SAFETY ALERT

Fatal accident inquiry report

To
General Managers, HSE Managers and Engineering Managers
Ensure that this fatal accident does not occur on your mine.

Minerals Commission
Inspectorate Division
Takoradi

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 INSPECTORATE DIVISION OF MINERALS COMMISSION

10TH MARCH 2017

REPORT OF THE INVESTIGATION CONDUCTED ON THE PROPERTY OF GHANA

MANGANESE COMPANY LIMITED, NSUTA-WASSAW ON WEDNESDAY,
1ST MARCH 2017, ON THE FATAL ACCIDENT THAT OCCURRED AT THE
WASHING PLANT TOP 11KV POWER LINES ON MONDAY,
20TH FEBRUARY 2017

MINERALS AND MINING (HEALTH, SAFETY AND TECHNICAL)

REGULATIONS 16 AND 17 OF 2012, L.I. 2182

ING. DANIEL PADDI NARTEY, SENIOR INSPECTOR OF MINES, MACHINERY

P. O. BOX 254, GSTS ROAD, TAKORADI, GHANA

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CONTENTS

1. Covering letter......i
2. Cover page.......ii
3. Present at the enquiry......1
4. Initial information ..1
5. General information........2
6. Description of issues leading to the fatal accident.....3
7. Findings......4
8. Root Cause Analysis ..........8
9. Root cause analysis of the fatal accident ...8
10. Potential root cause of the fatality .9
11. Conclusion ....9
12. Recommendations .9
13. Enforcement .....10

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1.0 Present at the Enquiry:
Goldfields Ghana Limited, Tarkwa Mine
Emmanuel Bosomtwi Senior Electrical Engineer

Ghana Manganese Company Limited, Nsuta

Joseph Ampong General Mine Manager
Leon Coetzer General Operations Manager
Issah Salifu Taylor Commercial Manager
Steve Ofori Asamoah Engineering Manager
John CK Otoo Health, Safety and Environment Manager
Anthony E. Eshun Human Resource Officer
Emmanuel Coffie-Anum Environmental Coordinator
Sauty Omar Timley PMSU/HR
Bright Asare Sarpong PMSU
Anthony Yenzu GMWU Branch Union Chairman
James k. Acquah (ID# 1127) Electrical Supervisor
Isaac asamoah (3187) Electrician
Samuel tsawo (3226) Forklift Operator
Moses Edzi gyapong (1143) Electrical Superintendent
Abraham nyamson 33kv Substation Attendant
Richmond Bonsu (3215) - Power House Attendant

2.0 Initial Information

On Monday, 20th February 2017 at approximately 4:50pm, electricians were to interchange
cables on an 11KV line at the Washing Plant Top. Two persons were lifted in a cage to
assess the line. The deceased tried to fix the hook on his safety belt onto the bar of the
electric pole. In the process his colleague noticed spark and prompted the cage operator to
lower the cage. While lowering the cage the deceased fell off midway down the pole. He was
rushed to the hospital and was attended to by the resident medical doctor who pronounced
him dead after a few minutes

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3.0 General Information
On Monday, 20th February 2017, we were notified by the General Mine Manager of Ghana
Manganese Company Limited, Nsuta that at approximately 4:50pm on that day, a fatality had
occurred on his mine specifically, at the Washing Plant Top.

We proceeded immediately to the mine and held a meeting with management of the mine for
a briefing on the fatal accident. But then Samuel Appiah (deceased) had already been taken
to the mine clinic where he (deceased) was attended to by the resident medical doctor who
pronounced him dead after a few minutes. On Tuesday, 21st February 2017, the deceased
was taken to the Tarkwa New Government Hospital mortuary.

On Tuesday, 21st February 2017 we met Dr. Scali Godfred Kwablah Agodlo The resident
Doctor, at the mine clinic and he narrated the state of the deceased when he saw him at the
mine clinic, thus, on quote;
My attention was drawn to the patient bleeding - The patient was struggling with a lot of
blood oozing from his mouth and nostrils - the nurses attended to him Profusely bleeding, I
(Doctor) examined him Examined his pulse - It was an acute emergency - Approximately
17:15 GMT his heart rate stopped - He (deceased) had a bruise Indicating a fracture of the
base of the skull It was a difficult accident to survive - I (Doctor) tried to resuscitate him
but it did not work.

Together with the Doctor, the General Mine Manager, and the Human Resources Manager
with the assistance of the mortuary men the body of the deceased was examined and photos
were taken Blood was still oozing from the deceased nostrils and mouth whilst still at the
mortuary.

A careful examination of the body revealed the following;

The deceased had bruised on the left forehead An indication of electrical bruise;
He (deceased) had swollen eyelids;
He (deceased) had burns/abrasion on his right thigh (rt) indicating Electrical burns.
He (deceased) had bruises on his back closer to the chest wall

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 He (deceased) had Fracture of the neck which moves freely on the left and somehow
restricted on the right.
It appears that the bruises/burns on the deceased body was an evident indicating electrocution
before the deceased fell from height breaking his neck.

As per the Minerals and Mining (Health, Safety and Technical) Regulation 16 {1} C of 2012,
L.I. 2182, we conducted an inquiry into the circumstances leading to the fatal accident.

The objectives of the inquiry are:

To find out the cause(s) leading to the fatal accident
To find out whether the minimum standards of operation at the scene were consistent
with the tenets of the Minerals and Mining (Health, Safety and Technical)
Regulations of 2012, (L.I. 2182).
To find out the occurrence of any operational challenges.
To institute mitigating measures to obviate any future occurrence of the accident.
To determine the occasion of breaches to the Minerals and Mining Regulations.
To make recommendations to forestall future occurrence

4.0 Description of issues leading to the fatal accident

On Monday, 20th of February 2017, at approximately 4:47pm, James k. Acquah, the electrical
supervisor, called Abraham Nyamson, the 33KV substation attendant, on radio to isolate power
(i.e. switch off the 33KV breaker located at the 33KV substation), to the power house/washing
plant top 11KV power lines. Abraham Nyamson isolated (switched off) power as instructed and
confirmed to James k. Acquah, that he (Abraham Nyamson) had isolated power to the power
house/washing plant top 11KV power lines.

Upon receiving a confirmation from Abraham Nyamson, the 33KV substation attendant, that he
(Abraham Nyamson) had isolated power to the washing plant top 11KV power lines, James k.
Acquah, the electrical supervisor, called Richmond Bonsu, the power House Attendant, on radio
to start the generators and it was alleged that James k. Acquah further instructed him to supply
power to the village power lines

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At approximately 4:50pm on Monday, 20th February 2017, Richmond Bonsu started the
generators and then called James k. Acquah on radio to confirm that he (Richmond Bonsu) had
started the generators.

In the process, power was supplied to the washing plant top 11KV power lines from the power
house. Hence, when while Samuel Appiah (deceased) tried to fix the hook on his safety harness
onto the bar of the electric pole (i.e. to secure himself), his temple got in contact with the live
power line (-L1-). His colleague, Isaac Asamoah, an electrician, whom Samuel Appiah
(deceased) was working with in the lifted cage, noticed a spark between the temple of Samuel
Appiah (deceased) and the power line (-L1-), and prompted the cage operator to lower the cage
immediately. While lowering the cage Samuel Appiah (deceased) fell off midway down the pole.

Having on Monday, 20th February 2017, held a meeting with management of the mine, having
visited the scene of the fatal accident and conducted High Voltage (HV) test on the washing
plant top 11KV power lines on Tuesday, 21st February 2017 and on Monday, 27th February 2017,
and having held technical enquires into the cause(s) thereof on Wednesday, 1st March 2017, we
wish to bring our findings to you.

5.0 Findings

We find that;
On Monday, 20th February 2017, Moses Gyapong, the electrical superintendent,
James k. Acquah, the electrical supervisor, Isaac Asamoah, and Samuel Appiah
(deceased), both electricians, and Samuel Tsawo, the forklift operator, planned to
execute a task. The task was to interchange cables on 11KV power line at the
Washing Plant Top. The task involved the performance/securing of basic yet standard
safety codes, however, the safety codes were disregarded and the workmen relied
solely on the 33KV substation attendant and the power house attendant. It appears
that they relied solely on the attendants possibly due to an inherent practice
unchecked by the health, safety and environment unit/department as stipulated in the
Minerals and Mining (Health, Safety and Technical) Regulation 42(a) of 2012,
(L.I.2182). The safety codes were;

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 Risk assessment (JHA/JSA)
Work at height permit
High Voltage (HV) access permit
Elevation permit for the forklift
Lock out
Tag out
Try-out at the 33KV substation
Try-out at the power house
Try-out at the 11kv pole where task to be executed
Reliable grounding at the 33KV substation
Reliable grounding at the power house
Reliable grounding at the 11KV pole where task to be executed
Safe to Commence Work conditions (STCW).

Isaac Asamoah, and Samuel Appiah were lifted up in a cage to assess the line in the
presence of Moses Gyapong, the electrical superintendent, and James k. Acquah, the
electrical supervisor. The cage used to lift the two electricians Isaac Asamoah and
Samuel Appiah (deceased), was defective and the forklift had not been permitted
(elevation permit) for such purpose.
Unaware that the 11KV power lines were live, Samuel Appiah (deceased) tried to fix
the hook on his safety harness onto the bar of the electric pole. In the process his
temple got in contact with the 11KV power line (-L1-). At that moment, his colleague
noticed a spark between Samuel Appiah (deceased) temple and the power line (-L1-)
and prompted the cage operator to lower the cage. While lowering the cage the
deceased fell off midway down the pole.

Moses Gyapong, the electrical superintendent, James k. Acquah, the electrical

supervisor, Isaac Asamoah, the electrician, failed woefully by not adhering to the
basic safety codes resulting in the fatal accident. This is in breach of the Minerals and
Mining (Health, Safety and Technical) Regulation 56, 550 and 553 of 2012,
(L.I.2182).

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 Samuel Tsawo, the forklift operator, failed woefully to, conduct Risk assessment,
secure High Voltage (HV) access permit, secure elevation permit for the forklift,
perform lock-out and tag-out resulting in the fatal accident. This is in breach of the
Minerals and Mining (Health, Safety and Technical) Regulation 18, 56 (3), 550 and
553 of 2012, (L.I.2182).

Between April and June in the year 2016, Moses Gyapong, the electrical
superintendent, had issued a verbal instruction that the 33KV breaker located at the
power house must not be isolated, i.e. it must be left in the ON STATE all the time
due to technical issues on that breaker. However, when the technical issues on the
breaker were resolved, Moses Gyapong did not revert to the power house attendants
for a counter instruction. Hence, the 33KV breaker was not being operated. Meaning
that, whenever the generators were started, the washing plant top power lines and
other power lines were supplied with electrical power.
Moses Gyapong is in breach of the Minerals and Mining (Health, Safety and
Technical) Regulations 18, 56 (3), 550 and 553 of 2012, (L.I. 2182)

Instructions were issued to the 33KV substation and the power house attendants by
their superiors (i.e. the electrical superintendent and the electrical supervisor) without
prior knowledge of reasons for the instructions or the specific task involve, in effect,
they were not to isolate the 33KV breaker until they were instructed to do so and on
the 20th of February 2017, Richmond Bonsu, the power House Attendant, was not
instructed further by James k. Acquah, the electrical supervisor, to isolate the 33KV
breaker at the power house.
This act of James k. Acquah, the electrical supervisor, is in breach of the Minerals
and Mining (Health, Safety and Technical) Regulations 56 (3), 550 and 553 of 2012,
(L.I. 2182).

On Monday, 20th February 2017, Moses Gyapong, the electrical superintendent, and
James k. Acquah, the electrical supervisor, mislead the investigators by stating, on
quote the power house does not supply power to the washing plant top 11KV power

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 lines. This is in breach of the Minerals and Mining (Health, Safety and Technical)
Regulation 16(4) and 56 (3) of 2012, (L.I. 2182).

There was no evidence of planned task observation conducted by the supervisor or his
superior on the deceased prior to the task.
The reticulation diagrams had not been updated since 2015.
Moses Gyapong, the electrical superintendent, had not taken his annual leave in about
two (2) years and James k. Acquah, the electrical supervisor, had not taken his annual
leave in about three (3) years. This is in breach of the Labour Act, 2003, (ACT 651),
Part IV, Sub-Part 1, Section 31; which stipulate that Any agreement to relinquish the
entitlement to annual leave or to forgo such leave is void.

The mine did not have a competent electrical engineer, hence, Moses Gyapong, the
electrical superintendent, was constantly working under pressure. This is in breach of
the Minerals and Mining (Health, Safety and Technical) Regulations 352 and 56 of
2012, (L.I. 2182).

John Otoo, the health, safety and environment manager, alleged that his
unit/department was not aware of the task being performed by the electrical team.

The health, safety and environment unit/department is faced with the following
challenges;
1. Inadequate labour
2. Low Head of Department support and equally low departmental heads support
3. Absence of health, safety and environment disciplinary committee to take
actions against HSE breaches
4. Effect of culture on his work
5. Absence of management system.

Basic standard operating procedures for working on HV power lines were not followed;
Risk assessment on the HV task was not performed
Work at height permit was not secured
High Voltage (HV) access permit was not secured

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 Elevation permit for the forklift was not secured
The man cage used was defective.
Lock out was not carried out by the workmen
Tag out was not carried out by the workmen
Try-out at the 33KV substation was not performed
Try-out at the power house was not performed
Try-out at the 11kv pole were job was being carried out was not performed
Reliable grounding at the 33KV substation was not carried out
Reliable grounding at the power house was not carried out
Reliable grounding at the 11KV pole was not carried out
Safe to Commence Work conditions (STCW) was not satisfied.
Generally, all the Standard Operating Procedures (SOP) had not been approved as
stipulated in the Minerals and Mining (Health, Safety and Technical) regulation 515
of 2012, (L.I. 2182).

All the related Standard Operating Procedures used at the mine were substandard;
General electrical works on circuit with voltages >50V
Working on a high tension line (11/33KV)
Laying cables/ pipes/ fiber underground
Mounting equipment on an antenna pole
Building renovation electrical procedure

The Health, Safety and Environment unit/department did not act reliably/steadfastly in
the discharge of their assigned duty/responsibility as stipulated in the Minerals and
Mining (Health, Safety and Technical) regulation 42 of 2012, (L.I. 2182).

It appears that the potential cause of the fatal accident was;

Electrocution, however, Samuel Appiah (deceased) could have stayed alive had he
not falling head-on at a height onto the ground.
Impact of the deceased head upon landing on the ground

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6.0 Conclusion
It appears that the electrical workmen did not adhere to basic standard operating
procedures for working on High Voltage (H.V) power lines. This act had been an
inherent practice unchecked. The potential cause of the fatal accident was
electrocution, however, Samuel Appiah (deceased) could have stayed alive had he not
falling head-on at a height onto the ground. The impact of the deceased head upon
landing on the ground affected him (deceased) severely. Ghana Manganese Company
Limited did not have the requisite electrical safety equipment; High Voltage Detector,
HV phase comparator, phasing stick, standard-reliable grounding conductors and
phasing suite complete. An evidence indicating that the electrical workmen had not
been protecting themselves when working on electrical power Indicating also, low
safety standard.

7.0 Recommendations
The manager of the mine shall review all safe working codes which ensures that a person
in the mine is not exposed to an operational hazard at the mine and forward to the
inspector for approval as stipulated in the Minerals and Mining (Health, Safety and
Technical) regulations 515 and 287 of 2012, (L.I. 2182).
The manager of the mine shall ensure that the health, safety and environment
unit/department assumes full responsibility of health, safety and environment related
issues at the mine as stipulated in the Minerals and Mining (Health, Safety and
Technical) regulation 42 of 2012, (L.I. 2182).
The manager of the mine should ensure that, all reticulation diagrams are updated
regularly.
Related safety codes must be adhered to, at the mine
Mandatory use of arc flash pro-wear protective clothing and kits when carrying out works
on live electrical power lives.
Mandatory use of electrical safety equipment and power line testers for both LV and HV
works.
Mandatory satisfaction of safety codes and permit requirement when working at the mine
Mandatory use of blue-print when troubleshooting faults on power lines

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 All the electrical workmen must be adequately and regularly trained as stipulated in the
Minerals and Mining (Health, Safety and Technical) regulation 547 of 2012, (L.I. 2182).
The manager of the mine is entreated to address the challenges facing the health, safety
and environment section/unit/department immediately. i.e.
1. Inadequate labour
2. Low Head of Department (i.e. the General Mine Manager) support and
equally low departmental heads support
3. Absence of health, safety and environment disciplinary committee to take
actions against HSE breaches
4. Effect of culture on his work
5. Absence of management system

8.0 Enforcement
1) For woefully exhibiting negligence, incompetence, carelessness, misleading the
investigators and for not ensuring the safety of his subordinates, Moses Gyapong, the
electrical superintendent, is in breach of the Minerals and Mining (Health, Safety and
Technical) Regulations 16(4), 18, 56(3), 550(1) and 553(a) & (b) of 2012,
(L.I. 2182). Moses Gyapong is therefore suspended from all operations on the mine
for a period of three (3) months without remuneration with effect from Wednesday,
15th March 2017. In addition, Moses Gyapong is demoted to the position of sectional
engineer with immediate effect. Copies of his suspension and demotion letters should
be forwarded to the Chief Inspector of Mines, Accra, and the Head of Inspectorate,
Takoradi, before Friday, 17th March 2017.

2) For woefully exhibiting negligence, incompetence, carelessness, ineffective

communication, misleading the investigators and for not ensuring the safety of his
subordinates, James k. Acquah, the electrical supervisor, is in breach of the Minerals
and Mining (Health, Safety and Technical) Regulations 16(4), 56(3), 550(1) and
553(a) (b) of 2012, (L.I. 2182). James k. Acquah therefore should be paid off from
the mine with effect from Wednesday, 15th March 2017. Copies of his parting letter

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 should be forwarded to the Chief Inspector of Mines, Accra, and the Head of
Inspectorate, Takoradi, before Friday, 17th March 2017.

3) For not ensuring that the electrical workmen adhered to the safety codes on the mine,
use appropriate equipment and work safely thereby resulting in the fatal accident,
John Otoo, the health, safety and environment manager, is in breach of the Minerals
and Mining (Health, Safety and Technical) Regulations 42(a), 56 (1) (3), 550 and 553
(a)(b) of 2012, (L.I. 2182). John Otoo is therefore suspended from all operations on
the mine for a period of three (3) months without remuneration with effect from
Wednesday, 15th March 2017. Copies of his suspension letter should be forwarded to
the Chief Inspector of Mines, Accra, and the Head of Inspectorate, Takoradi, before
Friday, 17th March 2017.

4) For exhibiting negligence, incompetence, carelessness, and for not ensuring safety of
himself and his colleague (deceased), Isaac Asamoah, the electrician, is in breach of
the Minerals and Mining (Health, Safety and Technical) Regulations 56 (1)(3), 550
and 553(a) (b) of 2012, (L.I. 2182). Isaac Asamoah is therefore suspended from all
operations on the mine for a period of one (1) month without remuneration with effect
from Wednesday, 15th March 2017. Copies of his suspension letter should be
forwarded to the Chief Inspector of Mines, Accra, and the Head of Inspectorate,
Takoradi, before Friday, 17th March 2017.
Upon resumption of duty Isaac Asamoah, the electrician, must be certified as
competent by the Inspectorate Division of Minerals Commission.

5) Samuel Tsawo, the forklift operator, failed woefully in the following;

Samuel Tsawo did not exhibit competence in the discharge of his duty
He used a defective man cage to elevate workmen at a height,
He did not secure elevation permit for the equipment prior to the task.
He did not ensure that the workmen work safety.
He did not follow standard operating procedures for such task

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 Samuel Tsawo is in breach of the Minerals and Mining (Health, Safety and
Technical) Regulations 18, 56(1) (3), 550 and 553(a) & (b) of 2012, (L.I. 2182).
Samuel Tsawo, the forklift operator, is therefore suspended from all operations on
the mine for a period of one (1) month without remuneration with effect from
15th March 2017. Copies of his suspension letter should be forwarded to the Chief
Inspector of Mines, Accra, and the Head of Inspectorate, Takoradi, before Friday,
17th March 2017.

6) For not ensuring safety on the mine, Ghana Manganese Company Limited, Nsuta, is
in breach of the Minerals and Mining (Health, Safety and Technical) Regulations 35,
41, 56(1)(3), 300, 316, 352, 543, 547 and 550 of 2012, (L.I. 2182). We are
sanctioning the mine with a fine of Ghana Cedis equivalent of Ten Thousand United
States Dollars (USD10,000) to be paid to the Minerals Commission before Friday,
31st March 2017. Prove of payment should be forwarded to the Chief Inspector of
Mines, Accra, and the Head of Inspectorate, Takoradi, before Friday, 7th April 2017.

Ing. Daniel P. Nartey Mr. Francis Annobil Jnr.

Senior Inspector of Mines, Machinery Senior Inspector of Mines, Machinery
Minerals Commission Minerals Commission
Inspectorate Division Inspectorate Division
Takoradi Takoradi

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