DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
North Central District
Metal/Nonmetal Mine Safety and Health
ACCIDENT INVESTIGATION REPORT
SURFACE NONMETAL MINE
FATAL DROWNING ACCIDENT
Detroit Lime Company (I.D. No. 20-00365)
Detroit Lime Company
Detroit, Wayne County, Michigan
November 3, 1995
Gerald D. Holeman
Mine Safety and Health Specialist
Mine Safety and Health Administration
515 West First Street, #228
Duluth, Minnesota 55802-1302
James M. Salois
Thomas McKinney, laborer, age 47, drowned in the River Rouge on November 3, 1995, sometime between 4:45 and 6:30 p.m. The river was adjacent to his assigned work area.
The Lansing, Michigan field office of the Mine Safety and Health Administration (MSHA) learned of the accident on Monday morning at 7:30 a.m., November 6, 1995, after receiving a recorded telephone message placed on November 4, 1995, at approximately 10:00 a.m., by James A. Bradner, Vice President and General Manager, Detroit Lime Company. An accident investigation was initiated by MSHA on November 6, 1995.
Detroit Lime Company is a mill facility located at 125 S. Dix, Detroit, Wayne County, Michigan. The operating official and person in charge of health and safety at the mine was James Bradner. The operation employed 50 persons working three, 8-12 hour shifts, seven days a week.
The mill facility was located on the River Rouge and included a dock where crushed limestone purchased from outside sources was received by ship and off-loaded for mill processing. The limestone was fed to the kiln by a surge pile conveyor system. The heated material was then air cooled, screened, crushed, and stored in silos. Finished products were sold for use in steel and paper manufacturing and as an environmental desulphurization agent in flue gases.
The last regular inspection of Detroit Lime Company was April
PHYSICAL FACTORS INVOLVED
The concrete boat dock adjacent to where the employee was working was located along the north side of the storage silos. The dock measured approximately 36 feet wide and 290 feet long. A 30 inch high, corrugated metal guardrail was installed 17 inches from the dock's edge along its entire length. Bollards, used as tie-off points by docking ships, were randomly spaced in the center of openings along the guardrail system. There were 28- to 29-inch openings in the guardrail on each side of the bollards. Railroad timbers were used as bumper blocks for ships and were mounted 5 feet below the top of the dock along its entire length.
The River Rouge water level was 9 feet below the dock's surface and varied in depth from 13 feet along the dock to approximately 25 feet in the center of the river to accommodate marine traffic.
Two small granular storage silos, used to load bulk trucks and metal tote bins by McKinney, were mounted on a steel structure between the dock guardrail and larger main storage silos. The steel support legs of the structure were 7 feet 6 inches from the dock guardrail.
One discharge line from the west overhead granular silo was constructed to load lime products into empty tote bins which were placed on the scales at the southeast corner of the structure prior to loading. The bins were filled to capacity and weight specifications prior to shipping or storage.
On the day of the accident it was cool and there was no precipitation. The concrete dock site was muddy in some areas from recent accumulations of spillage, rain, and melting snow.
Physical evidence had been removed by local law enforcement and/or released for use by the company prior to the MSHA accident investigation. Based on interview statements, photos, and notes the following factors were determined: A Toyota forklift used by McKinney that shift was found parked with the engine off near the northwest corner of the granular silo bin structure, 72 inches away from the dock guardrail. A pen, a marker, and a tobacco pouch were found floating in the water approximately 10- to 15-feet from the dock. McKinney was later located by divers in this vicinity. At the east end of the dock a right hand glove and a second tobacco pouch were found. McKinney's hardhat was found in the water beyond the east end of the dock.
The death certificate listed drowning as the cause of death.
DESCRIPTION OF THE ACCIDENT
On the day of the accident, Thomas McKinney reported to work at approximately 11:00 a.m. John Abad, shift supervisor, saw McKinney at the start of the shift and was aware he was unloading empty tote bins from a truck and reloading with tote bins full of product, along with other normal duties. Abad saw McKinney once again in the kiln control room having coffee at approximately 2:30 p.m.
Jerry W. Satterfield, maintenance worker, saw McKinney as they passed each other in the shop between 4:30 and 4:45 p.m. and stated McKinney appeared normal. At about 4:45 p.m., Gary Sluss, production manager, saw McKinney as they passed each other between the compressor room and lunchroom.
While Abad was making his workplace rounds at about 5:30 p.m., he noticed the Toyota forklift parked parallel to the guardrail at the granular silos and presumed McKinney was on break. Prior to leaving for the day, Abad again observed the forklift parked in the same location. He returned to his office at about 6:30 p.m. and summoned Gary Longworth, assistant kiln operator, and Mark Christy, general utility man, and asked them to search for McKinney.
Longworth and Christy went to McKinney's work area where the forklift was parked. They looked into the river and saw a pouch of tobacco floating in the water. They returned to Abad's office and summoned him to the work site. An ink pen and marker, each characteristic to the work McKinney performed, were located along the dock. Abad then summoned emergency help.
Emergency police, harbor patrol, and diving units responded,
along with investigators from the Detroit Police Department. At
about 10:30 p.m. McKinney was found in the water in the
approximate location where the first tobacco pouch was observed.
There was no evidence to determine what caused McKinney to enter
the water. His work on the day of the accident required him to
be in the general dock area but did not require him to work near
or at the dock's edge.
The following violations were issued during the investigation:
Citation No. 4105993; Issued 12/7/95 at 1100 hours; Part/Section of Title 30 CFR: 50.10; Type of Action: 104(a)
The mine operator failed to immediately notify the Mine Safety and Health Administration of an accident. On 11/03/95 an employee drowned. The employee was not located until approximately 10:30 p.m. The mine operator called the Lansing, MI MSHA field office on Saturday 11/04/95 at approximately 10:00 a.m. and left a message of the occurrence on the phone recorder. The mine operator had not contacted the district office for reporting the accident as instructed on the telephone recording and mandated within the standard.
Citation No. 4105994; Issued 12/7/95 at 1105 hours; Part/Section of Title 30 CFR: 50.12; Type of Action 104(a)
The mine operator failed to maintain evidence of an employee drowning accident until an MSHA investigation of the incident could be conducted. A Toyota forklift, serial number 5FG45-20084, reportedly used by the employee, was removed from its parked location at the accident scene prior to an MSHA investigation and without prior consent by MSHA.
Respectfully submitted by:
/s/ Gerald D. Holeman
Mine Safety and Health Specialist
James M. Salois
Related Fatal Alert Bulletin: