MINE SAFETY AND HEALTH ADMINISTRATION
Metal and Nonmetal Mine Safety and Health
REPORT OF INVESTIGATION
Surface Nonmetal Mine
Fatal Machinery Accident
December 8, 1999
Harper Greenmeadows Quarry
Florida Rock Industries, Inc.
Ft. Myers, Lee County, Florida
Mine I.D. 08-01276
Supervisory Mine Safety and Health Inspector
Bobby A. Underwood
Mine Safety and Health Inspector
Jose J. Figueroa
Mine Safety and Health Inspector
D. Michael Campbell
Originating Office - Mine Safety and Health Administration
135 Gemini Circle, Suite 212; Birmingham, AL 35209
Martin Rosta, District Manager
On December 8, 1999, M. L. Brumfield, dozer operator, age 57, drowned when he backed a Caterpillar dozer over the edge of a dragline workpad and landed in approximately 28 feet of water. Brumfield was using the dozer blade to back-drag the workpad to prepare the area for the dragline to be relocated.
The accident occurred because berms had not been provided. Brumfield had a total of 5-� years mining experience, all as a dozer and equipment operator with this company. He had received training in accordance with 30 CFR, Part 48.
The Harper Greenmeadows Quarry, a crushed limestone operation, owned and operated by Florida Rock Industries, Inc., was located 6 miles east of Interstate 75, along Alico Road, Ft. Myers, Lee County, Florida. The principal operating official was Curtis D. Zimmerman, plant manager. The mine was normally operated two, 14-hour shifts a day, 5-� to 6 days a week. Total employment was 77 persons.
After removing overburden, the area to be mined was normally below the water table. Broken limestone was placed on top of the mining site where it was leveled and compacted to form a working pad that was slightly above the water table. This working pad supported the draglines, drills, front-end loaders, haulage trucks, and other equipment.
Limestone was drilled and blasted, then excavated by dragline from under water and stockpiled for drying. The material was then loaded by front-end loader into haul trucks and transported to the milling area to be crushed, sized, screened, and stockpiled. The product was sold for use as construction aggregate.
The last regular inspection of this operation was completed July 29, 1999. A regular inspection was conducted following the investigation.
DESCRIPTION OF ACCIDENT
On the day of the accident M. L. Brumfield (victim) reported to work at 1:30 a.m., his regular starting time. He conducted a pre-shift inspection of the L320 Michigan front-end loader and at about 2:30 a.m., he started stockpiling material. This was his normal duty at the beginning of his shift. He continued to stockpile the material until approximately 5:20 a.m., when the day shift operator arrived and used the loader to load customer trucks.
Roy F. Hardy, pit supervisor, picked up Brumfield at about 5:20 a.m. and transported him in the company pick-up truck to work area No. 2. Hardy instructed Brumfield to operate the D8R Caterpillar dozer to push an opening through the berm to enable the drillers to place a water hose into the lake. Hardy also instructed Brumfield to finish leveling the dragline pad area to allow the 4600 Manitowac dragline to be moved so it could start excavating material in a different location.
Hardy then took Brumfield to area No. 6, approximately one mile away, to where the D8R Caterpillar Dozer had been parked the previous day.
After conducting a pre-shift inspection, Brumfield took the dozer to the No. 2 work area. He arrived there at about 6:00 a.m., just as the drilling crew arrived, and pushed through the berm to make an opening for the driller's to get the water hose into the pit to pump water to the drill.
The No. 2 work area was in the shape of a peninsula with an irregular shoreline on the eastern side. At about 6:30 a.m., Brumfield started back-dragging with the dozer to level the ground area. From the center of the peninsula, he backed the dozer north, parallel with the water's edge. He made several passes without incident. Material that had been removed previously by the dragline on the eastern edge of the peninsula left an inlet of approximately 10 feet from the edge of the peninsula to the center. This area was in line with the last pass made by Brumfield. As he backed the dozer, it continued over the edge of the inlet and into the water.
The drilling crew observed the dozer entering the water and immediately ran to the dragline positioned at the south end of the peninsula and notified Vernon L. Milan, dragline operator of the accident. Milan contacted Hardy by radio and told him that the dozer had gone into the lake and that they couldn't see it. Mike Brown, shop supervisor, was with Hardy when the message was received and he telephoned the local county rescue squad. Brown then contacted Paul Furbay, plant foreman, who was off-site, and notified him of the accident. Furbay notified the County Sheriff's Department Dive Team to request assistance.
The dive team arrived on site at about 7:45 a.m. and began recovery efforts. The dozer was submerged in approximately 28 feet of water, resting on the material slope. The dive team recovered the victim from the operator's cab of the dozer and he was pronounced dead at the scene by the local authorities.
INVESTIGATION OF THE ACCIDENT
At about 7:30 a.m. on December 8, 1999, Emmett Turner, Mine Safety and Health Inspector in MSHA's Bartow, Florida Field Office was notified of the accident by a telephone call from Gene Bryant, safety coordinator for Florida Rock Industries, Inc.. Turner notified the MSHA Southeastern District Office in Birmingham, Alabama, and an investigation was started the same day with the assistance of mine management and mine employees. There was no designated miners' representative at the mine.
1. The No. 2 work area, where the accident occurred, was shaped like a peninsula. The area had an average width of 90 feet (east to west) and an average length of 500 feet (north to south). The eastern side of the peninsula was irregular because some areas had been drilled and blasted and the material mined. The accident occurred on the eastern edge of the peninsula adjacent to one of the areas where the dragline had removed material.
2. Water on the eastern and southern sides of the No. 2 work area had an approximate depth of 50 feet. On the western side of the peninsula, sand overburden material had been removed from the limestone rock to create a pond, approximately 10 feet deep. The pond was used to deposit the limestone material as it was excavated from the peninsula.
3. There were no berms provided along the eastern or southern sides of the work area. A 6- to 8-foot high berm was present in areas along the water's edge directly adjacent to the work area.
4. The track dozer involved in the accident was a Caterpillar D8R, equipped with a blade but not with a ripper attachment. The operating weight of the dozer was 78,000 pounds. It was equipped with a six cylinder Caterpillar 3406 diesel engine. The transmission had three forward speeds and three reverse speeds.
5. The cab of the dozer was fully enclosed with sliding windows on the left and right side. The maximum widow opening was 8-1/4 inches by 24 inches. When the dozer was recovered, both windows were fully opened. A door was provided on each side of the operator. The cab was equipped with a rear view mirror.
6. The dozer was equipped with two lights facing rearwards on the machine deck behind the operator, two lights facing forward that were installed on the top of the blade lift cylinders, and two forward facing lights mounted on the sides of the machine, alongside the top of the radiator. Two light switches were provided. Both switches were found in the "on" position following recovery of the dozer.
7. Service brakes were spring applied and hydraulically released. The braking force was controlled by varying the hydraulic release pressure. When the brake pedal was in the released position, pressurized oil was sent to the brake housings. This would hold the brakes in the released position and allow the outer axle shafts to turn and allow machine movement. When the foot brake was pushed, the release pressure decreased, allowing the Belleville springs to push the brake pistons against the disc and plates to stop the machine. The parking brake lever could also be used to apply the same Belleville spring-applied brake system. When the parking brake lever was in the engaged position, the spring-applied brake was fully applied. When the parking brake lever was in the released position, pressurized oil was sent to the brake housings to fully release the spring-applied brakes.
8. When the dozer was recovered, the governor lever was found to be pulled back in the high idle position. This control was a hand-operated lever that extended from the floor up to the right side of the dashboard. This lever could have been moved during the recovery.
9. Both the decelerator pedal and service brake pedal were found in the fully released position. The decelerator pedal was used to override the governor and reduce engine speed. Both pedals moved freely and no obstructions were found that interfered with pedal movement.
10. The steering control was found in the neutral position. Steering and transmission shifting were controlled using the same joystick which was operated with the left hand. When the lever was moved forward, the dozer turned in a counterclockwise direction. When the lever was moved to the rear, it turned the dozer in a clockwise direction. The steering control was designed to return to the neutral position when released.
11. The transmission was found in first forward gear. The transmission was shifted by twisting the steering lever. The operator could choose forward, neutral, or reverse. A rotating knob on the end of the steering lever was the transmission speed selector, which was always engaged in one of three speeds. To shift gears would require a firm twisting action on the steering lever, so it is unlikely that this control position would have changed during the recovery. It is believed that when the dozer started going off the embankment, Brumfield shifted the transmission to a forward gear.
12. The dozer blade was found in the neutral (hold) position. The blade was controlled by a separate joystick lever using the right hand.
13. The ignition switch was found in the run position. Temperature controls for the heater and air conditioner were both found at maximum, and the blower fan speed was found in the "off" position.
14. Following the recovery of the dozer from the water, the holding capacity of the service brake was tested by pushing on the dozer with a Caterpillar 992 front-end loader. This test was done with the dozer engine not running. The spring-applied service brake would therefore be in the fully applied state since no hydraulic release pressure would be available. Under these conditions, the dozer did not move as the pushing force from the Caterpillar 992 loader was slowly increased up to the point where the loader wheels started spinning.
15. No equipment-related defects were found that could have contributed to the accident.
16. Weather at the time of the accident was clear. The temperature was about 60 Fahrenheit.
The cause of the accident was failure to construct and maintain berms. Contributing to the accident was the practice of back-dragging with the dozer parallel with the embankment.
Order No. 7758507 was issued on December 8, 1999, under provisions of Section 103 (k) of the Mine Act:
A fatal accident occurred at this mine on December 8, 1999, when a dozer operator lost control of the machine and apparently drowned after the machine entered approximately 25 feet of water in the number two mining area. This order is issued to assure the safety of persons at this mine 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.This order was modified on December 9, 1999, to allow contractors to retrieve the D8R Caterpillar dozer from the lake.
This order was terminated on December 10, 1999. Conditions that contributed to the accident have been corrected and normal mine operations can resume.
Citation No. 7787940 was issued on December 23, 1999, under provisions of 104(a) of the Mine Act for violation of 30 CFR, Part 56.9101:
A dozer operator was fatally injured at this operation on December 8, 1999, when the D8R Caterpillar dozer he was operating over-traveled the edge of an embankment, fell into a water-filled pit and became totally submerged. The victim lost control of the equipment while in the process of back dragging a pad for the dragline to operate from in the number two work area.This citation was terminated on January 6, 2000. Additional training has been conducted for the equipment operators at this operation regarding keeping equipment under control.
Citation No. 7787941 was issued on December 23, 1999, under provisions of 104(d)(1) of the Mine Act for violation of 30 CFR, Part 56.9300(a):
A dozer operator was fatally injured at this operation on December 8, 1999, when the D8R Caterpillar dozer he was operating over-traveled the edge of an embankment, fell into a water-filled pit and became totally submerged. The victim was in the process of back-dragging a pad for the dragline to operate from in the number two work area. Berms or guardrails were not provided along the outer edges of the pit area. This area is frequently traveled by maintenance trucks as well as supervisors and other employee vehicles. Failure to provide berms along the outer edges of the pad demonstrates a serous lack of reasonable care which constitutes more than ordinary negligence and is an unwarrantable failure to comply with a mandatory safety standard.This citation was terminated on January 6, 1999. Berms have been provided along the roadways to the dragline pads where a drop off exists of sufficient grade or depth to cause equipment to overturn or endanger persons in equipment. Additional training has been conducted.
Related Fatal Alert Bulletin:
Persons Participating in the Investigation Florida Rock Industries, Inc.
Curtis D. Zimmerman ................. plant managerLee County Sheriff's Department
Mark Klinepeter ................. director of safety
Gene Bryant ................. safety manager
Donald McKinney ................. safety manager
Sgt. Linda King ................. investigatorLee County Medical Examiners Office
Dr. Rebecca Hamilton ................. medical examinerMine Safety and Health Administration
Mitchell Adams ................. supervisor mine inspectorAPPENDIX B
Bobby A. Underwood ................. mine safety and health inspector
Jose J. Figueroa ................. mine safety and health inspector
Ronald Medina ................. mechanical engineer
D. Michael Campbell ................. civil engineer
Florida Rock Industries, Inc.
Roy F. Hardy ................. pit supervisorSouth Miami Heavy Equipment, Incorporated
Michael W. Brown ................. maintenance supervisor
Vernon L. Milan ................. dragline operator
Ronald Torres ................. dragline oiler
Eduardo Torres ................. drill helper
Wilfredo Garcia ................. drill operator