|
DEPARTMENT OF LABOR MINE SAFETY AND HEALTH ADMINISTRATION Northeastern District Accident Investigation Report Dredge Other (Drowning) Chase Sand Plant ID No. 18-00581 Redland Genstar, Incorporated Chase, Baltimore County, Maryland April 17, 1996 by Dale R. St.Laurent Supervisory Mining Engineer Ricky J. Horn Mine Safety and Health Inspector Mine Safety and Health Administration Northeastern District 230 Executive Drive, Suite 2 Cranberry Township, Pennsylvania, 16066-6415 James R. Petrie District Manager GENERAL INFORMATION Herman Gunther, dredge operator, age 41, and Charles Puzak, lead mechanic, age 58, drowned at about 11:30 a.m. on April 17, 1996, when the work boat they were riding in sank. A third employee, Joseph Kozlowski Jr., maintenance mechanic, age 28, who was also in the boat, swam ashore. Gunther had about 24 years mining experience, 23 years as a dredge operator, all at this mine. Puzak had about 11 years mining experience, the last 2 years at this mine. Kozlowski had about 7 1/2 years mining experience, the last 6 years at this mine. MSHA was notified at 12:35 p.m. on the day of the accident by a telephone call from R. Jeffrey Carey, safety advisor. An investigation was started the following day. The Chase Sand Plant, a sand and gravel operation owned and operated by Redland Genstar, Inc., was located at Chase, Baltimore County, Maryland. The principal operating official was Thomas Rock, superintendent. The plant was normally operated two, 8-hour shifts a day, 5 days a week. A second shift had recently been added. A total of 15 persons was employed. Sand and gravel was extracted by a combination of pond dredging and excavating using hydraulic backhoes loading into trucks. The material was transported to an adjacent processing plant by truck or pumped there from the dredge. The finished products were masonry sand and aggregate. All three accident victims had received training in accordance with 30 CFR Part 48. The last regular inspection of this mine was completed October 31, 1995. Another inspection was conducted in conjunction with this investigation. Physical Factors Involved The work boat involved in the accident was a flat-bottomed "John boat" powered by a 25-hp Johnson outboard motor. It measured approximately 19 1/2 feet long, 5 feet wide, and 2 feet high. The boat was purchased used in 1981, and reportedly had been fabricated by its prior owner. Maximum speed was estimated to be 5-10 mph. The boat was constructed of steel plate and weighed 3,800 pounds. The estimated weight of the motor was an additional 70 pounds. The only other significant cargo in the boat at the time of the accident was a 6-gallon plastic gas can, which was 3/4 full, and the three passengers. Each of the passengers weighed between 225 and 286 pounds in their work clothes. The weather was cold and they were wearing multiple layers of clothing. Reportedly, the boat had 1� inches of water in it at the time of the accident, which would have weighed an estimated 375 pounds. The boat had a single flotation chamber which measured 4 feet long, 5 feet wide, and 2 feet deep. It was an empty air chamber located in the center of the boat and did not contain any flotation material. The chamber displaced 2,496 pounds of water and was inadequate to keep the boat afloat if swamped or loaded with more than a few inches of water. Calculations of the person load capacity for the boat indicated that the capacity was approximately 300 pounds, excluding the weight of the water in the bottom of the boat at the time of the accident. The person load capacity in pounds is the weight of persons in the boat that, if exceeded, would compromise the boat's performance. The boat's freeboard was measured on-site with the motor in place and three persons in the boat. One person was seated at the stern, one on the bench seat in front of the flotation chamber, and one at the bow. Under these conditions, the freeboard measured 7� inches on the port side at the bow, 10� inches on the starboard side at the bow, and 13 inches on both the port and starboard side at the stern. In February 1995, repairs were made to the boat which consisted of welding on additional steel plates and angle iron. Reportedly, after the repairs were made, the boat sat lower in the water, listed to port at the bow, and handled more sluggishly than before. The boat sank in water about 20-25 feet deep. It was found 75 to 100 feet from shore and 100 to 125 feet from the dredge. Reportedly, Gunther was a good swimmer, Kozlowski was an adequate swimmer, and Puzak could not swim. Life jackets had been issued to all three victims and written company policy required their use, however, employees frequently rode in the boat without using them. Several spares were also available. Although the make, model, and design of these life jackets varied, all of them were Type III Personal Flotation Devices, U.S. Coast Guard approved, and were adequately sized. Four life jackets were found in the operator's cabin on the dredge. Another life jacket was found behind the seat of the welding truck driven by Kozlowski, and one was behind the seat of the pickup truck driven by Puzak. Kozlowski recalled that there may have been a life jacket on the floor of the boat. The rescue squad reported finding a life jacket floating in the water after the accident. Weather conditions at the time of the accident were cold and windy. The water and air temperatures were estimated to be in the low 40-degree level. Winds were estimated to be 15 to 30 mph at pond level. Waves were estimated by witnesses and rescue workers to average 6 inches with occasional waves up to a foot. Description of Accident On the day of the accident, Charles Puzak and Herman Gunther (victims) and Joseph Kozlowski Jr. (survivor) reported for work at 6:30 a.m., their regular time. Gunther took the work boat to the dredge and started the hydraulic pumps to try and clear a blockage in the pipeline. Kozlowski drove the welding truck to the booster pump to see if he could find the source of the blockage. Puzak began maintenance work in the shop. Shortly after starting the pumps on the dredge, Gunther reported via radio that the radiator for the diesel engine that powered the pumps was leaking. Puzak heard the report and went to get a replacement. About 9:45 or 10:00 a.m., Gunther brought the boat to shore where he met Puzak and Kozlowski with the radiator. After placing it in the boat, the three of them rode out to the dredge. None of them wore life jackets. Kozlowski stated that, on the way out to the dredge, some waves splashed into the boat and added about � inch of water to the inch or so already in the bottom. He further stated that due to the weight of the boat, its bow did not rise when going through waves. They replaced the leaking radiator on the dredge and, at about 11:25 a.m., they all decided to return to shore to eat lunch and get a hose clamp and antifreeze which they needed to complete their job. Gunther sat in the back of the boat to run the motor, Kozlowski and Puzak sat on the front of the flotation chamber. Again, no one wore a life jacket. Kozlowski stated that, on the way back to shore, they were heading into the wind and hitting the waves head-on. He estimated that the wave height was 5 to 6 inches. He said that they had gone 50 to 75 yards when a wave filled the front of the boat causing it to submerge. The boat went straight down and sank within seconds. Upon entering the water, Kozlowski struggled for several minutes to remove his boots and coveralls. He then swam over to Puzak, who was unresponsive and floating face down. Kozlowski grabbed Puzak with one hand and, with the other hand, grabbed the boat's gas can which was floating nearby. Despite the added flotation provided by the gas can, Kozlowski was unable to keep both Puzak and himself afloat. He was forced to let go of Puzak, who then sank out-of-sight. Kozlowski spotted Gunther about 10 feet away. Gunther was also floating face down and was unresponsive. Kozlowski swam over to him and was able to pull him to shore. Upon reaching the shore, Kozlowski checked Gunther for signs of life and found none. Kozlowski waved to Douglas Shock, backhoe operator, and then ran to his truck to call for help. Shock, who worked for a contractor, was loading trucks on the northeast side of the pit. Shock said he had observed the three men coming from the dredge in the work boat. He looked away momentarily and when he looked again, he saw someone swimming in the water and didn't see the boat. Shock ran to the shore to help. Thomas Rock, superintendent, was in the scale house when he heard Kozlowski call for help on the radio. He told the scale house worker to call 911, and then drove to the dredge pond. When he arrived, Shock informed him that Gunther had no pulse, so Rock went to look for the other two men. He could not find Puzak, but found Kozlowski sitting in his truck shaking and disoriented. Rock drove Kozlowski back to the mine road, where they met the arriving ambulance. Several local rescue squads arrived with an ambulance, a boat, and a dive unit a short time later. Gunther was reported dead at the scene. Rescue squads began searching for Puzak, using divers and dragging the pond. They recovered his body about 1:45 p.m. The work boat was recovered later that day. Conclusions The primary cause of the accident was that the boat, used for access to and from the dredge, was in unsafe condition in that it was overloaded, lacked adequate flotation, had negative trim (bow and port side sat lower in water than the stern and starboard side), and its minimum freeboard was close to the estimated wave height at the time of the accident. Failure to wear life preservers contributed to the severity of the accident. Violations Order No. 4439382 Issued on April 17, 1996, under the provisions of Section 103(k) of the Mine Act to insure the safety of persons during the recovery operations and until the affected areas of the mine could return to normal. This order was terminated on May 7, 1996. Citation No. 4440182 Issued on May 6, 1996, under the provisions of Section 104(a) of the Mine Act for violation of 30 CFR 56.15020: Citation No. 4440814 Issued on May 6, 1996, under the provisions of Section 104(a) of the Mine Act for violation of 30 CFR 56.11001: //s// Dale R. St.Laurent Supervisory Mining Engineer //s// Ricky J. Horn Mine Safety and Health Inspector Approved by: James R. Petrie District Manager BR> Related Fatal Alert Bulletin:  [FAB96M12]
|
