MINE SAFETY AND HEALTH ADMINISTRATION
ROCKY MOUNTAIN DISTRICT
Metal and Nonmetal Mine Safety and Health
Accident Investigation Report
Surface Nonmetal Mine
(Limestone)
Fatal Machinery Accident
Midwest Minerals, Incorporated
Portable Plant No. 2
Chetopa, Labette County, Kansas
I.D. No. 14-01463
Date of Injury: June 22, 1998
Date of Death: July 20, 1998
By
Wayne J. Wasson
Supervisory Mine Safety and Health Inspector
David R. Moehle
Mine Safety and Health Inspector
Originating Office
Rocky Mountain District
P.O. Box 25367, DFC
Denver, CO 80225-0367
Robert M. Friend
District Manager
William F. Feathers, plant superintendent, age 67, was severely injured at about 2:25 p.m. on June 22, 1998, when he started the pony motor (starting engine) on a bulldozer and engaged the main engine with the transmission in reverse gear crushing him between the moving track and the frame of the dozer. He died on July 20, 1998, while undergoing treatment. Feathers had a total of 26 years mining experience, all as a supervisor, three of which were with this company at this mine. He had received training in accordance with 30 CFR Part 48.
MSHA was notified at 10:15 a.m. on the day following the accident by a telephone call from the corporate director of safety. An investigation was started the same day.
Portable Plant No. 2, a crushing plant, owned and operated by Midwest Minerals, Inc., was being operated at a company-owned limestone quarry, located approximately eight miles southwest of Chetopa, Labette County, Kansas. Principal operating officials were Richard Alkinson, president, and Steve Slaon, vice president. The plant was normally operated one, 10-hour shift a day, 5 days a week. A total of 11 persons was employed.
Limestone was blasted from a single bench in the quarry and transported to the plant by front-end loader. The material was then crushed, screened, and stockpiled. The finished product was sold for road construction material.
The last regular inspection at this operation was completed April 28, 1998.
The equipment involved in the accident was a Caterpillar bulldozer, Model D-7B, manufactured in 1955. The dozer was equipped with a "pony" motor used to start the main diesel engine. The pony motor was started from either a kneeling position on the left track or by standing on the blade push arm and leaning over the track, or a variation of the two positions. After starting the pony motor, the clutch was engaged and the main engine could be started. Clearance between the track and frame (platform) was 4-1/2 to 4-3/4 inches.
Weather conditions at the time of the accident were clear, hot and dry.
On the day of the accident William Feathers (victim) reported for work at 7:00 a.m., his usual starting time. In the early afternoon, Feathers moved the dozer to a relatively level area near the chips stockpile to adjust the track tension. He was assisted by James Mayberry, water truck driver. His pickup truck was parked about 4 feet behind the dozer. The track adjustments werecompleted between 2:20 and 2:25 p.m., and Mayberry left to water the roads. Feathers climbed onto the left track of the dozer and started the pony motor, then engaged the clutch and started the main engine. He had previously backed the dozer into position and had left the transmission in reverse gear. When the main engine started, the dozer moved backward and Feathers was pulled between the track and the operator's platform, which extended over a portion of the track. The dozer backed into the pickup truck and he was thrown onto the hood, then fell clear. The dozer traveled backward for a distance of approximately 110 feet and stopped when it struck a gate post.
Floyd Ash, a customer, and Larry Allen, scale house operator, saw the dozer strike the pickup and realized that something must have happened to Feathers. Ash, an off-duty sheriff's deputy, was first to reach the victim. He started first-aid treatment and instructed Allen to call the local 911 emergency assistance number. Feathers was conscious and coherent. Reportedly he stated that, "Someone must have put it in reverse."
Local emergency medical personnel were summoned and Feathers was taken by helicopter to a hospital in Joplin, Missouri, where he was treated for a compound fracture to his right femur, a broken pelvis, and extensive abdominal injuries. Feathers succumbed to his injuries on July 20, 1998.
The direct cause of the accident was failure to ensure that the dozer's transmission was in neutral before starting the main engine and failure to follow the manufacturer's instructions for starting the engine.
Citation No. 7925923 was issued on June 26, 1998, under the provisions of Section 104 (a) of the Mine Act for violation of 30 CFR 50.10:
On June 22, 1998, at 1425 hours, a plant superintendent suffered serious multiple injuries which had the potential to cause death. The accident was not reported until June 23, 1998, at 1015 hours. The victim died on July 20, 1998, as a result of his injuries.
This citation was terminated on June 26, 1998, after the mine operator committed to compliance with the reporting requirements specified in 30 CFR Part 50.
Citation No. 7925924 was issued on June 26, 1998, under the provisions of Section 104(d)(1) of the Mine Act for violation of 30 CFR 56.9101:
The plant superintendent was seriously injured at this mine on June 22, 1998, and later died of his injuries on July 20, 1998, when he failed to maintain control of the Caterpillar D-7B dozer, in that he started the main diesel engine by engaging the pony (starting) motor with the transmission in reverse gear. The main engine started and the tractor moved backward. He was standing or kneeling on the track and was drawn between the track and the operator's platform/framework. The superintendent's actions constituted more than ordinary negligence and is an unwarrantable failure to comply with a mandatory safety standard.
This citation was terminated on August 6, 1998. The mine operator has developed a written procedure for safely starting the Caterpillar D-7B dozer. The procedure was posted and all the employees were trained.
Midwest Minerals, Inc.
Jerry Piatt ..... West Quarry Supervisor
James A. Mayberry ..... Mechanic
Larry Allen ..... Scale House Operator
Kenneth Ash ...... Acting Superintendent
Others
Floyd Ash ..... Customer
Mine Safety and Health Administration
Wayne J. Wasson ..... Supervisory Mine Safety and
Health Inspector
David R. Moehle ..... Mine Safety and Health Inspector
Related Fatal Alert Bulletin:
FAB98M29