30 July 2021 - NW1310
Cachalia, Mr G K to ask the Minister of Public Enterprises
With reference to his reply to question 567 on 16 April 2021, what (a) were the findings of the investigation that was conducted by Transnet and (b) was the scope of the investigation?
According to the information received from TRANSNET:
(a) Findings of the investigation
In March 2020, Transnet Port Terminals (TPT) in Cape Town had an incident where an external truck driver was killed when a TPT Rubber Tyred Gantry (RTG) spreader fell, resulting in a container hitting the truck cabin with the driver inside.
A summary of the core findings of the internal investigation undertaken by TPT are set out herein below.
- On the day of the incident, the Operator of the Lifting Equipment (OLE) advised of an unusual sound emanating from the hoist breaks. The artisan attended to the RTG and recorded the sound for further consultation. Upon consulting with a Senior Artisan, and upon receiving advice to stop the machine immediately, the responsible Equipment Coordinator was called to stop the machine. The Equipment Coordinator did not timeously convey the instruction to stop the machine to the OLE operator resulting in operations continuing.
- The RTG25 hoist brake shoe was loose and eventually dislodged as the OLE operator was positioning the equipment. The spreader lowered by itself resulting in the braking system not responding. This resulted in the spreader falling on the truck cabin positioned under the crane waiting to be loaded.
- The OLE operator panicked and attempted to warn the driver by continuously hooting, however the driver did not hear the warning.
- The findings from the investigation suggest that possibly the hoist brake bolts were not correctly tightened to the right settings by the service provider when refurbished in May 2017. As a result, the bolt became lose over time and ultimately dislodged. This is a brake unit with a number of components that is refurbished by the service provider. These refurbished units are maintained as spares and used when required for maintenance purposes.
- The maintenance regime undertaken on the machine at the time did not trigger the need to check the torque settings of the brake pads and ensure that any loose bolts were detected and repaired accordingly.
- It is important to note that since the occurrence Transnet has tracked and ensured implementation of the control measures identified in the internal investigation in order to avoid the re-occurrence.
(b) What was the scope of the investigation?
The scope of the investigation is outlined in the Transnet Integrated Management System (“TIMS”) Occurrence and Non-conformance Management 013 Procedure.
An internal investigation was conducted by Transnet Port Terminals. A Board of Inquiry was not commissioned as the country had just entered COVID-19 Level 5 at the time.
The internal investigation team was required to investigate the fatality to determine the following:
- The root causes/facts/immediate/underlying and contributing causes surrounding and leading up to the occurrence; and
- Develop robust recommendations to avoid the recurrence of similar occurrences in the future.
Further to establishing the facts surrounding the occurrence, the investigation team also focused on:
- The activation, execution and management of the emergency processes and relevant directives;
- The effectiveness and execution of safety procedures at the site;
- The identification of the measurement of control – risk assessments and mitigation processes; and
- Adherence to procedures pertaining to giving and obeying lawful instructions.
The internal investigation report was based on the evidence collected and included for example, the review of governance documentation, interviewing of key witnesses, and the analysis of evidence provided.
The investigation team was requested to formulate their recommendations in such a way that:
- The recommendations are clear, specific and unambiguous as to what is expected by whom;
- The recommendations are measurable, practicable and attainable; and
- The recommendations are results orientated and coupled to specific timeframes.