Date of incident: August 2023
Notice of incident number: 2023182060046
Employers: Mineral exploration company; mining company

Incident summary
Workers from a mineral exploration company were giving a tour of a mine site to workers from a mining company. Three utility terrain vehicles (UTVs), each with two or three people, drove up to the mine site. On the way back down, three workers were in one of the UTVs, driving down the steep gravel road, when suddenly the UTV began picking up speed. The UTV was unable to slow down or navigate a turn in the road, and the UTV left the road and crashed into large trees. One worker sustained fatal injuries, and the other two workers sustained serious injuries.

Investigation conclusions

Cause

• UTV was travelling downslope with no braking control. Just before going down a 17° slope, while in motion, the UTV was shifted to low gear, in order to engage the engine braking system and slow the UTV. However, the engine braking system did not engage, allowing the UTV to freewheel instead. This required the use of the brakes to slow down, to the point that the brakes overheated and were not effective in slowing the UTV. The parking brake cable was seized and had zero function. The UTV therefore could not be slowed down to navigate the upcoming turn, and the UTV drove off the road into the forest.

Contributing factors

• Operating on steep slope. The mineral exploration company had been using leased UTVs for over a decade at the mine site. The terrain leading up to the mine and at the mine site had slopes greater than 15°. Using these UTVs in this type of terrain is contrary to the manufacturer’s recommendations and led to mechanical failure resulting in the loss of control of the UTV.
• Seat belts missing or not functioning. The UTV owner’s manual states that seat belts are to be worn. Of the three installed seat belts in the UTV, only two were available; however, those seat belts were found to be not functioning. The middle seat belt was missing. Had the seat belts been maintained and used, the injuries sustained in the incident might not have been as serious.
• Manufacturer’s warnings not followed. Although the owner’s manual was in the glove box of the UTV, the mineral exploration company did not follow the manufacturer’s recommendations. Specifically, the company exceeded the operational limits of the UTV on steep slopes, failed to maintain the UTV in a safe manner, and ignored important safety requirements such as the correct use of transmission gears, the use of seat belts, wearing eye protection, and the completion of pre-use inspections.
• Inadequate maintenance of UTV. The mineral exploration company demonstrated that at certain points in time the UTV involved in the incident had been maintained. However, significant items were not addressed, such as the removal of the doors and safety netting, the removal of the middle seat belt, the lack of functionality of the two remaining seat belts, the seized parking brake that had not been adjusted regularly, a seized bearing in the engine braking system, over-filled and dirty oil in the engine, and worn inside bearings on the third axle. The company did not maintain the UTV to an acceptable standard.
• No emergency or evacuation plan. No safety briefings were conducted before the UTV convoy went up to the mine site. There was no discussion about emergency procedures or first aid protocols. No satellite phone was available at the remote site, which hindered the emergency response. Because no plan had been discussed, there was some chaos after the incident. One of the other workers on the tour performed first aid for the workers with only a basic first aid kit, no other resources, and no additional persons available to help manage three seriously injured workers. The mine site’s “Mine Emergency Response Plan” was not used effectively to inform emergency services that there was an incident. The company did not ensure that there was an emergency plan and adequate first aid available.

Other health and safety issues

• Lack of procedures and records. The mineral exploration company had no employee records of training or orientation for some of its workers. The company also did not have any written procedures or policies for UTVs, specifically the use of seat belts. It did not have a system for inspecting the UTVs prior to use and recording and addressing any mechanical issues or missing safety hardware, such as the seat belts, side doors, safety netting, and windshield, which were missing from the UTV.

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