DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
North Central District
Metal and Nonmetal Mine Safety and Health
Accident Investigation Report
Surface Nonmetal Mine
Fatal Powered Haulage Accident
GTS Transport Company, Incorporated
I.D. No. 8GM
Dundee, Monroe County, Michigan
Mine I.D. No. 20-00022
March 13, 1998
C. Okey Reitter, Jr.
Supervisory Mine Safety and Health Inspector
James M. Hautamaki
Mine Safety and Health Inspector
Joseph F. Judeikis
Mine Safety and Health Administration
Federal Building, U.S. Courthouse
515 W. First Street, #333
Duluth, MN 55802-1302
Felix A. Quintana
Richard E. Wells, contract truck driver, age 63, was fatally injured at about 1:20 p.m. on March 13, 1998, when he was crushed between the two trailers of his tractor-trailer rig. Wells had no mining experience, but had been driving over-the-road trucks to this operation for a total of seven years. He had not received training in accordance with 30 CFR Part 48.
MSHA was notified by a telephone call from the human resource manager for the mining company at 1:30 p.m. on the day of the accident. An investigation was started the following day.
GTS Transport Co., Inc., headquartered in Coldwater, Michigan, was a commercial trucking company contracted by Michigan Central Power to transport fly ash from their power plant in Litchfield, Michigan to the Dundee Plant for use in the production of cement. The principal operating official was Todd Brayton, owner. The company employed a total of nine persons; of this number, two employees routinely hauled fly ash to the Dundee Plant.
The Dundee Plant, a cement producing operation, owned and operated by Holnam, Inc., was located at Dundee, Monroe County, Michigan. The principal operating official was Donald Schena, plant manager. The plant was normally operated three, 8-hour shifts a day, seven days a week. One hundred and seventy-three persons were employed.
Limestone was mined from an adjacent quarry, transported to the plant, and manufactured into Portland cement. The finished product was shipped to customers by rail and truck.
The last regular inspection of this operation was completed on February 11, 1998. Another inspection was conducted following this investigation.
PHYSICAL FACTORS INVOLVEDThe accident occurred at the fly ash dump site located at the south end of the quarry. The dump site area was approximately 150 feet long and 90 feet wide and was level where the trucks had to dump. The grade leading from this area was approximately 5 percent. Ground surface conditions were generally good with standing water and mud in some areas.
The victim was operating a tandem axle, 1990 Ford truck, model LTS-9000, powered by a 425 Caterpillar engine and 13-speed transmission, pulling two 29-foot trailers. The tractor-trailer unit was used to haul fly ash from the Michigan Central Power plant in Litchfield, Michigan to the Dundee Plant, approximately 70 miles. The unit made two round trips each day with each trip taking approximately four and one-half hours. The tractor and trailers were owned by GTS Transport Co., Inc. The rig consisted of the tractor and two triple-axle trailers with a tandem dolly connecting the two trailers. There was a total of 11 axles with service and/or parking brakes at each axle.
The parking brake system consisted of 12 spring applied/air released Type 30 chambers actuating 12 of the 22 service brakes plus the air applied service brakes on the front axle of each trailer. These four service brakes (two on the front axle of each trailer) were automatically actuated by application of the parking brake through the use of an emergency relay valve. This configuration resulted in the application of potentially 16 brakes by setting the unit's parking brakes. This parking brake application could be achieved by pulling out a square yellow knob on the left portion of the dashboard adjacent to the driver's doorjamb.
A second parking brake application method could be achieved by pulling out a red octagon knob located directly above the yellow knob. This actuated eight spring applied/air released Type 30 chambers located on axles number 5, 6, 10 and 11, as well as the service brakes on axles number 4 and 9.
The service braking system was a straight air type with S cam expanding shoes operating against 22 brake drums. The air supply system consisted of an engine gear driven air compressor, desiccant air dryer and ten air reservoirs. An examination of the air system showed that it played no role in the accident.
This unit was equipped to provide service brake application using a "hand valve" mounted on the right side of the steering column. This valve was designed to be used to temporarily apply the trailer brakes to prevent a jackknife or to hold the unit on a grade when pulling away because it freed the driver's right foot to operate the accelerator. The "hand valve" applied only the trailer and dolly service brakes and was clearly marked "Not For Parking". These valves typically have a spring return feature that assists in moving the valve to the brake released position when the operator releases the handle.
All brake friction materials were above minimum acceptable thickness levels. The brake push rod travel on all 11 axles was in correct adjustment and the slack adjuster lengths were acceptable.
Drawbar pull tests were conducted to determine if the spring applied parking brakes were adequate to hold the loaded unit on the grade involved in this accident. Those tests showed the parking brake system provided four times the braking required to keep the unit stationary at the accident site.
Inspection of impressions left in the mud at the top of the incline leaving the dump site appeared to show that the tractor's front driver side tire had stopped in that area. From that mark to the front of the tire after the accident indicated that the rig may have drifted approximately 70 feet before coming to rest in the jackknifed position.
The Ford tractor was found with the engine running at a high idle and a hydraulic hose between the two trailers was ruptured, pumping fluids out. The parking brake did not appear to have been set and there were no tire skid marks.
Temperature was approximately 21 degrees, with winds ranging from 5 to 10 miles per hour.
DESCRIPTION OF ACCIDENT
On the day of the accident, Richard Wells (victim) reported for work at the GTS company shop in Coldwater, Michigan about 6:00 a.m., his regular starting time. He prepared his tractor-trailer rig for the day and started on his route. He drove a short distance before noticing that one set of tires on the lead trailer was locked up. He returned to the shop and waited until the mechanics arrived at 8:00 a.m. to free the brakes and replace all four tires on that axle. Reportedly, they checked all other brake adjustments before releasing the truck.
After the repairs were made, Wells left for Litchfield to pick up his first load of fly ash. Records at the Dundee Plant indicate that Wells arrived at 12:47 p.m. and traveled on to the dump site in the quarry.
Wells dumped his rear trailer and pulled forward for about 140 feet where he stopped to disconnect the rear trailer preparatory to dumping the lead trailer. Apparently, while he was performing this task, the unit rolled down the grade and jackknifed, crushing him between the lead trailer and the left front side of the rear trailer.
Moments after the accident, mobile maintenance employees Rob Lowe and Brandon Hudgins drove by and saw the jackknifed rig. They got closer and saw the victim's feet by the hitch and called out to him, but got no response. They then drove to a nearby drill rig to summon help. The truck engine was running at a high idle and hydraulic fluid was pumping from a ruptured line between the trailers. Hudgins turned the engine off and the men again attempted to get a response from Wells. By this time, company emergency medical technicians arrived and mobile maintenance supervisor, Mark Wellhousen, moved the truck ahead about 12 inches in order to release the victim. Wellhousen stated that he noticed the yellow park brake knob popped out after he pulled forward, which indicated the parking brakes were not set before he moved the truck.
Wells was airlifted to a local hospital where he died at 4:15 p.m.
An examination of the truck showed that the service and parking brake systems were functional. Apparently, Wells stopped the truck and applied the "hand valve" brake. The valve subsequently released, allowing the unit to roll backwards, crushing him between the two trailers.
Order No. 4564566 was issued on March 13, 1998, under provisions of Section 103k of the Mine Act prohibiting activity and work around the 1990 Ford LTS 9000 tractor and dual East-Pusher trailers. This order is issued to ensure the safety of persons at this operation until the mine or affected areas can be returned to normal mining operations as determined by an authorized representative of the Secretary.
This order was terminated on March 17, 1998 after it was determined that the mine could safely resume normal operation.
GTS Transport Co., Inc.
Citation No. 7822012 was issued on March 31, 1998, under the provisions of Section 104a of the Mine Act for violation of 30 CFR 56.14207:
A contract truck driver was fatally injured at this operation on March 13, 1998 when he was crushed between the front and rear trailers of his tractor-trailer rig. The victim had dumped the rear trailer and was disconnecting it in preparation to dump the lead trailer when the unit drifted down the grade and jackknifed. The parking brakes had not been set and the wheels were not chocked or turned into the embankment.This citation was terminated on April 8, 1998:
All drivers employed by the company were issued the new policy statement and were trained in the proper procedures of parking and dumping of materials. The braking systems of the trucks were reviewed. This training will be given to all new drivers and reviewed during safety meetings during the year.
Related Fatal Alert Bulletin: