DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
Metal and Nonmetal Mine Safety and Health
REPORT OF INVESTIGATION
Surface Metal Mine
Fatal Powered Haulage Accident
July 25, 1999
Empire Iron Mining Partnership
Palmer, Marquette County, Michigan
Russell T. Jarvi, Jr.
Supervisory Mine Safety and Health Inspector
Arthur J. Toscano
Mine Safety and Health Inspector
F. Terry Marshall
Mine Safety and Health Administration
North Central District
515 West First Street, Room 333
Duluth, MN 55802-1302
Felix A. Quintana, District Manager
On July 25, 1999, Gerald F. Gorman, plant repairman, age 61, was fatally injured while directing a summer employee who was operating a skid-steer loader. After instructing the employee, the victim walked away, then turned and walked back to the loader and was inadvertently caught by the right rear tire and run over.
The primary cause of the accident was that eye contact was not made between the victim and the skid-steer loader operator prior to the victim approaching the skid-steer loader.
Gorman had a total of 24 years mining experience, all at this mine, with 20 years as a plant repairman. He had received training in accordance with 30 CFR Part 48.
Empire Mine, a surface taconite operation, owned jointly by Inland Steel Company, J & L Empire, Inc., Wheeling-Pittsburgh/Cliffs Partnership, Cliffs Empire, Inc., Empire-Cliffs Partnership, was located at Palmer, Marquette County, Michigan. The day-to-day operation of this mine was directed and managed by Cleveland Cliffs Inc., Cleveland, Ohio. The principal operating official was Tom S. Peterson, general manager. The mine was normally operated three, 8-hour shifts a day, seven days a week. Total employment was 1,033 persons.
Taconite ore was drilled, blasted, loaded on haul trucks, and transported to the plant where it was crushed, milled, and pelletized. The finished product was sold for use in steel manufacturing.
The last regular inspection of this operation was completed on March 8, 1999. Another regular inspection was started August 18, 1999.
DESCRIPTION OF THE ACCIDENT
On the day of the accident, Gerald Gorman (victim) reported for work at 11:00 p.m., his normal starting time. At about 11:30 p.m., he and George Hardes, plant repairman, were assigned to install a water line to the feed chute of line No. 21 grinding mill. Gorman and Hardes went to the feed end of the mill and noticed a large amount of material spillage in the area where they had to set up a man-lift in order to install the section of pipe.
Gorman called Kenneth Roberts, shift maintenance supervisor, and requested a loader to clean the area. Richard Robinson, summer hire/loader operator, was assigned to assist with the clean up. Robinson found the skid-steer loader parked in the mill building and drove it to the No. 21 grinding mill where he was stopped by Gorman. Gorman spoke briefly to Robinson, explaining the needed clean-up. He turned to walk away from the loader, then he turned and walked back toward the loader which was already starting to move forward. Hardes momentarily lost sight of Gorman, who had stepped behind a column. He next saw Gorman being pulled down under the rear tire of the loader and yelled to Robinson to stop the machine.
Hardes then directed Aaron Kippola, summer hire/maintenance helper, to get help. The mine EMTs arrived in a few minutes and, with the aid of a forklift, removed the victim from under the tire of the skid-steer loader. Local emergency personnel arrived a short time later and Gorman was transported to a local hospital where he was pronounced dead.
INVESTIGATION OF THE ACCIDENT
At about 1:00 a.m. on July 25, 1999, Felix Quintana, district manager, North Central District, was notified of the accident by a telephone call from the office manager for the mining company. An investigation was begun on the same day and an order under the provisions of Section 103(k) was issued to ensure the safety of the miners until the affected area of the mine could be returned to normal operations. MSHA conducted an investigation with the assistance of mine management and representatives of miners from United Steelworkers of America, Locals 4950 and 4974.
The loader involved in the accident was a 1999 Case skid-steer, model 75 XT.
1) The loader was hydrostatically driven with hand steering control levers, powered by a 60 HP diesel engine. Power was supplied by two hydraulic drive motors, one for the right side wheels and one for the left side wheels. Each hydraulic drive motor used a chain final drive to transfer power to the wheels. Hydrostatic braking was controlled by the hand steering control lever positions. The operating load capacity of the machine was 2200 lb. It had logged approximately 195 hours on the engine hour meter.
2) The key switch was functional and was found in the >off= position. The operator stated that he used this key switch to turn the machine off immediately after the accident.
3) The engine throttle hand lever was found against the stop, in the full throttle position. The engine throttle assembly that controls engine speed allows the operator initially to set the throttle with the hand lever and control the engine speed by depressing a foot pedal, as needed. With the spring loaded foot pedal released, throttle control reverts to the hand lever position. These two throttle controls operated smoothly throughout their ranges. The hand lever remained in any position that it was placed during operation and throttle control reverted to hand lever control once the foot pedal was released.
4) The parking brake was functional and was activated by the parking brake switch, the seat bar switch, and the operator presence switch.
5) The hydraulic circuit lockout for the loader controls was functional and was activated by the seat bar switch and the operator presence switch.
6) Dynamic tests conducted on the skid-steer loader indicated that hydrostatic braking was functional and that the machine responded to the hand steering control levers. The hand steering control levers moved to neutral when hand pressure was released from the controls from either the forward or reverse tram positions.
7) The operator stated that no alarm was sounded before the machine began moving. When tested, the horn sounded when the horn button was pushed. The button was on the right hand steering control lever.
8) The backup alarm was functional and operated when either of the hand steering control levers was moved to a reverse tram position. The response of the machine to the hand steering control levers was such that machine movement occurred before activation of the backup alarm.
9) An amber strobe lamp was mounted on the right side of the upper engine access door located behind the operator's compartment. It was functional and was on whenever the key switch was in the >on= position. Due to the machine design and the amber strobe lamp placement, the lamp was only visible from the rear area of the machine. The lamp placement also allowed the light produced by this lamp to illuminate the operator=s compartment.
10) No mechanical defects were found with the Case 75 XT skid-steer loader that contributed to the accident.
11) The noise levels in the work area were high. Communications in the accident area during the investigation required very close proximity between parties to communicate effectively.
12) According to the witnesses, the victim explained the cleanup needed for the maintenance crew to set up the man-lift. The victim turned to walk away then turned and walked back between a column and the loader. The witnesses lost visual site of the victim for about 4 to 5 seconds and, when visual contact was again made, the victim was being pulled down under the rear tire of the loader.
13) The operator stated that the victim approached the right side of the machine and stood between the front and rear tires to communicate cleanup instructions to him, then turned and walked out of his line of sight, toward the rear of the loader.
14) The victim was wearing a dark hardhat, a dark T-shirt, and dark pants.
15) General area lighting was provided in the accident area and illumination was adequate.
16) Two switches controlling the mobile equipment's drive lights were found in the >on= position. One switch controlled the two front drive lights while the other switch controlled a single rear drive light. These drive lights provided front and rear illumination but did not provide additional area illumination to either side of the machine next to the operator=s seating area.
17) The machine had Falling Object Protective Structures installed on both sides of the Roll Over Protective Structure of the operator's compartment.
18) The bucket of the machine was in the carry position when the accident occurred. This means that the lift arm assembly did not create additional blind areas for the operator to the sides of the machine. The bucket was about 2 to b full of various sized rock.
19) A portable two-way radio was found on the right side of the operator=s seat but none was known to be available to the victim at the time of the accident.
20) All four tires were solid rubber Case TY 31x10-20. They all were measured to have a tread edge radius of 15 inches and a tread width of 10 inches.
21) The ground clearance to the bottom of the belly pan at the midpoint between the right side tires was approximately 83 inches.
22) Product literature estimates the machine's empty weight to be 4,850 pounds.
The primary cause of the accident was that eye contact was not made between the victim and the skid-steer loader operator prior to the victim approaching the loader.
Order No. 7807403 was issued on July 25, 1999, under the provisions of Section 103(k) of the Mine Act:
A fatal accident occurred near No. 21 primary mill (concentrator building) when a plant repairman was struck by a rubber-tired front-end loader which was performing clean-up in the area. This order is issued to assure the safety of persons in the affected area until it can be returned to normal mining operations as determined by an authorized representative of the Secretary. The mine operator shall obtain approval from an authorized representative for all actions to recover equipment and/or restore operations in the affected area.This order was terminated on July 26, 1999. Conditions that contributed to the accident have been corrected and normal mining operations can resume.
Related Fatal Alert Bulletin:
Persons Participating in the Investigation
Empire Iron Mining Partnership
John Correll, Cleveland Cliffs Inc. director of safetyUnited Steelworkers of America, Local 4950 and 4974
William Hansard, safety coordinator
Stephen Roberts, safety coordinator
James Pafford, area manager, safety and environmental
Paul Korpi, senior area manager
Robert Veale, area manager, maintenance
Edward O'Brien, safety chairmanMine Safety and Health Administration
W. Brad Waters, safety chairman, concentrator
Tommy Spencer, safety co-chairman
Russell Jarvi, Jr., supervisory mine safety and health inspectorAPPENDIX B
Arthur Toscano, mine safety and health inspector
F. Terry Marshall, mechanical engineer
Stephen Field, mine safety and health inspector
Richard Robinson, loader operator (summer hire)
George Hardes, plant repairman
Kenneth Roberts, shift supervisor, maintenance
Aaron Kippola, maintenance helper (summer hire)
Beth Lehto, medical first responder (quality lab-tech)
Greg Hoiem, EMT (plant operator)
Jon Jarvainen, fill-in foreman