1. Energy Coal, HSEC, September 2009 ICAM : Oil Circuit Breaker Explosion Incident date: Saturday 5 th September, 2009 Before After

2. Energy Coal, HSEC, September 2009 Incident Description DateTimeMine 5 th Sept 200916h20MMS (Douglas Plant) Employee / Contractor / 3rd Party Controlled / Monitored / Uncontrolled EmployeeControlled Zero Barrier?Repeat Incident? Yes No Description of Incident The authorised electrician undertook remote switching of an 11kV Oil Circuit Breaker (OCB) at the Douglas Plant main substation. The OCB exploded, probably due to mechanical failure, and the resultant blast wave blew off the doors of the substation, and seriously damaged the building. The electrician broke his upper right arm when the door behind which he was standing was forced violently open. An intense fire followed, destroying all equipment within the substation.

3. Energy Coal, HSEC, September 2009 Diagram of substation layout Main incomer from Eskom Outgoing cables to plant, etc. Outgoing cable to river pump mini-substation. It was this line that had a fault that caused the initial trip. OCB Rope lanyard to OCB X X Position of authorised Electrician when switching Position of second electrician Front doors blown off, and went through a chain- link fence, finally landed 20m away.

4. Energy Coal, HSEC, September 2009 Incident Overview (photos) Position of electrician when switching. Note the flash-suit worn during operation. This door was latched, top and bottom, and exploded outwards

5. Energy Coal, HSEC, September 2009 Incident Overview (photos) Bank of OCB’s. The unit second from right exploded. The rest were damaged by the blast and ensuing fire. Relays housed in this unit Breakers in this unit, submerge d in oil. Note blast damage to steel casing.

6. Energy Coal, HSEC, September 2009 Incident Overview (photos) Above: Position of front doors. They were blown towards the camera position, and though a chain-link fence, the remains of which can be seen in the foreground. Left: Doors behind which electrician sheltered during switching. Note the cracks in the brickwork. Supports were installed after the event.

7. Energy Coal, HSEC, September 2009 Underlying Root Cause & Key Contributing Factors Underlying Root Cause: The contacts in the switchgear did not engage or disengage correctly in time to prevent prolonged arcing and subsequent oil vaporisation, which led to a violent explosion within the substation. Key Contributing Factors: 1.Age of the switching equipment (OCB switchgear) 2.Cable fault and the electromechanical relay not flagging the cause of the trip prior to the incident occurring 3.Risk assessment not considering the explosion potential Key Learnings: 1.Following procedures to the letter can save lives - operational discipline 2.OCB switchgear has explosion potential and must be managed accordingly 3.The fundamental success of safety depends on thorough risk assessments

8. Energy Coal, HSEC, September 2009 Permanent Corrective Actions to be Taken ActionHOCBy whoBy when Replace all OCB's with modern technology (SF6 or vacuum) Substitute J Page / Operations 31 August 2011 Ensure electrical remote switching is fitted to all medium voltage switchgear to allow for switching from outside the building (at a safe distance) in which the switchgear is housed Separate J Page / Operations16 October 2009 Where OCB's are currently used, all baseline risk assessments must be reviewed to include mitigation strategies for explosions. The hierarchy of controls must be applied. Revise procedures accordingly Administrate S Lipp 30 September 2009 Comprehensive testing must be done on all medium voltage switchgear. This includes oil testing, speed tests and testing of all mechanisms. Administrate S Lipp 31 December 2009 Align Douglas Plant emergency procedure with that of Middelburg Mining Services Administrate L van Tonder 30 September 2009 Full flash suits must be worn when local racking and spring charging takes place on medium voltage switchgear PPE S Lipp 30 September 2009