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UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION


Rocky Mountain District

Accident Investigation Report
Surface

Fatal Powered Haulage Accident

Kilauea Crushers, Inc. (mine)
I.D. No. 02-02479
Kilauea Crushers, Inc.
Wickenburg, Maricopa County, Arizona


April 26, 1997


By

Wayne J. Wasson
Supervisory Mine Safety & Health Inspector

Eldon E. Ramage
Mine Safety & Health Inspector


Rocky Mountain District Office
P.O. Box 25367, DFC
Denver, CO 80225-0367


Robert M. Friend
District Manager



GENERAL INFORMATION



John Eugene Meyer, welder, age 56, was fatally injured on April 26, 1997, at approximately 1:00 p.m., when he was run over by the front-end loader he was operating. Meyer had a total of 25 years experience as a welder, the last 15 weeks at this operation. He had a total of 15 weeks mining experience. The victim had not received training in accordance with 30 CFR, Part 48.



Charles W. Nichols, president, notified the Mesa, Arizona field office of the accident by telephone on April 28, 1997, at about 7:25 a.m. An investigation was started on that day.



The Kilauea mine, owned and operated by Kilauea Crushers, Inc., was located about 8 miles north of mile marker 11, off Highway SR 74, southeast of Wickenburg, Maricopa County, Arizona. Rhyolite was drilled, blasted, loaded into haul trucks and transported to the plant for crushing and sizing. The material was stockpiled onsite and was sold to customers for use as decorative stone. Total mine employment was 12 persons working one, 11 hour shift on four days and one, 10 hour shift on two days of each week.



Principal operating officials for Kilauea Crushers, Inc. were:
Charles W. Nichols, President
Marcilline Nichols, Vice President
James W. Nichols, Operations Manager



The last regular inspection of this operation was conducted on September 24 and 25, 1996. Another inspection was conducted at the conclusion of the accident investigation.

PHYSICAL FACTORS INVOLVED



Raw materials were mined from multiple pits. Two principle pits were described as the Apache Pink and the Palomino Gold pits for the colors of the stone they produced.



The accident occurred on the haul road leading to the Palomino Gold pit on a portion of the road that inclined about 19 percent. The one mile roadway was well maintained, about 34 feet wide and the inclined section of the road was approximately 1,200 feet in length. A substantial berm was provided along the right shoulder of the road.



A 1973 Caterpillar 910 front-end loader, Serial Number 80U0832, was involved in the accident. The mine operator had purchased the loader at an auction. A Balderson Quick Coupler had been installed by the previous owner. The loader was equipped with a roll-over- protective-structure, as well as a seatbelt. The seatbelt was found to be defective, however, it did not cause or contribute to the cause or severity of the accident. A citation on the seatbelt was issued separately. The service brakes were hydraulically actuated, caliper disc type, mounted on the front and rear wheels. In the event engine power is lost, the service brakes can still be applied through mechanical linkage by increased effort on the brake pedal. A mechanical drum-shoe park brake was mounted on the drive shaft. Adjustment of the park brake was accomplished with a twist knob on the end of the brake lever, which was located under the left instrument panel.



The park brake lever was difficult to reach because the operating controls for the Balderson Quick Coupler were located between the loader operator's seat and the lever. In order to apply the park brake lever, operators would normally have to stand up, reach over the Balderson controls, and then down to the park brake lever which was under the instrument panel.



The Balderson Quick Coupler installed on the loader allowed for the removal of the bucket so the loader could be utilized as a forklift or crane. At the time of the accident the loader was equipped with the fork attachment.



The loader and the accident site were inspected during the investigation and revealed the following conditions:
1. The service brake and park brake were tested and were operational.
2. The gear selector lever was in first gear forward.
3. The forks were 30 inches off the ground.
4. The park brake had not been set.
5. The radiator cap was missing.
6. Both rear tires were flat (result of loader turning over).
7. An information plate "Warning if engine stops, brake and steering boost pressure is lost, apply park brake to stop the machine" was affixed to the loader.
8. Engine coolant was on the roadway at the location where the loader had stopped, before rolling backwards.
9. Depressions in the ground, at the scene of the accident, indicated that one tire of the welder had dug into the roadway.
10. There were no external leaks in the hydraulic system.



Also involved in the accident was a diesel-powered Dualweld 500 welder, Serial Number 1104721, manufactured by Multi-Quip, Inc. The welder weighed 2,240 pounds and was mounted on a single axle chassis that was equipped with a ball hitch.

DESCRIPTION OF ACCIDENT



John Eugene Meyer (victim) reported for work at 6:00 a.m., his normal starting time. He performed various welding and fabrication tasks until approximately 11:30 a.m., when James W. Nichols, operations manager, instructed Meyer to perform a minor welding repair on the drill. Nichols informed Meyer that the drill was located in the Apache Pink pit. Meyer was told to contact Nichols for instructions on the task when he was ready to do the work.



At about 1:00 p.m., Meyer had not contacted Nichols, so Nichols went to the drill but could not find the employee. While returning to the main plant from the drill, he saw the welding machine and an object laying on the inclined section of the road leading to the Palomino Gold pit. He then saw the loader laying on its' side in a ravine, approximately 240 feet back down the road from the welding machine. Nichols turned around and started toward the area, picking up a haul truck driver on the way.



The two men saw Meyer in the road, checked for vital signs, but found none. Nichols phoned 911 for assistance. Paramedics from the local rescue squad responded. Meyer was pronounced dead at the scene by emergency medical personnel. Death was the result of blunt injuries.

CONCLUSION



The equipment operator/welder was moving a welding machine using a front-end loader which had been adapted to function as a forklift. The loader was being used to carry the welding machine up a 19% grade when one of the wheels of the welding machine struck the ground. The loader stopped. This caused the loader to descend backward down the grade. The engine of the loader either stalled or was turned off. Engine coolant on the ground indicated that the loader may have overheated. A warning notice posted on the equipment indicated that the service brake would not function when the engine was not operating.



The factors of this accident include failure to examine the equipment prior to use; altering equipment in a manner which affected access to the parking brake; and the victim leaving the moving loader.

VIOLATIONS



Order No. 4702020
Issued at 1545 hours on 4/28/97, under the provisions of Section 103(k) of the Mine Act:

A welder repairman was fatally injured when he was transporting a portable welder up an elevated mine haul road, with a forklift, a Caterpillar 910. The employee was found on the road and the forklift was found about 300 feet down the road in a 15 feet deep dry creek. The accident occurred at the Kilauea Crushers, Inc., mine on the elevated Palomino Gold haul road. There were no witnesses. This order is issued to ensure the safety of any persons in the area of the Caterpillar 910 front-end loader pending an investigation to determine if it is safe to resume operations. This order was verbally issued over the telephone by MSHA, supervisory mine inspector, Bill Wilson, at 0725 hours, 4/28/97.

This order was terminated on completion of the onsite investigation on 4/29/97.



Citation No. 7925205
Issued under the provisions of Section 104(a) on 5/30/97, for a violation of 30 CFR 50.10:

An employee was fatally injured at about 1:00 p.m., on 4/26/97, when he was run over by a front-end loader. The accident was not reported by the mine operator until 0725 hours, on 4/28/97. A death of an individual at a mine site is immediately reportable to MSHA.

This citation was terminated 5/30/97.



Citation No. 7925206
Issued under the provisions of Section 104(a) on 5/30/97, for violation of 30 CFR 56.14100(a):

The operator of the Caterpillar front-end loader, Serial Number 80U0832, was fatally injured at approximately 1300 hours, on 4/26/97, when he was run over by the loader. The accident investigation revealed that the loader was not inspected for defects affecting safety before being placed in service. A defect affecting safety was observed on the loader.

The citation was terminated 5/30/97.



Citation No. 7925207
Issued under the provisions of Section 104(a) on 5/30/97, for violation of 30 CFR 56.14100(b):

An accident resulting in a fatality occurred on 4/26/97, at about 1300 hours, when the operator of a Caterpillar front-end loader was run over by the loader. The accident occurred on the roadway leading to the Palomino Gold pit of the mine. This section of the road was sloped at about 19 percent. The actuating lever for the park brake was made difficult to reach due to modifications to the loader. A Balderson Quick Coupler had been added to the loader so the bucket could be removed and forks or a crane could be utilized. The park brake lever was located under the left side of the instrument panel and in front of the coupler controls which made it difficult to reach. The manufacturer recommends to use the park brake in case of emergency. An inspection of the loader after the accident revealed that the park brake had not been set.

The citation was terminated 7/7/97.



Citation No. 7925204
Issued under the provisions of Section 104(a) on 5/30/97, for violation of 30 CFR 56.18006:

An employee (welder) operating the Caterpillar 910 front-end loader/forklift was fatally injured at approximately 1300 hours, on 4/26/97, when he was run over by the loader. The employee had not been indoctrinated in safety rules and safe work procedures.

The citation was terminated 5/30/97.



/s/ Wayne J. Wasson
Supervisory Mine Safety & Health Inspector


/s/ Eldon E. Ramage
Mine Safety & Health Inspector



Approved by: Robert M. Friend, District Manager

Related Fatal Alert Bulletin:
Fatal Alert Bulletin Icon [FAB97M25]