Nothing Was Holding It: The Missing Step Behind an $810,000 Ravensthorpe Fine

On 18 March 2023, workers at the Ravensthorpe Nickel Operation in Western Australia were changing a Roman Shield on the Saprolite Stacker. They unfastened it before it had been secured. The shield rotated, struck a worker and pinned him. He later needed spinal fusion surgery. On 6 October 2026 FQM Australia Nickel Pty Ltd was fined $810,000 plus $11,096.20 in costs in the Albany Magistrates Court after pleading guilty to a Category 2 offence. Two facts from the case stay with me. The job hazard analysis had no control for uncontrolled movement. The supervisor allocated to the task was not directly supervising it.

That is not a story about a missing procedure. It is a story about a procedure that never asked the one question that mattered: what happens to this component when we let it go?

Stored Energy Is Not Only Electrical

When most of us hear "isolation" we think of switches, locks and tags. But a heavy shield held in place by its fasteners is storing energy too. Gravity is energy. A component that can rotate, roll, drop or spring back the moment a bolt comes out is just as dangerous as a live circuit. Yet maintenance JHAs often list the electrical isolation in detail and say nothing about the mass of the thing being removed.

Ask yourself about the last maintenance task you signed off:

• Did the JHA name every way the component could move once it was unfastened?
• Was there a specific restraint step, like a sling, a chain block, a pin or a prop, before the first fastener came out?
• Did it say where each worker must stand so they are not in the line of fire if the restraint fails?
• Would a new worker reading it know the order of steps or only the list of hazards?

The Same Gap in a Hunter Valley Pit

This week's brief carried a second story built on the same failure. The NSW Resources Regulator published its full investigation report into a February 2025 incident at a Hunter coal mine. A 789 haul truck was reversing to have stuck material scraped from its tray by an excavator, a practice known as "backscratching". The operators had not communicated. The truck struck the cabin of the 49-tonne excavator and the operator had to be freed from the damaged cab. Remarkably, they were uninjured.

Here is the detail I keep coming back to. The site's own job hazard analysis already required positive communication and line-of-fire separation. The control was written down. It just wasn't happening. The regulator's recommendations include fixed in-cab radios checked when plant arrives on site, hard barriers or windrows, backscratching only at risk-assessed locations and change management for unscheduled tasks.

So we have one JHA that missed the hazard entirely and another that named it correctly but didn't change what people did. Both ended with someone pinned or trapped.

A Name on the Task Is Not Supervision

At Ravensthorpe a supervisor had been allocated. On paper the task was supervised. In practice nobody was watching the moment the shield came loose. I suspect this happens far more often than we admit. A supervisor gets assigned to three or four jobs at once and the paperwork looks fine. Supervision only counts if the supervisor is present at the critical step and knows which step that is.

• Does your JHA template mark the critical step where supervision must be direct?
• Can your supervisors tell you which step that is on each task they are assigned?
• When an unplanned task pops up, like backscratching a stuck load, does anyone stop and assess it before it starts?

One Thing to Do This Week

Pull out one plant maintenance JHA from your site. Find the step where something heavy is unfastened, lifted or released. Read what it says about restraint and about where people stand. If it says nothing, rewrite that step with the crew who do the job. Then ask them whether the written version matches how they actually do it.

If you asked your most experienced maintainer what holds the load the moment the last bolt comes out, would the answer be in your JHA or only in their head?