DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
Western District
Metal and Nonmetal Mine Safety and Health
ACCIDENT INVESTIGATION REPORT
SURFACE NONMETAL MINE
FATAL POWERED HAULAGE ACCIDENT
Nevada Cement Company Cement Plant [ID No. 26-00015]
Nevada Cement Company
Fernley, Lyon County, Nevada
May 22, 1995
By
Gary W. Fowler
Mine Safety and Health Inspector
Larry Stevenson
Mine Safety and Health Inspector
Western District Office
3333 Vaca Valley Parkway, Suite 600
Vacaville, California 95688
Fred M. Hansen, District Manager
GENERAL INFORMATION
Preston F. Niemeyer, a 42 year old mechanic, was fatally injured when run over by a service truck that he was working beneath. Niemeyer had 20 years mining experience, 16 at this operation. He had been rated as a Class A mechanic for the past 3 years.
Gary Frey, MSHA Reno Nevada Field Office Supervisor, was notified of the accident at 6:55 a.m., May 22, 1995, by Wayne Hughes, Safety Director for Nevada Cement Co. An investigation was started the same day.
The accident occurred at the Nevada Cement Company Cement Plant.
The plant, located in Fernley, Nevada, operated 24 hours a day, seven days a week. There were 120 employees working eight to ten hour shifts.
Operating officials for the Nevada Cement Company were:
Steven Rowley, Plant Manager
Wayne Hughes, Safety Director
MSHA is prohibited by congressionally imposed budget restrictions from enforcing the training requirements of 30 CFR, Part 48 at this operation. However, Part 48 training was being conducted. A review of company records indicated the victim had completed refresher training within the past year.
The last regular inspection of this property was conducted March
22 and 23, 1995.
PHYSICAL FACTORS INVOLVED
The accident occurred at the truck shop, which was used to service both quarry and product delivery trucks. The shop was constructed of steel and had level concrete floors. There were four service bays, with overhead garage doors at the north and south ends of the building. Each bay was approximately 15 feet wide and 116 feet deep.
The truck involved in the accident was a 1972 International, Model 1600, flat bed service truck, serial no. 106620H304949, company no. 315. It had two axles, with rear dual wheels, and an estimated gross vehicle weight of 18,450 pounds. The truck was equipped with cab-high tool boxes along the sides, a welder mounted in the bed, and an electric hoist, with a rating of 2,200 pounds, located on the right rear. The vehicle was approximately 20' long and 8' wide. It had a gasoline engine, rated at 345 hp, a five-speed transmission, and a two-speed differential. The exhaust system was standard for this type engine.
At the time of the accident, the truck's transmission was in first gear, the parking brake was not set, and the wheels had not been chocked.
The truck's starter was located on the right side of the engine, with the solenoid to the outside. The starter and solenoid were protected by a heat shield (noted as no. 7 in the attached Appendix no. 2).
Originally, the heat shield had been spot welded to an angle brace attached to the engine block. It was also attached to the main exhaust pipe with a hose clamp. It appears that Niemeyer had, in dismantling the old exhaust system, removed the hose clamp and bolts holding the pipe to the manifold.
During the investigation it was found that the heat shield had separated from the brace. Also, there was evidence of electrical arcing in two places where the shield made contact with the starter, and one place on the shield near the brace.
The service truck traveled approximately 32' after the starter
was energized and the engine started. The vehicle came to a stop
after striking another truck, parked in the same service bay, and
pushing it approximately 16 inches.
DESCRIPTION OF ACCIDENT
Niemeyer reported for work on May 22, 1995 prior to 6:00 a.m., his regular starting time. Ed McCoy, lead mechanic, assigned him the job of changing out the exhaust system on the 1972 International flatbed service truck.
There were no witnesses to the accident but the investigation disclosed that Niemeyer was in the process of removing the old exhaust pipe. He had removed the left head pipe from the manifold and loosened the head pipe on the right side when, either due to the pipe coming down and distorting the heat shield or his pulling on the system to get it out, the heat shield contacted the starter terminals causing the engine to start and the vehicle to roll over him.
Moments before the accident, Phelan Teton, a mechanic who had been working on another vehicle in the shop, left the area to obtain additional tools. He returned as the service truck struck the vehicle he had been working on. Teton, and McCoy who had just returned to the shop, went over to where the victim was lying on his back on the floor. McCoy visually checked the victim and immediately made a call to 911. He then instructed a mechanic in the paint bay to call the lab to contact David Jones, E.M.T. McCoy then drove to the plant office to get Ed Rajki, another E.M.T., and Wayne Hughes, Safety Director.
Jones received the call for assistance at approximately 6:50 a.m. and immediately proceeded to the shop. He checked the victim for breathing and a pulse and found neither. Shortly thereafter, Rajki arrived to assist. At approximately 6:55 a.m., they began CPR. The Lyon County Ambulance paramedics entered the scene about four minutes later. They instructed the two to continue CPR while they checked for vital signs. The paramedics contacted Churchill County Hospital by radio and relayed the results of their assessment. They were instructed to discontinue CPR. The time was 7:28 a.m.
Lyon County Deputy Sheriff Mike Serenko arrived at approximately
6:56 a.m. and secured the scene. Deputy Sheriff James Cassel, a
deputy coroner, pronounced Niemeyer dead at 7:44 a.m. The body
was taken to the Washoe County Hospital in Reno, Nevada.
According to the death certificate the victim died from multiple
injuries, including a fractured neck caused by blunt force
trauma.
CONCLUSION
There were several contributing causes to this accident. The
parking brake was not engaged, the transmission had been placed
in first gear, the wheels had not been chocked to prevent
hazardous motion and, despite the fact that metal tools and a
metal exhaust system were being handled in proximity to the
starter/solonoid terminals, the battery had not been
disconnected. As a result of these conditions, when the weight
of the disconnected exhaust pipe forced the heat shield into
contact with the starter/solenoid terminals the engine started
and the truck moved forward.
VIOLATIONS
The following violations were cited during the investigation:
Order No. 4140512, 103K, Issued on 5-22-95
A service truck ran over a mechanic working beneath it. This order is to secure the area in and around the accident site until an investigation can be made by MSHA to determine the cause of the accident.
Citation No. 4140701, 104(a), Section 56.14207, Issued on 5-23-95.
On May 22, 1995 a fatal powered haulage accident occurred at the plant's truck shop. A mechanic was working on a service truck when the engine accidentally started and rolled over him. The victim was under the truck working on the exhaust system. The truck's parking brake had not been set to prevent accidental movement. Mobile equipment shall not be left unattended unless the controls are placed in the park position and the parking brake, if provided, is set. In addition to the parking brake not being set, the manual transmission was left in first gear.
Citation No. 4140702, 104(a), Section 56.14105, Issued 5-23-95.
On May 22, 1995 a fatal powered haulage accident occurred at the plant's truck shop. A mechanic was working on a service truck when the engine accidentally started and rolled over him. The victim was under the truck working on the exhaust system. The truck had not been blocked/chocked to prevent accidental movement. Repairs or maintenance on machinery or equipment shall be performed only after power is off and the machinery or equipment is blocked/chocked against hazardous motion/movement. Also the parking brake had not been set and the manual transmission was left in first gear.
Respectfully submitted by:
/s/ Gary W. Fowler
Mine Safety and Health Inspector
/s/ Larry Stevenson
Mine Safety and Health Inspector
Approved by:
Fred M. Hansen,
Western District Manager
Related Fatal Alert Bulletin:
[FAB95M19]