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DEPARTMENT OF LABOR MINE SAFETY AND HEALTH ADMINISTRATION ROCKY MOUNTAIN DISTRICT Accident Investigation Report Surface Nonmetal Mine Fatal Slip/Fall of Person Accident Leamington Plant Mine I.D. No. 42-01665 Ash Grove Cement Company Leamington, Juab County, Utah June 25, 1997 By William Wilson Supervisory Mine Safety & Health Inspector Andrew D. Lowe Mine Safety & Health Inspector Rocky Mountain District P.O. Box 25367, DFC Denver, CO 80225-0367 Robert M. Friend District Manager GENERAL INFORMATION Roger C. Green, maintenance specialist, age 44, was fatally injured at approximately 10:00 a.m., on June 25, 1997, when he fell down an elevator shaft in the preheater tower. The victim had a total of 15 years and 25 weeks of mining experience, all at this operation. The company informed the investigators that Green had received training in the use of fall protection and safety harness and lanyard use. There was no record indicating that he had received training in accordance with Part 48. G. Duane Crutchfield, plant manager, notified MSHA of the accident by phone at 12:50 p.m., on June 25, 1997. An investigation was started the same day. Principal operating officials for Ash Grove Cement Company were: Charles T. Wiedenhoft, Senior Vice President of Manufacturing The Leamington Plant, owned and operated by Ash Grove Cement Company, was located in Leamington, Juab County, Utah. Limestone was quarried from four ridges in the mountain above the plant. Silica, alumina, and iron were brought to the plant from outside sources. The raw materials were crushed, milled, heated, and processed to form cement. The finished product was distributed to construction and manufacturing clients throughout the Intermountain West. Total employment at the operation was 85 persons working three, 8 hour production shifts per day, 7 days a week. The maintenance department worked two, 8 hour shifts per day, 5 days a week. The last regular MSHA inspection was completed on October 17, 1996. PHYSICAL FACTORS INVOLVED The accident occurred in the elevator shaft located in the 210-foot high preheater tower. The shaft was 74 inches by 102 inches. The elevator compartment was 66 inches by 76 inches and was 86 inches high. The tower had ten floors that were accessible by stairs or the passenger elevator. Involved in the accident was a Model 430H, 2,000 pound capacity, Viola elevator. The elevator had two doors, one outer door on each floor and an inner door on the passenger compartment. The outer doors had an electro-mechanical interlock which prevented them from opening unless the elevator was in position at the floor. The elevator would not move unless the inner door was securely closed. The outer door interlock could be by-passed for maintenance and repair to the elevator shaft or passenger compartment by inserting a key in a slot on the upper left side of the door. Use of the key allowed the outer doors to be opened irrespective of the location of the passenger compartment. The manufacturer recommended that the key be made available only to authorized personnel. Rank-and-file employees stated that they routinely by-passed the outer door interlocking mechanism by using welding rods with a hook formed on one end. This allowed them to open the outer doors to check on the location of the passenger compartment. Additionally, a miner stated that in 1991, he opened the outer door to the elevator shaft on the 4th floor and fell about 10 feet because the passenger compartment had not leveled to that floor. No safety belts or harnesses were used while engaging in this practice, and employees stated that they held onto the tower's handrails or the door frame to prevent falling into the shaft. Two company foreman were aware of this activity and did not stop it. None of the floors were equipped with structures or mechanisms on which safety lines or lanyards could be secured. The falling hazard could be from a few feet to about 200 feet dependent on the location of the passenger compartment. The elevator shaft doors were 34-1/2 inches wide and 83 inches high. The doors opened into the travelway of the tower. A hydraulic door closer was installed on each door to prevent them from closing too fast. A number of the door closers were leaking oil. A performance test of the door closers on all ten floors was conducted. The doors were opened to 90 degrees and allowed to close. The doors on all floors closed between 2 and 4.5 seconds. During this inspection, it was discovered that the fourth floor's outer door interlock system was defective. This defect allowed the door to be opened without using a key to disable the mechanical interlock. A citation was issued on a miscellaneous inspection, as the defect did not contribute to the accident. Maintenance personnel, including the victim, were assigned to inspect and maintain the elevator. Computer generated check lists were used to document defects and record repairs and maintenance. According to the sheets, preventive maintenance was conducted on a monthly, quarterly, or yearly basis, depending on what was required. The preventive maintenance personnel were instructed to complete the sheet, note any deficiencies, and return them to their foreman. If defects were noted during those inspections, the foreman determined if they warranted repair by company mechanics or electricians. After that determination, the sheets were returned to the planning department for final disposition. The elevator was last certified for passenger use by the State of Utah on May 14, 1997. It was last serviced by personnel from Thyssen Elevator Company on June 23, 1997, at which time the safeties were reset. No defects affecting safety were noted. After the accident, all mechanical and electrical systems on the preheater tower elevator were examined and tested. The tests revealed that there were no defects in the elevator's mechanical or electrical systems other than the previously noted defective shaft door interlock on the fourth floor. The victim carried a hand-held radio which enabled him to contact his supervisor or other plant personnel. It was tested and found to be operable. There were no outside walls on the preheater tower, thus it was exposed to the elements except where piping and other components of the tower blocked some of the wind. Conversely, the elevator shaft was fully enclosed. One miner described the wind on the day of the accident as "blowing hard". There were no witnesses to the accident. The top of the passenger compartment was damaged at the location where the victim was found. Scratches and other marks were found inside the elevator shaft just below the ninth floor of the shaft. The victim had abrasions on his fingers and a scuff mark on one of his boots. DESCRIPTION OF ACCIDENT Roger Green reported for work at 7:00 a.m., his normal starting time. He was assigned to perform a preventive maintenance inspection of the preheater tower and coal areas. He was observed by coworkers working in various areas of the tower during the early hours of the shift. At about 10:15 a.m., Phil Halden, Fuller Company, tried to use the elevator to access the tower's fourth floor to check ductwork temperatures and fly dampers. The elevator did not respond when he pushed the button. He used the stairway and completed his tasks. At about 11:00 a.m., Adrian Beal, production assistant, went to the tower to conduct various duties. Arriving at the first floor, he called for the elevator by pushing the button but received no response. Beal saw that there was no operating light nor bell noise being generated by the elevator. He walked up the stairway to the fourth floor and en route, stopped at each floor and called the elevator but did not receive a response. He arrived at the fourth floor and accomplished his task. Curious at the elevator's failure to respond to his calls, he walked up the stairway to investigate. When Beal got to the sixth floor, he opened the outer shaft door by defeating the interlock with a welding rod and saw the passenger compartment several feet above him. He was not using a safety belt or lanyard during this activity. At approximately 11:30 a.m., he walked up to the seventh floor and again used a welding rod to open the outer door. He saw the victim on top of the elevator passenger compartment between the 6th and 7th floors. Beal called to Green but received no response. He radioed his supervisor and informed him of the situation. Maintenance specialist, Cory Frampton, an emergency medical technician (EMT), arrived within a few minutes of Beal's radio call. Frampton climbed into the shaft to assist the victim. Frampton was soon joined by electricians, James Rasch and Bart Walker, one an EMT and the other a first responder. They checked for vital signs and none were detected. First aid was administered. He was removed from the shaft, placed into an ambulance and transported to the local hospital. He was pronounced dead at 12:43 p.m., as the result of blunt force injuries and compression. Green was not using a safety belt and lanyard during his activities on the day of the accident. His PM sheets were found on a clipboard on the ninth floor of the preheater tower near the elevator's outer shaft door. The sheets indicated that he had completed a mechanical inspection of pneumatic hammers on the third floor and a similar inspection of the same items on the sixth and ninth floors. The accident occurred when the victim fell onto the passenger compartment of the elevator which was between the 6th and 7th floors of the preheater tower. The company had allowed the practice of by-passing the outer door interlocking safety system by using welding rods to open the doors, exposing miners to the elevator shaft. Safety lines were not located on any of the floors of the plant, nor were there structures on which safety lines or lanyards could be easily secured. CONCLUSION The accident was caused by the practice of allowing miners to by-pass the interlocking outer door safety mechanisms, failure to require the use of safety lines where known hazards presented a risk of falling, and failure to assure that structures were available to secure lines and lanyards to protect the safety of miners. VIOLATIONS Order No. 4662461 Issued at 12:50 p.m., June 25, 1997, under the provisions of Section 103(k)of the Mine Act: Citation No. 4652842 Issued under the provisions of Section 104(d)(1) on August 15, 1997, for violation of 30 CFR 56.15005: Order No. 4652843 Issued under the provisions of Section 104(d)(1) on August 15, 1997, for violation of 30 CFR 56.18002(a): //s// William Wilson Supv. Mine Safety & Health Inspector //s// Andrew D. Lowe Mine Safety & Health Inspector Approved by: Robert M. Friend, District Manager Related Fatal Alert Bulletin:  [FAB97M36]
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