6. Agenda de competitividad
6.4. Marco lógico de la Agenda de Competitividad
The Board visited the CMR and the underground, including the accident scene, on February 13 and 14, 2014. The following maintenance-related issues were identified:
There was significant buildup of engine and hydraulic oil on other mining equipment including Salt Haul Truck 74U006A. (Figure 13)
There was a three-foot diameter puddle of hydraulic fluid underneath Salt Haul Truck 74U006A. (Figure 14)
The daily Operator’s Checklist was completed on February 5, 2014, for Salt Haul Truck 74U006A with no deficiencies indicated.
There was an Out of Service tag on Salt Haul Truck 74U006A
indicating that a lighting deficiency existed.
Several mine phones were found to be inoperable (run to battery failure). Twelve of 40 phones tested were non-functional.
Numerous components of the mine ventilation system were out of
Figure 13: Buildup of Engine Fluids on the Underside of Vehicles in the Mine
service or otherwise impaired for an extended period of time, some since installation: Exhaust Fan 413, 41-B-700-A since January 27, 2014.
Exhaust Fan 413, 41-B-700-B since June 15, 2013.
707 bulkhead door that divides the construction split from the disposal split requires manual operation and cannot be remotely shut, which is necessary for shifting to filtration mode. During the initial entries after the event, underground services shut the 707 bulkhead door and regulator the afternoon of February 14, 2014. This allowed the ventilation system to be placed in filtration mode. After the radiological event the evening of February 14, 2014, it would not have been possible to place the ventilation in filtration mode if 707 bulkhead door had remained open.
401 bulkhead door has been chained open for a long period of time. It cannot be operated remotely from the CMR in the chained condition. This is the bulkhead door from the Air Intake Shaft. See Figure 15 for an example.
EXO regulator was not working. The garage door was opened about two feet, and allowed smoke in the EXO space. In its current configuration, this regulator cannot be remotely operated from the CMR.
504 bulkhead door was chained open for a long period of time. It cannot be operated remotely from the CMR in the chained condition. This is the bulkhead door to the Salt Handling Shaft.
308 bulkhead regulator cannot be remotely operated from the CMR due to the regulator being out of service or impaired. This bulkhead is located between the Waste Shaft and the exhaust shaft.
Numerous other pieces of equipment were out of service or otherwise impaired:
534-CAM-001-152 has only been operational a total of 29 days in the last 22 months. Building 463 Compressor Building trouble alarm has not been energized since May 21,
2013.
Area 451 CMR Fire Alarm Panel impaired since June 5, 2013.
Building 486 Northeast site, Riser Flow Switch Valve closed due to system leaking on August 9, 2013.
Hydrant #23 out of service since September 10, 2013.
Hydrant #3 out of service due to no flowing water since September 16, 2013. Auxiliary Warehouse FAP Broken Pull Station since October 27, 2013.
Fire Water PIV #FW-Y-PIV-21 unable to operate in the closed direction since December 23, 2013.
Fire Water PIV #FW-Y-PIV-27 is shut to isolate Hydrant #5 due to leakage since December 30, 2013.
Fire Panel 031 not sending alarm signal to CMR since January 6, 2014. Gate House fire panel light going out since January 28, 2014.
Additionally witness statements and interviews from personnel yielded the following: PA announcements were difficult to hear or understand.
There is a difference in expectations for waste-handling vs non-waste-handling vehicles. Pre-operational checks are not identifying equipment problems that need to be addressed
other than light and horn issues.
Some mine phones were reported as not working properly or difficulty in hearing was experienced.
Thirty-three emergency lights in the Waste Handling Building have been inoperable for as long as two years.
Analysis
The Board determined that the use of fire resistant fluid in the hydraulic system could have significantly reduced the quantity of combustible liquid on the haul truck. Additionally, rigorous inspections and policing of oil and grease accumulation could have further reduced the
combustible loading on the haul truck.
The Board determined that there is a significant delta between the preventive maintenance prescribed in the service manual and what is performed. Routine monitoring and adjustments that are not included in the NWP procedures are important maintenance items that could affect engine performance, resulting in higher than normal operating temperatures. Additionally, several decisions regarding maintenance and upkeep of the salt haul trucks were made without sound engineering judgment and evaluation. Discontinuing use of the wash station and opting
for compressed air as the means to keep the vehicle clean significantly inhibits the ability of maintenance personnel to identify and correct fluid leaks, resulting in continued buildup of combustibles.
The Board reviewed the equipment status and condition in the CMR and the U/G. The condition of critical pieces of equipment, such as the 700 exhaust fans, indicates that management has not taken prompt action to resolve longstanding deficiencies. Many items have been out of service or in a reduced status for more than six months. It was not clear that NWP had a clear approach to prioritizing maintenance activities in regard to critical equipment or that there is an effective formal process to identify compensatory measures other than a fire watch for impaired safety- related equipment. Additionally, the equipment and components that affect normal operation of the mine ventilation system did not appear to have been effectively evaluated and dispositioned regarding their impact on system operation. (Figure 16)
Figure 16: Fire Protection System Impairment (Out-of-Service Tags) in the CMR CON 6: The NWP preventive and corrective maintenance program did not prevent or correct
the buildup of combustible fluids on the salt haul truck.
JON 13: NWP management needs to reevaluate and modify the approach to conducting
preventative and corrective maintenance on all underground (U/G) vehicles such that combustible fluids are effectively managed to prevent the recurrence of fires.
CON 7: NWP and CBFO management is not adequately considering overall facility impact with
regard to operations, emergency response, and maintenance, which affects the safety posture of the facility, e.g., salt haul truck combustible build-up, conversion of the automatic fire
suppression system to manual, removal of the automatic fire detection capability, not using fire resistant hydraulic fluid, discontinued use of the vehicle wash station, chaining of ventilation doors and an out-of-service regulator and fans, inoperable mine phones, and other non-waste- handling related equipment.
JON 14: NWP and CBFO need to develop and implement a rigorous process that effectively
evaluates:
changes to facilities, equipment, and operations for their impact on safety, e.g., plant operations review process;
impairment and corresponding compensatory measures on safety-related equipment; and the impact of different approaches in maintaining waste-handling and non-waste-handling
equipment.
JON 15: NWP needs to determine the extent of this condition and develop a comprehensive
corrective action plan to address identified deficiencies.
CON 8: NWP and CBFO management have not effectively managed the quantity and duration
of out-of-service equipment.
JON 16: NWP needs to develop and implement a process that ensures comprehensive and
timely impact evaluation and correction of impaired or out-of-service equipment.
JON 17: CBFO needs to ensure that its contractor oversight structure includes elements for
comprehensive and timely evaluation and correction of impaired or out-of-service equipment.
CON 9: NWP management has allowed less than acceptable rigor in the performance of
equipment inspections allowing the operation of U/G equipment in unacceptable condition.
JON 18: NWP needs to develop and reinforce clear expectations regarding the performance of
rigorous equipment inspections in accordance with manufacturer recommendations, established technical requirements; corrective action; and trending of deficiencies.