chemistry from Cambridge University and post-graduate studies in Environmental Studies, Outdoor Education and Business Administration. He is a member and chartered Chemist of the Royal Australian Chemical Institute, Environmental Chemistry Section, a Member of the Combustion Institute, Member of the Safety Institute of Australia, Past President of the Queensland Branch of the Clean Air Society and a Member of the Australasian Institute of Mining and Metallurgy.

Page 102 of 101

Documents

Emergency Exercise: Kestrel Coal Mine Tuesday, 27 November ... · Emergency Exercise: Kestrel Coal Mine Tuesday, 27 November 2001 SCENARIO Longwall panel 205 is a 3.5km block with