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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
Sand and Gravel

Fatal Powered Haulage Accident

Cedar Lake Sand and Gravel Pit (I.D. No. 47-00792)
Cedar Lake Sand and Gravel Company, Incorporated
Hartford, Washington County, Wisconsin

August 6, 1999

by

Donald J. Foster
Supervisory Mine Safety and Health Inspector

James D. Strickler
Mine Safety and Health Inspector

Dennis L. Ferlich
Mechanical Engineer

Larry G. Wilson
Civil Engineer

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


OVERVIEW


On August 6, 1999, Ronald D. Ferguson, equipment operator, age 49, was fatally injured when the front-end loader that he was operating slid off an embankment and overturned. Ferguson was hauling discharged silt and sand from the wet plant and dumping it over the north edge of the impoundment roadway.

The accident occurred because the roadway and dumping facilities were constructed from discharged materials that did not support the loads to which they were subjected. Inadequate berm height at the dumping location, hydraulic system defects which affected the ability to control the loader when dumping and loading, and failure to visually inspect the dumping location prior to work commencing also contributed to the accident. Failure to wear a seat belt may have contributed to the severity of the accident.

Ferguson had a total of 11 years mining experience as an equipment operator, one year at this mine. He had received training in accordance with 30 CFR, Part 48.

GENERAL INFORMATION


The Cedar Lake Sand and Gravel Pit, a surface sand and gravel operation owned and operated by Cedar Lake Sand and Gravel Company Incorporated, was located at 5189 Aurora Road, Hartford, Washington County, Wisconsin. The principal operating official was Bruce Gilbert, owner and company president. The mine was normally operated two, 12-hour shifts a day, five days a week, and one, 8-hour shift on Saturdays. Total employment was 15 persons.

Sand and gravel was extracted from a single bench with front-end loaders. The material was transported by conveyor to the plant where it was screened, washed, and stockpiled. The finished product was sold for use in the construction industry.

The last regular inspection of this operation was completed on June 16, 1999. Another inspection was conducted at the conclusion of this investigation.

DESCRIPTION OF THE ACCIDENT


On the day of the accident, Ronald Ferguson (victim) reported for work at 12:00 p.m., his normal starting time. Clint Gerlach, day shift foreman, instructed Ferguson in his duties for the day. Ferguson loaded customer trucks at the stockpile area of the plant until about 3:00 p.m., when he was relieved by Lee Phillip, equipment operator. Ferguson then proceeded to the impoundment roadway to haul discharge material from the wet plant.

At about 6:15 p.m., Joe Strachan, lead man, was traveling to the impoundment area to assign Ferguson additional duties when he observed the front-end loader over the embankment. Strachan called for help on the CB radio and traveled to the accident site where he discovered the victim in the operator's cab, covered by mud and fine sand. Dan Feiter, equipment operator, responded to the accident and assisted Strachan in freeing Ferguson. Feiter felt for a pulse and could not detect one. They continued to remove material until emergency medical personnel arrived a short time later.

Ferguson was pronounced dead at the scene by the assistant county coroner. Death was attributed to mechanical asphyxia due to suffocation.

INVESTIGATION OF THE ACCIDENT


MSHA was notified at about 9:00 p.m. on the day of the accident by a phone call from Bruce Gilbert, president and owner of the company, to Felix Quintana, district manager of the North Central District. An investigation was started on August 7, 1999. Upon arrival at the mine, MSHA's accident investigation team issued an order under the provisions of Section 103(k) of the Federal Mine Safety and Health Act of 1977 to ensure the safety of the miners until the affected area and equipment could be returned to normal operations. The investigation was conducted with the assistance of the mine employees. Mine management declined to be interviewed during the investigation. Neither the mine employees nor the victim were represented by a union or miner's representative.

DISCUSSION


The accident occurred on a roadway located on top of an impoundment used to retain discharged silt and water from the wet plant. The roadway was about 740 feet in length and averaged 15 feet wide. The accident site was 430 feet east of the wet plant material discharge area. The width at the accident site had been reduced to 13 feet when the edge failed under the weight of the front-end loader.

> The roadway was bordered on the south edge by the silt and water filled pond. The pond was estimated to be at least 10 feet deep. The roadway was bordered on the north edge by an embankment. The height of the embankment was calculated to be about 18 feet high based on a slope distance of 27 feet from the edge of the roadway to the toe of the embankment. The downstream face of the embankment at the accident site was measured to be about 42 degrees from the horizontal.

> Access to the impoundment roadway was provided by a ramp on the far east end. The roadway was built from silty sand material that had been discharged from the wet plant, with little or no compaction effort other than normal vehicle traffic. The material was very fine grained and easily erodible. Several tension cracks, erosion gullies, and slides were observed on the crest and slope of the embankment.

A wet plant cyclone discharge pipe and a flocculation tank were located at the far west end of the roadway. Discharged material was removed from the impoundment by a cat mounted hoe and stored at the west end of the impoundment roadway. A front-end loader was used to haul and dump the discharged material over the embankment on the north edge of the roadway. Mine vehicles also traveled the roadway to check the discharged material levels and add flocculent to the tank.

> Interviews revealed that, due to the narrow width of the roadway at the dumping locations, the front-end loader would have to be fully articulated in order to get part of the material to flow over the embankment. The procedure placed the left front wheel near the edge of the embankment. After dumping several loads on the edge, the loader would push the remaining material over. On occasion, the edge of the roadway would start to slip and the front-end loader would have to be rapidly backed out to prevent it from going over. Tire tracks and stress cracks were observed in several locations along the north edge of the roadway. The embankment was constructed from the discharged material that was resting at the angle of repose. Severe slippage and erosion were present along the majority of the embankment face.

The dumping location being used at the time of the accident was not provided with an adequate berm or other similar device to impede over-travel or overturning. The berm to the immediate west of the dumping facility measured 18 inches high. The mid-axle height of the front-end loader was 33 inches. The dumping location was not visually inspected prior to using the dump facility.

> A sediment pond was located at the base of the downstream embankment. The pond was used to collect fine material that was dipped from the main pond and discharged material that was dumped over the embankment.

The mine was idled from July 21 to July 28, 1999 due to heavy rains that caused flooding in portions of the mine. The rain continued during the next week with reports of about 8 inches received throughout the two-week period. During this period, the sediment pond had failed about 100 feet below the accident site.

> The front-end loader slid sideways down the embankment for a distance of 18 feet and completed a 270-degree rotation before coming to rest in the sediment pond. The loader was laying on its right side with the bucket in the raised position and facing east. The rollover was evidenced by material lodged in the hand holds on the cab and the imprint of the top of the cab in the embankment.

Loose material from the embankment entered the cab of the front-end loader through the front and rear windows. Ferguson was completely engulfed by the material with the exception of his lower legs and one arm. He was found with his pelvis area lodged under the side of the seat. He was not wearing the provided seat belt.

> The front-end loader was a Caterpillar, Model 980B, serial number 89P5371, manufactured in 1976 and weighed about 51,800 pounds. The loader was equipped with a 5 cubic yard general purpose bucket capable of a load capacity of about 1,500 pounds.

The loader was 115 inches wide, measured from the outside wheel base, and had an overall length of 24 feet, 10 inches, including the bucket. The center axle height, with type 26.5-25/R25 tires installed, was 33 inches.

> The loader was powered by a Caterpillar, Model 3306, 6-cylinder, 4 cycle turbo-charged diesel engine, rated at 260 BHP at 2200 RPM. The transmission was a planetary power shift transmission with four forward and three reverse speeds. The loader was found in the forward, first gear position.

The steering was a center point frame articulated hydraulic system that operated when the engine was running. Tests conducted on August 13, 1999 revealed that the front-end loader had hydraulic system defects which affected the ability to control the loader when dumping or loading. With the engine operating at the idle speed setting of 530 RPM, which it was found, the engine stalled every time when the bucket was tilted back to the stops, or dumped to the stops. The loader also stalled each time the bucket lift arms were raised to the stops and when down pressure was applied to lower the bucket to the ground. The speed setting was increased to the manufacturer's recommended setting of 630 RPM and the tests were repeated with the same results. Interviews revealed that the loader had been stalling during normal operation, prior to the accident.

CONCLUSION


The primary cause of the accident was management's failure to design and construct the roadway and dumping facilities with materials capable of supporting the loads to which they were subjected. Failure to provide adequate berms, proper road and dumping width to accommodate the equipment using the facilities, and the proper maintenance of the front-end loader were contributing factors. Failure to wear a seat belt may have contributed to the severity of the accident.

ENFORCEMENT ACTIONS


Order No. 7832606 was issued on August 7, 1999, under the provisions of Section 103(k) of the Mine Act:
A fatal accident occurred at this operation on August 6, 1999, when a front-end loader slid off the edge of a roadway and overturned. This order is issued to assure 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. The mine operator shall obtain approval from an authorized representative for all actions to recover equipment and/or return affected areas of the mine to normal.
Citation No. 7832607 was issued on September 11, 1999, under the provisions of Section 104(d)(1) of the Mine Act for a violation of 30 CFR Part 56.9303:
A fatal accident occurred at this operation on August 6, 1999, when a front-end loader slid off an embankment and overturned. The roadway and dumping facilities were constructed from discharged silt and sand material and did not support the loads to which they were subjected. The dumping location was not provided with adequate width and clearance to safely accommodate the equipment which was being used. The edge of the roadway collapsed under the weight of the machine when the front-end loader crowded the edge at full articulation. The mine operator's failure to provide adequate dumping facilities 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. 7832608 was issued on September 11, 1999, under the provisions of Section 104(d)(1) of the Mine Act for a violation of 30 CFR Part 56.9304(a):
A fatal accident occurred at this operation on August 6, 1999, when a front-end loader slid off an embankment and overturned. The dumping location was not visually inspected prior to work commencing. The affected area had been subjected to heavy rains prior to the accident. Mine management was aware of the recent heavy rain yet failed to conduct an inspection prior to using the dumping facility. The mine operator's failure to visually inspect the dumping facility 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. 7832609 was issued on September 11, 1999, under the provisions of Section 104(d)(1) of the Mine Act for a violation of 30 CFR Part 56.9301:
A fatal accident occurred at this operation on August 6, 1999, when a front-end loader slid off an embankment and overturned. The dumping location was not provided with an adequate berm, bumper block, or similar device to impede over-travel or overturning. The mine operator's failure to provide adequate berms or impeding devices at dumping locations 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. 7832610 was issued on September 11, 1999, under the provisions of Section 104(d)(1) of the Mine Act for a violation of 30 CFR Part 56.14130(g):
A fatal accident occurred at this operation on August 6, 1999, when a front-end loader slid off an embankment and overturned. A seat belt was not being worn at the time of the accident. The mine operator did not enforce seat belt usage at this operation. The mine operator's failure to enforce seat belt usage 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. 7832611 was issued on September 11, 1999, under the provisions of Section 104(d)(1) of the Mine Act for a violation of 30 CFR Part 56.14100(c):
A fatal accident occurred at this operation on August 6, 1999, when a front-end loader slid off an embankment and overturned. The front-end loader had hydraulic system defects which affected the ability to control the loader when dumping and loading. The mine operator's failure to remove the loader from service 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 FAB99M30

APPENDIX A

Persons Participating in the Investigation

Cedar Lake Sand and Gravel Company Incorporated

Bruce Gilbert, president
Eric Gilbert, vice president
Associated Builders and Contractors of Wisconsin, Inc. (Representing Cedar Lake)
Donald Moen, safety director
State of Wisconsin, Department of Commerce, Division of Safety and Buildings
Patrick Murphy, mine safety specialist
Washington County Sheriff's Department
Robert Konstanz, detective
Mine Safety and Health Administration
Donald Foster, supervisory mine safety and health inspector
James Strickler, mine safety and health inspector
Thomas Pavlat, mine safety and health specialist
Dennis Ferlich, mechanical engineer
Larry Wilson, civil engineer


APPENDIX B

Persons Interviewed

Cedar Lake Sand and Gravel Company Incorporated
Trevor Alsberg, plant operator
David Stange, mechanic/equipment operator
Lee Phillip, equipment operator
Daniel Feiter, equipment operator
Joseph Strachan, lead man
Anthony Wagner, crushing plant operator