MINE SAFETY AND HEALTH ADMINISTRATION
Metal and Nonmetal Mine Safety and Health
REPORT OF INVESTIGATION
Underground Metal Mine
Fatal Hoisting Accident
October 18, 1999
West Fork Mine/Mill
The Doe Run Company
Bunker, Reynolds, Missouri
I.D. No. 23-00457
Michael A. Davis
Supervisory Mine Safety and Health Inspector
Robert D. Seelke
Mine Safety and Health Inspector
Vernon E. Miller
Mine Safety and Health Inspector
Thomas D. Barkand
Mine Safety and Health Administration
South Central District Office
1100 Commerce Street, Room 4C50
Dallas, Texas 75242-0499
Doyle D. Fink
On October 18, 1999, at about 9:30 a.m., James W. Vest, shaft maintenance repairman, age 48, was fatally injured while performing a routine shaft inspection. Vest and a co-worker had accessed the work deck on top of the production skip while it was positioned at the shaft collar. Vest radioed the hoistman to raise them and as the skip moved upward Vest=s lanyard, which hung in a loop from his safety belt, caught on a guide rail splice bolt, jerking him down and into the work deck handrail and the guide roller guard.
The accident occurred because the repairman did not secure his safety lanyard prior to signaling the hoistman to move the skip.
Vest had a total of 13 years and 9 months experience, all at this mine. He had held the job of shaft maintenance repairman for 2 years and 9 months. He had received training in accordance with 30 CFR Part 48.
West Fork Mine/Mill, an underground lead, zinc and copper operation, owned and operated by The Doe Run Company, was located on highway KK east of Bunker, Reynolds County, Missouri. In 1998, The Doe Run Company took over the operation from ASARCO Incorporated. The principal operating official was Guthrie L. Scaggs, production unit manager. The mine was normally operated two, ten-hour shifts per day, five days a week. Total employment was 101 employees.
The ore body was drilled, blasted, loaded onto haul trucks, and transported to the production shaft. The ore was hoisted by skip to the surface where it was crushed and conveyed to the mill. At the mill, lead, zinc and copper concentrates were separated by a floatation process. The finished products were sold for use in the manufacturing industry.
The last regular inspection of this operation was completed on March 8, 1999. Another regular inspection was conducted following this investigation.
DESCRIPTION OF THE ACCIDENT
On the day of the accident, James Vest (victim) reported for work at 6:30 a.m., one-half hour before his normal starting time. While waiting for his co-worker to arrive, Vest removed the safety catches disabling bolts on the production shaft skip. He then proceeded to the service hoist to start servicing and inspecting it.
At 7:00 a.m., Jerry Crocker, surface maintenance supervisor, held a safety meeting and immediately afterwards assigned Willard Cooper, maintenance repairman, to help Vest. At 7:15 a.m., Cooper joined Vest at the service hoist. They completed the activity by 9:00 a.m., and took a break.
Vest and Cooper positioned the production skip at the shaft collar so they could access the work deck on top of the skip. Cooper stood on top of the guide roller guard, adjacent to the hoist signal rope, and attached his lanyard to the hoist rope above the thimble attachment. Vest stood on the opposite side of the work deck from Cooper on the guide roller guard, but did not attach his lanyard. Vest=s lanyard was hanging outside of the work deck handrail in a loop, with both clips attached to the D ring of his safety belt.
Vest radioed Gary Huffman, hoistman, at approximately 9:30 a.m., to raise the skip so they could inspect the ore chutes in the head frame. The skip moved upward approximately one foot when Vest=s lanyard caught on a nut and bolt securing the guide rail splice bar(fishplate). The skip continued upward traveling approximately 2 feet, jerking the victim down into the work deck handrail and the guide roller guard.
Cooper turned and saw that Vest was injured and immediately belled the skip to a stop. He then belled the skip down so he could release Vest=s safety belt from around his waist. Cooper retrieved the radio from Vest=s jacket pocket and summoned help. Several employees responded and began to render aid to Vest. Emergency medical personnel were notified and arrived a short time later. Vest lost consciousness when he was placed on a backboard. While being lowered from the skip, they could not detect vital signs so CPR was started. He did not respond to the treatment and was pronounced dead at the scene. Death was attributed to crushing trauma to the pelvic region.
INVESTIGATION OF THE ACCIDENT
At about 11:25 a.m., on October 18, 1999, Robert Seelke, mine safety and health inspector, was notified of the accident by a telephone call from Arthur Albert, safety trainer, for The Doe Run Company. An investigation was begun the same day and an order was issued under the provisions of Section 103(k) of the Mine Act to ensure the safety of the miners until the affected areas of the mine could be returned to normal operations. MSHA conducted an investigation with the assistance of mine management and a company selected party of employees. The miners did not request, nor have, representation during the investigation.
The hoist involved in the accident was manufactured and installed in 1982 by Hepburn, J.T. Ltd., of Canada. The hoist was a model number PE-1. The double drum production hoist was equipped with pneumatically actuated drum brakes and was driven by a solid state controlled 800 HP dc motor. In the production mode, the hoist was typically operated automatically at a speed of 1,250 feet per minute. In the inspection mode, the hoist was operated manually between 50 and 100 feet per minute.
A thorough inspection of the production hoist=s electrical circuits and mechanical components revealed the hoist to be fully operational. Tests were performed on the limit switches, speed and over travel devices as well as the bell signal and all tested functional.
The 140 cubic feet skips were suspended in the 988 feet deep shaft by a 1 7/8 inch, 6X27,FC,FS,RLL wire rope manufactured by Wire Rope LTD. of Canada. The hoist rope for the east skip was installed on March 21, 1999.
The shaft inspection was performed from a work deck installed on the top of the skip. The work deck was provided with a top hand rail, mid rail and 4 inch high toe board around the perimeter of the work deck. The top hand rail was 40 inches above the deck floor and the midrail was 22 inches above the work deck floor. The top guide rollers projected above the work deck floor and were guarded by expanded metal enclosures 26.5 inches high by 12 inches deep by 30 inches wide. The work deck was protected by a 54x53 inch bonnet installed at a heigh of 93.5 inches above the deck floor.
The shaft opening was guarded with a handrail and provided with a gate for access onto the top of the skip. Additionally, the collar level access was restricted by a fence equipped with a gate.
The skip work deck was 47 inches above the collar. As stated by various witnesses, this was the exact position of the skip following the last bell signal to the hoistman at the time of the accident.
Communications during shaft inspection were maintained through bell signals and wireless radio. These were found to be fully operational. The hoistman=s visual observation of the skip was limited to the skip dump point in the head frame.
The last daily inspection of the hoist was completed on October 17, 1999. The last weekly exam was completed on October 11, 1999.
Assigned hoistman Gary Huffman had received a passing physical on September 10, 1999.
The accident occurred during the weekly hoist and shaft inspections that are typically performed on Monday mornings at this mine.
The safety belt was a Miller style 6679 serial number GO1473, manufactured in Franklin, PA. The lanyard was constructed from 3 inch vinyl coated wire rope with #USFC315590 clips. It measured 74 inches in length.
The primary cause of the accident was the failure to secure the safety lanyard to the center of the skip before signaling for the skip to be moved.
Order No. 7884521 was issued on October 18, 1999, under the provisions of Section 103(k) of the Mine Act:
A fatal accident occurred at this operation on 10/18/1999, when a shaft maintenance employee was conducting a shaft inspection of the production shaft. The lanyard the victim was wearing became entangled causing fatal injuries. This order is issued to assure the safety of persons at this operation until the mine or affected areas can be returned to normal operations as determined by an authorized representative of the Secretary. The mine operator shall obtain approval from an authorized representative of the Secretary for all actions to recover persons, equipment, and/or return affected areas of the mine to normal operation.This order was terminated on October 26, 1999. Conditions that contributed to the accident have been corrected and normal mining operations can resume.
Citation Number 7880464 was issued on January 24, 1999 under the provision of Section 104(a) of the Mine Act, for violation of 30 CFR Part 57.15005:
A shaft maintenance man was fatally injured at this operation on October 18, 1999, when his lanyard snagged a bolt on a shaft guide fish plate. The lanyard had not been attached to the hoist cable, instead it was left with both clips attached to the belts D-ring. Standing on the guard elevated the worker above the handrail, allowing a 32 inch loop to overhang the handrail and hook the bolt on the skips ascent.This citation was terminated on January 12, 2000 when a newly redesigned cage was installed. The work deck is now above the guide wheels and the attachment point for lanyards placed in the center of the canopy above the workers cage.
Citation Number 7880465 was issued on January 24, 1999 under the provision of Section 104(a) of the Mine Act, for violation of 30 CFR Part 50.10:
A shaft maintenance man was fatally injured at this operation on October 18, 1999, when his lanyard snagged a bolt head on a shaft guide fish plate. The accident occurred at approximately 9:30AM and was immediately recognized as life threatening. Mine Safety and Health was not notified until 11:25AM.This citation was terminated on January 24, 2000 when the operator posted the reporting requirements of 50.10 at the mine office.
For more information:
MSHA's Fatal Alert Bulletin
LIST OF PARTICIPANTS
THE DOE RUN COMPANY
Guthrie L. Scaggs, Jr. ........... production unit managerBUCHANAN INGERSOLL, PITTSBURGH, PA
Arthur A. Albert ........... safety trainer
Owen R. Erickson ........... safety specialist
G. Wesley Lloyd ........... maintenance coordinator
Jerry L. Crocker ........... surface maintenance supervisor
Willard R. Cooper ........... maintenance repairman
Gary G. Huffman ........... hoistman
Mark K. Laplant ........... 1st class mechanic
R. Henry Moore ........... attorneyMINE SAFETY AND HEALTH ADMINISTRATION
Michael A. Davis ........... supervisory mine inspectorSTATE OF MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
Vernon E. Miller ........... mine inspector
Robert D. Seelke ........... mine inspector
Thomas D. Barkand ........... electrical engineer
Ronald L. Palmer ........... mine and cave inspector