MINE SAFETY AND HEALTH ADMINISTRATION
SOUTH CENTRAL DISTRICT
Metal and Nonmetal Mine Safety and Health
Accident Investigation Report
Surface Nonmetal Mine
Fatal Machinery Accident
Holt Company of Texas
I.D. No. CX2
Reynolds Metals Company
Gregory, San Patricio, Texas
I.D. No. 41-00906
August 1, 1998
Michael A Davis
Supervisory Mine Safety and Health
Mine Safety and Health Inspector
Mine Safety and Health Administration
South Central District
1100 Commerce Street, Room 4C50
Dallas Texas 75242-0119
Doyle D. Fink
Benny L. Duncan, field service technician, age 61, was fatally injured at about 9:50 a.m. on August 1, 1998, when he was crushed between the bucket lift arms and the frame of a front-end loader while making hydraulic system repairs. Duncan had a total of 31 years experience as a heavy equipment mechanic, 14 years with this employer. He had not received training in accordance with 30 CFR, Part 48.
MSHA was notified at 10:40 a.m. on the day of the accident by a telephone call from the safety director for the mining company. An investigation was started the same day.
The Sherwin Plant, an alumina milling facility, owned and operated by Reynolds Metals Company, was located at Gregory, San Patricio county, Texas. The principal operating official was Frank Newchurch, plant manager. The mill was normally operated three, 8-hour shifts a day, seven days a week. A total of 830 persons was employed.
Bauxite ore was shipped from sources in foreign countries, and upgraded, using the Bayer Process, into calcined alumina oxide. The finished product was used to produce aluminum metal.
The victim was employed by Holt Company of Texas, an independent contractor in Corpus Christi, Nueces county, Texas. The contractor was enlisted by Reynolds Metals to service and repair heavy equipment at the plant. The principal operating official was Allan Archer, vice president and general manager.
The last regular inspection of this operation was conducted June 4, 1998. Another inspection was conducted following this investigation.
PHYSICAL FACTORS INVOLVED
The front-end loader involved in this accident was a diesel-powered, 1994, Caterpillar 990 series II wheel loader, equipped with a 14-cubic-yard bucket. The hydraulic systems consisted of two separate circuits, one for tilt, lift and brakes; the other for steering and the engine cooling fan. The systems functioned independently.
The bucket lifting mechanism consisted of two hydraulic cylinders and two lifting arms. The lifting arms were approximately four feet apart and connected with a cross brace. The bucket tilt mechanism consisted of a hydraulic cylinder and a Z-Bar linkage. The main valve bank assembly for the bucket tilt and lifting arms was located on the center front of the loader, below the lift arm pivots. The lifting arms needed to be raised to gain access to the valve assembly, which was about seven feet above ground level.
DESCRIPTION OF ACCIDENT
On the day of the accident, Benny Duncan, (victim) arrived at the Defense Logistics Agency area (DLA) of the sherwin plant at 7:00 a.m., after receiving a call from his dispatcher informing him the 990 front-end loader had developed a problem in the hydraulic system. At about 8:00 a.m., Duncan asked Marcus Smith, loader operator, to position the loader with the bucket rolled so that the cutting edge was straight down and resting on the ground. By doing so, the bucket lift arms were held in position by the static pressure inside the lift cylinder. Smith then set the parking brake, exited the loader and left the area.
Duncan used a six-foot ladder to reach the hydraulic valve bank located on the machine between the lift arms. After removing the cover panel he began removing the six hydraulic lines attached to the valve preparatory to removing the assembly. In removing the lines, the hydraulic pressure to the lifting assembly was released, causing the bucket to tilt backward and the lift arms to fall. Duncan was crushed between the lifting arms and the loader frame.
Robert Hadley, another Holt employee, was repairing the loader's air conditioning system a job he had started the previous day. At about 9:50 a.m., Hadley heard the sound of hydraulic pressure escaping and then heard Duncan cry out. He ran to the front of the loader and found Duncan pinned by the lift arms. He quickly started the loader but was not able to raise the bucket, probably because some of the hydraulic lines had been loosened or removed. He then ran to his truck and called the local emergency number, 911. A few moments later, He saw Smith on the haul road and yelled for help. Smith, in turn, called for the Reynold's emergency response team and several persons arrived momentarily.
Rescuers first attempted to raise the bucket with another front-end loader, but were unable to do so for fear of further injuring the victim. They were able to free him by using a crane in conjunction with another loader. Duncan was transported to a hospital in Corpus Christi where he was pronounced dead.
The direct cause of the accident was failure to block or secure the bucket to prevent accidental lowering before working on the hydraulic system. Failure to provide training and retraining for the victim might have been a contributing factor.
Order number 4713604 was issued to Reynolds Metals Company on August 1, 1998, under the provisions of Section 103 (k) of the Mine Act:
A mechanic was fatally injured when the elevated bucket arm of a Front-end loader fell and crushed him against the frame of the loader. This order is issued to assure the safety of persons at this operation until the loader can be returned to normal operation as determined by an authorized representative of the Secretary. The operator shall obtain approval from an authorized representative fro all actions to recover persons, equipment, and/or resume operation/or repair of the affected loader.
This order was terminated on August 5, 1998, when it was determined that it was safe to resume repairs to the loader.
Citation number 7852384 was issued to Holt Company of Texas on September 1, 1998, under the provisions of Section 104 (d)(1) of the Mine Act for violation of 30 CFR Part 56.14211 (c):
A fatal accident occurred at this operation on August 1, 1998, at about 9:50 a.m., when a mechanic was crushed between the bucket assembly and the frame of the loader. The bucket lift arms had not been blocked or supported to prevent accidental lowering of the component. The employer received supplemental information from the manufacturer that detailed safe work procedures which included the necessity to block or support the bucket lift arms whenever these types of repairs are made. The employer, however, did not pass the information on to the field technicians. Management engaged in aggravated conduct constituting more than ordinary negligence in that they had received information on safe work procedures that could have prevented this accident and did not distribute the information to the persons responsible for carrying out the tasks. This violation is an unwarrantable failure to comply with a mandatory standard.
Citation Number 7852383 was issued to Reynolds Metals Company on September 1, 1998, under the provisions of Section 104 (a) of the Mine Act for violation of 30 CFR Part 48.26:
A fatal accident occurred at this operation on August 1, 1998, at about 9:50 a.m., when a mechanic was crushed between the bucket assembly and the frame of the loader. The employee had not received comprehensive training in accordance with 30 CFR Part 48.26. The Federal Mine Safety and Health Act of 1977 declares an untrained miner is a hazard to himself and others. The mine operator was aware of these training requirements and their responsibilities regarding independent contractors.
The citation was terminated on September 3, 1998, after the company submitted a plan to MSHA identifying their list of contractors which included certification of training received.
Citation Number 7852385 was issued to Holt company of Texas on September 1, 1998, under the provisions of Section 104 (a) of the Mine Act for violation of 30 CFR Part 48.23:
A fatal accident occurred at this operation on August 1, 1998, at about 9:50 a.m., when a mechanic was crushed between the bucket assembly and the frame of a front-end loader. The contractor failed to submit a training plan in accordance with 30 CFR Part 48.23. The contractor was aware of these training requirements.
Citation Number 7852386 was issued to Holt Company of Texas on September 1, 1998, under the provisions of Section 104 (a) of the Mine Act for violation of 30 CFR Part 48.26:
A fatal accident occurred at this operation on August 1, 1998, at about 9:50 a.m., when a mechanic was crushed between the bucket assembly and the frame of a front-end loader. The employee had not received comprehensive training in accordance with 30 CFR Part 48.26. The Federal Mine Safety and Health Act of 1977 declares an untrained miner a hazard to himself and others. The contractor was aware of these training requirements.
Related Fatal Alert Bulletin: