According to the witness statements and the physical observation of the accident point, the accident happened while the de-miner was walking from the rest area to his clearance lane. He stepped on missed PMN anti-personnel mine in cleared area. Therefore, this mine was missed during the clearance operation. The exploded mine resulted in below knee amputation of deminer’s right leg, multiple injuries on his left leg, left foot heel, right hand palm and some minor injuries on his right arm. The de-miner was sent to Khost hospital after receiving first aids in the site. While accident happened the de-miner did not have PPE on, he was walking in cleared area to proceed to his clearance lane after the break time

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James Madison University

James Madison UniversityJMU Scholarly CommonsGlobal CWD Repository Center for International Stabilization and Recovery9-28-2010DDASaccident640Humanitarian Demining Accident and Incident DatabaseAIDFollow this and additional works at: https://commons.lib.jmu.edu/cisr-globalcwdPart of the Defense and Security Studies Commons, Peace and Conflict Studies Commons,Public Policy Commons, and the Social Policy CommonsThis Other is brought to you for free and open access by the Center for International Stabilization and Recovery at JMU Scholarly Commons. It hasbeen accepted for inclusion in Global CWD Repository by an authorized administrator of JMU Scholarly Commons. For more information, pleasecontact dc_admin@jmu.edu.Recommended CitationDatabase, Humanitarian Demining Accident and Incident, "DDASaccident640" (2010). Global CWD Repository. 839.https://commons.lib.jmu.edu/cisr-globalcwd/839DDAS Accident Report Accident details Report date: 07/07/2011 Accident number: 640 Accident time: 11:30 Accident Date: 28/09/2010 Where it occurred: AF/3203/07956, MF0034, Gosha Village, Tani District, Khost Province Country: Afghanistan Primary cause: Inadequate training (?) Secondary cause: Field control inadequacy (?) Class: Missed-mine accident Date of main report: 29/11/2010 ID original source: None Name of source: UNMACCA Organisation: [Name removed]  Mine/device: PMN-2 AP blast Ground condition: not recorded Date record created:  Date  last modified: 07/07/2011 No of victims: 1 No of documents: 1  Map details Longitude:  Latitude:  Alt. coord. system: Not recorded Coordinates fixed by:  Map east:  Map north:  Map scale:  Map series:  Map edition:  Map sheet:  Map name:    Accident Notes protective equipment not worn (?) visor not worn or worn raised (?) inadequate investigation (?) mine/device found in "cleared" area (?)  Accident report The only report of this accident that has been made available to date is a UNMACCA Lessons Learned document. Its conversion into a DDAS file has led to some of the original formatting being lost. Text in square brackets [ ] is editorial. This record will be revised if more information becomes available. The document is reproduced below, edited for anonymity. 1  LESSONS LEARNED SUMMARY OF [Demining group] DEMINING ACCIDENT  INTRODUCTION:  The demining investigation team was convened by AMAC Southeast to investigate the causes of demining accident occurred to [Demining group] involving Mr. Rasool Badshah S/O Syal Badshah the de-miner of [Demining group] CBDT-13. The accident occurred on 28 Sep 2010 at 11:30am in task No. AF/3203/07956/MF0034 located in Gosha village, Tani district of Khost province. SUMMARY: Task number AF/3203/07956/MF0034 is located on the top of a hill on west side of Gosha village. The area was mined by Russian troops during 1987-1992 to prevent their positions from the attacks of Mujahidin. The area was polygon surveyed by [Demining group] LIAT in November 2009, [Demining group] CBDT-13 started clearance operations there on 10 Dec 2009. 74% of the task was cleared and 53 AP mines destroyed by the team till the accident happened. According to the witness statements and the physical observation of the accident point, the accident happened while the de-miner was walking from the rest area to his clearance lane. He stepped on missed PMN anti-personnel mine in cleared area. Therefore, this mine was missed during the clearance operation. The exploded mine resulted in below knee amputation of deminer’s right leg, multiple injuries on his left leg, left foot heel, right hand palm and some minor injuries on his right arm. The de-miner was sent to Khost hospital after receiving first aids in the site. While accident happened the de-miner did not have PPE on, he was walking in cleared area to proceed to his clearance lane after the break time. The previous team leader of this team was shifted to other CBD project by [Demining group] and the new team leader was appointed to this team from the community. The QC check had not been conducted by section leader and team leader on the cleared lane where the mine was missed. CONCLUSIONS: A missed mine caused this accident.  RECOMMENDATIONS:  The following points are to be considered by [Demining group]: • [Demining group] operations department should make sure that the command group of the teams are conducting QC checks of the cleared ground as outlined in [Demining group] QM SOP, section 24-1. • The command group should make sure that the detectors are tested and compensated to the ground on daily basis.  • [Demining group] operations department should develop and implement a capacity development plan for their teams especially the CBD teams as the majority of [Demining group] accidents are relating to CBD projects.  • The deminers should check their detectors prior to start operations after any break. [The detector is use was the Ceia.] Feedback on any preventive and corrective actions taken by [Demining group] is required to be submitted to the MACCA within 7 days, effective from the issue of this report. 2  Victim Report Victim number: 823 Name: [Name removed] Age:  Gender: Male Status: deminer  Fit for work: not known Compensation: Not made available Time to hospital: Not made available Protection issued: Frontal apron Long visor Protection used: None  Summary of injuries: INJURIES: minor Arm, severe Foot, severe Hand, severe Leg AMPUTATION/LOSS: Leg Below knee COMMENT: No Medical report was made available. "below knee amputation of deminer's right leg, multiple injuries on his left leg, left foot heel, right hand palm and some minor injuries on his right arm".  Analysis The primary cause of this accident is listed as Inadequate training because the investigators recommended improved metal detector training to avoid missing mines. The secondary cause is listed as a Field Control Inadequacy because the area had not been subjected to an internal QA check and should not have been treated as clear until that check had been completed. The failure of the demining group’s managers to ensure that appropriate training was conducted and appropriate QA checks took place was a significant Management Control Inadequacy. Metal detector checks and calibration should be conducted regularly throughout the day because battery condition can deteriorate rapidly, and temperature variations can adversely effect ground calibration. The number of problems with this Ceia detector in this theatre raises questions about both the detector model and the training. The “Inadequate investigation” listed under notes refers to the absence of a full accident report. The UN supported MACCA has failed to make these widely available for some years, so ignoring the requirements of the IMAS. It is noteworthy that the Afghan national staff have been more responsible than those internationals who presume greater responsibility.  3 

DDASaccident640

While the deminer trying to recover an AP M14 mine using the heavy RAKE he applied a pressure in the pressure plate of a non visible M14 which in turn activated that mine in a depth of about 5-7 c

James Madison UniversityJMU Scholarly CommonsGlobal CWD Repository Center for International Stabilization and Recovery2-2-2009DDASaccident602Humanitarian Demining Accident and Incident DatabaseAIDFollow this and additional works at: https://commons.lib.jmu.edu/cisr-globalcwdPart of the Defense and Security Studies Commons, Peace and Conflict Studies Commons,Public Policy Commons, and the Social Policy CommonsThis Other is brought to you for free and open access by the Center for International Stabilization and Recovery at JMU Scholarly Commons. It hasbeen accepted for inclusion in Global CWD Repository by an authorized administrator of JMU Scholarly Commons. For more information, pleasecontact dc_admin@jmu.edu.Recommended CitationDatabase, Humanitarian Demining Accident and Incident, "DDASaccident602" (2009). Global CWD Repository. 801.https://commons.lib.jmu.edu/cisr-globalcwd/801DDAS Accident Report Accident details Report date: 04/03/2011 Accident number: 602 Accident time: 10:05 Accident Date: 02/02/2009 Where it occurred: MF 397, Um Al Quttain Village, Almafraq Province Country: Jordan Primary cause: Unavoidable (?) Secondary cause: Unavoidable (?) Class: Excavation accident Date of main report:  ID original source:  Name of source: Demining group Organisation: [Name removed]  Mine/device: M14 AP blast Ground condition: hard Date record created:  Date  last modified: 04/03/2011 No of victims: 1 No of documents: 2  Map details Longitude:  Latitude:  Alt. coord. system:  Coordinates fixed by:  Map east: 36 54' 8399E Map north: 32 35' 4799N Map scale:  Map series:  Map edition:  Map sheet:  Map name:    Accident Notes no independent investigation available (?) standing to excavate (?) use of rake (?) non injurious accident (?)  Accident report An internal demining group accident report was made available. The conversion into a DDAS file has led to some of the original formatting being lost.  Text in square brackets [ ] is editorial. The internal report is reproduced below, edited for anonymity.  INCIDENT INVESTIGATION FOR [Demining group] – MINE ACTION TEAM - JORDAN 1 GRID REF: 32 35’ 4799N: 36 54’ 8399E MINEFIELD NO – 397: MINEFIELD TASK ID - E 397 SABHA 6 INVESTIGATION CONDUCTED BY – [Demining group], [Name removed]. DEMINER: [the Victim]. DATE OF BIRTH: 4/10/1960 SECTION COMMANDER: [Name removed]. TEAM LEADER: [Name removed]. TIME OF INCIDENT: 10:05 AM. DATE OF INCIDENT: 2 FEB 2009 NATURE OF INJURY: No Injury. TYPE OF MINE: Anti Personnel M 14  IMSMA DETAILED REPORT FOR MINE INCIDENT Monday, 2 February 2009 Part 1 – Description of the incident 1. Organisation name: [Demining group], JORDAN. Team No: MANUAL TEAM SIX 2.Incident date: 2/02/2009. Time: 10:05 AM 3. Location of incident: EAST SECTOR, Province: ALMAFRAQ, Village: UM AL QUTTAIN, Project or task No: E 397 SABHA 6 4. Name of site manager or team leader: [Name removed] 5.Type of incident: M14 AP MINE, uncontrolled detonation of a mine. 6. Device was detonated by: deminer  7. Device detonated while: Raking with Heavy Rake, Investigating 8. Device was found in an area classified as: a known hazardous area 9. Narrative (Describe how the incident happened. Attach additional pages and photographs or diagrams to assist in clarifying the circumstances surrounding the incident): While the deminer trying to recover an AP M14 mine using the heavy RAKE he applied a pressure in the pressure plate of a non visible M14 which in turn activated that mine in a depth of about 5-7 cm Part 2 – Injuries 10. Did the incident result in any injuries? No 11. List people injured and nature of injury: [None] Part 3 – Equipment damages 12. Did the incident result in any damage to equipment or property? No 13. List any mine action equipment or property damage: [None] 14. List damage to equipment or property owned by a member of the public or the government. [None] Part 4 – Explosive hazard 15. Provide details of mines/UXO/ other devices that were involved in the incident. Device Type:           Method:       Determined by: AP (Blast) Mine       Buried          RAKING 16. State specific device (if known): M 14 AP MINE 2 17. Comments (include measurements of any crater resulting from the explosion): Crater Depth: approx. 15 cm / Width: approx. 40 cm Part 5 - Site conditions 18. Describe the conditions at the site at time of the incident Ground/Terrain: Hard, Flat, [Wet] Weather: Clear, Cold Vegetation: Light, Bush  [The accident site.] Part 6 – Team and task details 20. Qualifications of Member(s) involved in the incident: Name                  Position in Location             Occupation [The Victim]         Deminer                               Manual Team 6 21. How long had this team been? a. At this site? 5 weeks b. working on this task? 5 months c. working on the day? Two Hours 22. Detector type: N/A. Tripwire feeler used? No 23. Hand tool: HEAVY RAKE 24. PPE: Vest, Visor, [Blast boots] 25. Comments: [None] Part 7 - Medical & First Aid Medical treatment required? no 26. Medical Support at Incident Site: Medic, 1st Aid Kit, Stretcher, Ambulance, Safety Vehicle, Radio to call forward medic. 27. Was a Mine Incident Drill carried out? Yes  3 28. Time and distance data a. Time from incident to SECTION MEDICAL POINT: (01) minutes hours b. Time spent at site administering treatment: nil minute c. Time from evacuation FROM to arrival King Abdullah Hospital: nil minutes Part 8 – Reporting procedures Reported by: [Name removed], [Demining group] Amman Office to: [Demining group] Offices & NCDR Investigation conducted by: [Name removed], [Name removed] Report compiled/translated by: [Name removed], [Name removed] Verified by: [Name removed], [Name removed]  Observations and Recommendations According to the preliminary investigation the incident is caused due to a pressure applied to the mine from the heavy RAKE (the excavation tool) used by the deminer and the deminer didn’t expect to find a mine in that spot with that depth and may like accident could be avoided by using the metal detector to locate the non visible mine before using the standard RAKE drill. Signed: Operations Coordinator, 02 February 2009  Attachments: Statements by Injured Members Statements by Witnesses Photographs of Injuries [A photograph showed no injuries] Photographs of Incident Site Copy of Incident Report Victim Report Victim number: 785 Name: [Name removed] Age: 48 Gender: Male Status: deminer  Fit for work: yes Compensation: N/A Time to hospital: M/A Protection issued: Frontal apron Mask Visor blast boots Protection used: Frontal apron, Mask Visor, Blast boots  Summary of injuries: COMMENT: No recorded injuries. No Medical report was made available. Possible light ear damage. See Medic's statement. 4  Statements Statement 1: the Victim On Thursday the 29th of Jan 2009 while I was working on the scattered lane area (SML) I found an anti person (M14) mine on the centre lane belt, I informed the section commander [Name removed], team leader [Name removed] and the sector coordinator [Name removed] about it, they told me to continue my work carefully cause the mine was near the centre lane belt and they expected the existence of other missing mines there. On Monday the 2nd of February 2009 while am completing my work I used the light rake to expose the area in front of me but because of the hard greasy wet ground because of rain the light rake didn’t respond with me then I used the heavy rake I pulled in a proper way then a mine exploded in front of me and it was far from the mine I found on Thursday 6 cm but nothing has happened to me but because the sound I had a high pressure in my ears then I sat on the ground and I was evacuated outside the field. Answers to Investigator Questions: No, the mine wasn’t exposed at all. Yes, I was working very carefully as I expected to find missing mines in front of me. No, I wasn’t upset or sick that day or while am working. Yes, I was given the safety brief and work instructions from section commander and team leader. Yes, the section commander and team leader checked on me before the accident happened more than once.  Statement 2: Team leader On Thursday the 29th of Jan 2009 we found an anti person (M14) mine on the centre lane belt area the same scattered lane (SML) area mentioned before from the same de-miner as it’s strange to find a mine at that area, so I informed the sector coordinator [Name removed] about it, he came and checked on the mine and reported about it to [Name removed] the operations coordinator who came to the site and gave his instructions to work carefully at this area which might change the system we are working on, on Monday the 2nd of February 2009 while I was in section 11 I heard a sound of explosion from the south, immediately I knew it was from deminer [the Victim’s] site, I informed the ambulance and sector coordinator and went to the accident site, I found the deminer standing on his feet I asked him to sit and relax to be evacuated after a while. Answers to Investigator Questions: Yes, the section commander was doing his job very well. Yes, I assured on him to work carefully on that area because of the mine found on the centre lane belt area on Thursday 29th of Jan 2009. Yes, the deminer was following all the work instructions before the accident. Yes, I gave all the team a safety brief and work instructions before starting work.  5 Statement 3: Section commander On Monday the 2nd of February 2009 at 10:05 am I was standing in section 11 and the team leader [Name removed] was in the near area, I heard a sound of explosion from the south, I looked and knew it was from the deminer [the Victim’s] site, immediately I informed the ambulance and team leader about the accident and went to see the de-iner and found him standing on his feet, I asked him to sit on the ground, then he was evacuated outside the field without suffering anything. Answers to Investigator Questions: Yes, I visited him and checked on him before the accident happened because of the dangerous area he was working in as we found an anti person (M14) mine on Thursday 29th of Jan 2009 on the centre lane belt area. Yes, the deminer was very careful while he was working and he always follows all the work instructions. No, he wasn’t complaining of anything before starting work.  Statement 4: Medic We were informed about an anti person mine explosion happened with the deminer [the Victim] from the team leader [Name removed] on Monday the 2nd of February 2009 at 10:05 am, we reached the accident place and checked on the injured but he was in a good condition, we observed him he was fine and no complications happened, we asked him if he needs to go to the hospital he said no cause he is feeling well.  Analysis The primary and secondary causes of this accident are listed as Unavoidable because it seems that the Victim was working as directed when the accidental detonation occurred. The length or the tool, the procedure for using it, and the PPE combined to prevent injury. The demining group who made this report available is thanked for its transparency and its professional concern to share lessons that can be learned from accidents. This record, along with several other records where rakes were used, provide compelling evidence that the controlled use of rakes can be both effective and tolerably safe (reducing risk of injury to tolerable levels).  6 

DDASaccident602

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DDASaccident640

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