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UNITED STATES DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION

NORTH CENTRAL DISTRICT
Metal and Nonmetal Mine Safety and Health

Surface Nonmetal Mine
(Limestone)

Fatal Machinery Accident

L M S Contracting, Incorporated, I.D. No. ZIQ
Madison, Jefferson County, Indiana
at
Napoleon Quarry, I.D. No. 12-00089
New Point Stone Company, Incorporated
Napoleon, Ripley County, Indiana

July 9, 1999

by

Steven M. Richetta
Supervisory Mine Safety and Health Inspector

Stephen E. Alberti
Mine Safety and Health Inspector

Eugene D. Hennen
Mechanical Engineer

Robert A. Barrish
Civil Engineer

Originating Office
Mine Safety and Health Administration
North Central District
515 West First Street, #333; Duluth, MN 55802-1302
Felix A. Quintana, District Manager

OVERVIEW


On July 9, 1999, Christopher M. Jensen, contractor truck driver, age 29, was fatally injured when the road grader he was driving overturned. He had gone to the mine to load a haulage truck and transport it to a stripping job at a different quarry. After loading the haulage truck on a low boy, he was driving the contractor's road grader from the stripping area to where his tractor trailer was parked. He was nearly to the top of a hill, when the grader's engine stalled. As it rolled backwards, the left wheels went over the berm, causing the grader to overturn, crushing its cab.

The accident occurred as a result of the service brakes not being capable of stopping and holding the grader on the inclined roadway. The inadequate berm height also contributed to the accident.

Jensen had a total of two years experience as a truck driver/equipment mover with this contractor. He had not received training in accordance with 30 CFR, Part 48.

GENERAL INFORMATION


The Napoleon Quarry, a surface crushed limestone operation, owned and operated by New Point Stone Company Incorporated, was located along Highway 229 E, within the city limits of Napoleon, Ripley County, Indiana. The principal operating official was Steven L. Wanstrath, vice president. The quarry was normally operated one, 9-hour shift a day, five days a week. Total employment was 13 persons.

Limestone was mined after the overburden, consisting of dirt and clay, was removed. The limestone was drilled and blasted, sized, and sold for construction and agricultural use.

The mine operator had contracted LMS Contracting, Inc. of Madison, Indiana to remove and stockpile the overburden. The principal operating officials for the contractor were Larry D. Spann, president, and Anthony L. Hammock, operations manager. The contractor's equipment used at this job included a hydraulic excavator, a bulldozer, three articulated haul trucks, a water truck, and a road grader. The stripping crew at this mine totaled six persons. The person in charge at the site for the contractor during stripping was Michael R. Durocher, foreman. This stripping job had taken about two weeks and had been completed on July 8, 1999, the day before the accident.

The last regular inspection of this operation was completed June 9, 1999. Another inspection was conducted at the conclusion of this investigation.

DESCRIPTION OF ACCIDENT


On the day of the accident, Christopher Jensen (victim) reported for work at the contractor's shop in Madison, Indiana at 7:00 a.m., his normal starting time. He, along with Roy L. Poindexter, truck driver, and Michael L Schirmer, truck driver, were assigned to move equipment from Napoleon Quarry. Jensen left the shop about 8:15 a.m. and went directly to the mine.

Jensen arrived at Napoleon Quarry about 9:00 a.m. and proceeded to load an articulated haul truck onto a low boy. He then drove a bulldozer from the staging area near the mine shop to the stripping bench. At about 10:00 a.m., Jensen began driving the road grader from the stripping bench towards the mine shop staging area.

Schirmer had arrived at the mine at about 9:30 a.m., parked near Jensen's loaded tractor trailer, and waited for Jensen to get directions to the stripping area. After waiting several minutes, he went to the mine office and inquired about Jensen. He was told Jensen was seen driving the bulldozer towards the stripping area. After getting directions from the office personnel, Schirmer drove to the stripping area by way of the main haul road. He found the bulldozer parked, engine idling, but could not find Jensen. He made several trips with his tractor trailer between the stripping area and staging area at the mine shop but could not find him.

At about 11:00 a.m., Poindexter and John Perry, flag vehicle driver, arrived at the mine. They went to the stripping bench and helped Schirmer load the fuel tank on his truck. At about 12:00 p.m., Perry drove the bulldozer back to the staging area using the east shop service road and Poindexter followed in the flag vehicle. As they ascended the hill near the shop, Poindexter saw the road grader resting on its top in the weeds off the roadway. On closer observation, he saw that Jensen was in the collapsed cab of the grader. He rushed to the shop and summoned help.

Local emergency personnel were summoned and arrived a short time later. Jensen was pronounced dead at the scene due to massive internal injuries.

INVESTIGATION OF THE ACCIDENT


At about 2:00 p.m. on July 9, 1999, Steven M. Richetta, supervisory mine safety and health inspector of MSHA's Vincennes, Indiana field office, was notified of the accident by a telephone call from Kenneth T. Wanstrath, president of the mining company. An investigation was begun on the same day and a 103(K) order was issued. MSHA conducted its investigation with the assistance of contractor management, contractor employees, mine management and mine employees. Neither the mine employees nor the victim were represented by a union or miners' representative.

DISCUSSION


1. The accident occurred on the east access road to the shop, at an area where the roadway was inclined about 27 percent. This section of the roadway was near the top of the hill, curved to the right about 110 degrees, and was about 16 feet wide.

2. The height of the berm along the roadway ranged from near zero inches at the top to about 36 inches at the bottom. The berm area where the left rear grader wheel struck was about 12 inches high for a distance of about 2 feet due to slabs of flat rock lying in front of the stone berm. The left front grader wheel followed an area that had very little restriction due to an opening about 2 feet long between two sections of the berm.

3. The road grader was a Caterpillar, Model 12F, serial number 13K1128, manufactured in 1968 and weighed about 26,500 lbs.

4. The grader was powered by a Caterpillar Model D333 diesel engine. Tests conducted on the engine after the accident indicated that the engine was not running when the grader rolled over. The fuel tank was about two-thirds full.

5. The grader was not equipped with ROPS (Roll Over Protective Structure) and the canopy was crushed into the operator's compartment. The victim was not wearing the provided seat belt.

6. The grader had six wheels, with wheel diameters of 52 inches. The two steering wheels in the front were not equipped with service brakes by the manufacturer. A drum brake (two shoes in each drum brake) on each of the four drive wheels in the rear provided the service braking. Each drum brake had two wheel cylinders, one on the top and another on the bottom. The foot pedal activated the service brakes through a single master cylinder. The master cylinder had a hydraulic assist to improve brake performance which operated when the engine was running. A single brake line ran from the master cylinder through three tees to the drum brakes. The first tee split the flow to the left and right sides of the grader. The other two tees were used to split the flow to the front and rear drum brakes.

7. No brake lines were connected to the service brakes on the front drive wheels. This reduced the maximum service brake capability by 50 percent. On the right side, most of the brake line was missing. This line had been folded over and crimped in front of the splitter tee between the front and rear drive wheels prior to the accident. On the left side, the brake line was broken off at the top brake cylinder on the front drive wheel. This condition existed prior to the accident. The investigation revealed that a roofing nail had been placed in the end of this brake line where it was connected to the left splitter tee. This nail prevented the brake fluid from leaking out of the broken line.

8. During interviews, it was learned that for some time before the accident, the service brakes had to be pumped to achieve any braking. This condition was likely due to air in the brake system and a faulty brake shoe on the right rear drive wheel, which was discovered during the investigation.

9. A pull test conducted during the investigation indicated that the service brakes on the grader would not have held on the grade where the accident occurred, with or without the engine running. The tests indicated the braking system would have been considerably weaker with a stalled engine.

10. The parking brake drum had been covered with oil due to a leaky seal and test results indicated it would not have held on the grade where the accident occurred.

11. The grader was equipped with a wheel lean to aid in turning sharp corners. The investigation indicated the front wheels were nearly vertical but were slightly leaning to the left, opposite from the position that would have assisted a right turn.

12. The grader had a standard transmission with a high and low range. Both ranges had three forward speeds and two reverse speeds. The position of the transmission controls at the time of the accident could not be determined because the positions may have been moved during the recovery of the victim. The grader was not equipped with a synchronized transmission and it would have been difficult to shift gears unless the gear selected, forward speed, and engine rpms were compatible.

13. The contractor did not assure that mobile equipment operators perform safety checks of the equipment they operated before placing that equipment in operation. Rather, the foreman for the stripping crew inspected the equipment for the operators each day. On the day of the accident, the foreman was not present at the mine.

14. The weather on the day of accident was warm and the area dry.

CONCLUSION


The accident was caused by the failure to maintain the service brake system to be capable of stopping and holding the grader on the grade being traveled. The inadequate berm also contributed to the accident. The failure of the contractor's management to initiate action to correct the defective brakes was the root cause of the accident.

ENFORCEMENT ACTIONS


New Point Stone Company, Incorporated

Order No. 4614441 was issued on July 9, 1999, under the provisions of Section 103(k) of the Mine Act:
A fatal accident occurred at this operation on July 9, 1999, when a contract worker was involved in a rollover accident with a grader he was operating. This order is issued to assure the safety of the persons at this operation until MSHA has determined it is safe to resume normal operations with the grader.
This order was terminated on July 16, 1999. Conditions that contributed to the accident no longer exist, the grader has been removed from the mine.

Citation No. 7827601 was issued on August 24, 1999, under the provisions of Section 104(a) of the Mine Act for violation of 30 CFR Part 56.9300(b):
On July 9, 1999, a contractor employee was fatally injured when the road grader he was driving on the east shop access road rolled over after overtraveling the roadway. The berm was inadequate in that area in that the berm was only about 12 inches high for a distance of about 2 feet where the rear wheels traveled and nearly non-existent for a distance of about 2 feet where the front wheels followed as the grader traveled backwards off the roadway. This area of inadequate berm was not easily detected due to weeds.


L M S Contracting, Incorporated

Order No. 4614443 was issued on July 9, 1999, under the provisions of Section 103(k) of the Mine Act:
A fatal accident occurred at this quarry on July 9, 1999, when a contract worker was involved in a rollover accident with a grader he was operating. This order is issued to assure the safety of the persons at this operation until MSHA has determined it is safe to resume normal operations with the grader.
This order was terminated on July 16, 1999. Conditions that contributed to the accident no longer exist, the grader has been removed from the mine.

Citation No. 7827603 was issued on August 24, 1999, under the provisions of Section 104(d)(1) of the Mine Act for violation of 30 CFR Part 56.14101(a)(1):
On July 9, 1999, a contractor employee was fatally injured when the road grader he was driving on the east shop access road rolled over after overtraveling the roadway. The grader operator lost control of the grader as he was ascending the hill near the shop. He was unable to stop and hold the grader on the hill and it rolled backwards, left the roadway, and rolled over, crushing him. Tests later conducted on the service braking system indicated that the brakes were defective. Two of the four wheel brakes had been disconnected and the remaining two brakes were not adequate to hold the grader on the grade being traveled. Failure to equip the grader with service brakes capable of stopping and holding it is a serious lack of reasonable care which constitutes more than ordinary negligence and is an unwarrantable failure to comply with a mandatory standard.
Order No. 7827605 was issued on August 24, 1999, under the provisions of Section 104(d)(1) of the Mine Act for violation of 30 CFR Part 56.14100(c):
On July 9, 1999, a contractor employee was fatally injured when the road grader he was driving on the east shop access road rolled over after overtraveling the roadway. The grader operator lost control of the grader as he was ascending the hill near the shop. He was unable to stop and hold the grader on the hill and it rolled backwards, left the roadway, and rolled over, crushing him. Defects on the service brake system were known to exist by the foreman/mechanic during the previous work week and the road grader was not taken out of service and placed in a designated out-of-service area or tagged to prevent its use until those defects were corrected. This is an unwarrantable failure to comply with a mandatory standard.
Citation No. 7827607 was issued on August 24, 1999, under the provisions of Section 104(a) of the Mine Act for violation of 30 CFR Part 56.14101(a)(2):
On July 9, 1999, a contractor employee was fatally injured when the road grader he was driving on the east shop access road rolled over after overtraveling the roadway. The grader operator lost control of the grader as he was ascending the hill near the shop. He was unable to stop and hold the grader on the hill and it rolled backwards, left the roadway, and rolled over, crushing him. When later examined, the parking brake drum and shoes were found to be covered with grease or oil. When performance tested, the parking brake did not perform at the level that would have been required to hold the road grader on the grade that existed at the accident scene.
Order No. 7827608 was issued on August 24, 1999, under the provisions of Section 104(d)(1) of the Mine Act for violation of 30 CFR Part 56.14100(a):
On July 9, 1999, a contractor employee was fatally injured when the road grader he was driving on the east shop access road rolled over after overtraveling the roadway. The grader operator lost control of the grader as he was ascending the hill near the shop. He was unable to stop and hold the grader on the hill and it rolled backwards, left the roadway, and rolled over, crushing him. Tests later conducted on the service and park brakes indicated both were defective. The contractor did not have a policy in place to require that mobile equipment was checked for safety defects by the person operating it before placing it in operation. A properly conducted pre-operational check would have revealed the braking defects. Failure to establish proper pre-operational checking of mobile equipment is a serious lack of reasonable care which constitutes more than ordinary negligence and is an unwarrantable failure to comply with a mandatory standard.

Related Fatal Alert Bulletin:
Fatal Alert Bulletin Icon FAB99M24

APPENDIX A


Persons participating in the investigation:

New Point Stone Company, Incorporated

Steven L. Wanstrath, vice president
LMS Contracting, Incorporated
Larry D. Spann, president
Anthony L. Hammock, operations manager
Daniel H. Hobbs, safety director
Michael R. Durocher, foreman/mechanic/operator
Eric R. Smith, mechanic
Mine Safety and Health Administration
Steven M. Richetta, supervisory mine safety and health inspector
Stephen E. Alberti, mine safety and health inspector
Eugene D. Hennen, mechanical engineer
Robert A. Barrish, civil engineer
APPENDIX B

Persons Interviewed

New Point Stone Company, Incorporated
Steven L. Wanstrath, vice president
Donald L Weberling, loader operator
Dale W. Starke, mechanic
LMS Contracting, Incorporated
Larry D. Spann, president
Anthony L. Hammock, operations manager
Michael R. Durocher, foreman/mechanic/operator
Roy L. Poindexter, truck driver
Michael L. Schirmer, truck driver
Darren Gunter Excavating
Darren L. Gunter, owner