DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
Metal and Nonmetal Mine Safety and Health
REPORT OF INVESTIGATION
Surface Nonmetal Mine
(Sand Plant)
Fatal Fall of Person Accident
November 17, 2000
Texas Mining LP. dba/
Oglebay Norton Industrial Sands
Brady Plant
Brady, McCulloch County, Texas
ID No. 41-01371
Accident Investigators
Ralph Rodriguez
Supervisory Mine Safety and Health Inspector
Danny R. Ellis
Mine Safety and Health Inspector
Kevin L. Busby
Mine Safety and Health Inspector
Laman J. Lankford
Mine Safety and Health Specialist
Stephen B. Cole
Mechanical Engineer
Originating Office
Mine Safety and Health Administration
South Central District
1100 Commerce St., Room 4-C-50
Dallas, TX 75242-0499
Doyle D. Fink, District Manager
On November 17, 2000, Gilbert G. Rodriguez, Jr., maintenance mechanic, age 38, was fatally injured when he fell approximately 59 feet from a hoisted personnel platform to the pit floor. Rodriguez was kneeling beneath the handrail, and leaning out of the platform. He lost his balance as he attempted to lift a five-gallon bucket of water being handed to him by another employee who was standing below him on a fixed platform that extended out over the edge of the pit.
The root cause of the accident was the failure to provide safe working conditions and procedures for hoisting personnel. Contributing to the severity of the accident was the failure to tie-off while working from an elevated personnel platform.
Rodriguez had eleven years mining experience, including six years at this mine, and eleven years as a maintenance mechanic. He had received training in accordance with 30 CFR, Part 46.
The Brady Plant, a sand mill preparation plant, owned and operated by Texas Mining LP.dba/Oglebay Norton Industrial Sands, was located about eight miles east of Brady in McCulloch County, Texas. The principal operating official was Mike Peel, plant superintendent. The plant operated two, 10-hour shifts, five days per week. Total employment was 75 persons.
The plant rewashed sand from tailing ponds left by the previous owner. No active mining was being conducted at the pit. A new tailings discharge system was being constructed at the pit to discharge silt material and recover water to be recycled to the plant. The four employees working on the system were on loan from the Voca Pit and Plant, owned by the same operator.
The last regular inspection at this operation was completed on July 19, 2000.
On the day of the accident, Gilbert G. Rodriguez, Jr. (victim) reported to work at 6:00 a.m., his regular starting time. He performed various tasks in other areas before he began work at the tailings discharge system shortly after 1:00 p.m. Joe Bara, mechanic/crane operator, had set the Tadano crane in position before the others had arrived. Hamie Cortes, mechanic/welder, was welding and installing floor grating on the tailings discharge system platform, which extended out over the edge of the pit. John Potter, work crew leader, left the site to go to the shop to retrieve more grating shortly before Rodriguez climbed onto the elevated platform. Subsequently Rodriguez was hoisted nine feet above, and several feet out from, the system platform. He began installing the six-inch water recovery piping from the cyclone.
At about 2:05 p.m., Rodriguez was lowered to the ground to get an anti-siphoning device, then hoisted back into position where he continued the installation work. He accidentally dropped the anti-siphoning device into the large pipe and was unable to retrieve it. He shouted to Bara to get him a bucket of water so that the device could be washed out of the pipe. Bara left his operator's position in the crane cab, partially filled a 5-gallon bucket with water, and carried it over to the edge of the system platform. Stepping onto the midrail of the handrail system surrounding the platform, he lifted the bucket up to Rodriguez. Rodriguez knelt on the floor of the hoisted platform, under its handrailing, to reach for the bucket. To support himself he grabbed hold of the system framework, which caused the platform he was on to swing away from the structure. At that point he lost his balance and fell 59 feet to the pit floor. He was pronounced dead at the scene.
MSHA was notified at 2:30 p.m. on the day of the accident by a telephone call from Larry Henderson, regional manager for Texas Mining LP.dba/Oglebay Norton Industrial Sands, to Danny Ellis, mine safety and health inspector. An investigation was started the same day. MSHA's accident investigation team traveled to the mine, conducted a physical inspection of the accident site, interviewed a number of persons, reviewed documents relative to the job being performed, and reviewed the victim's training records. An order was issued under the provisions of section 103(k) of the Mine Act to ensure the safety of miners. MSHA conducted the investigation with the assistance of mine management and miners.
� The accident occurred at the partially constructed tailings cyclone discharge system at the pit. The system consisted of piping from the wash plant to the cyclone for discharge of solids and recovery of water. The water was diverted to a tank mounted on the system platform. An electric pump and piping would recycle the recovered water back to the plant. Construction had been ongoing for approximately two months. On the day of the accident, piping for the water recovery was installed and the installation of an anti-siphoning device was to be completed.
� The mobile hoisting crane was a model TR 350XL, serial number 560318, manufactured in 1994 by Tadano, Ltd. Its wheelbase measured eleven feet long by seven feet wide. It was powered by a Mitsubishi model 6D16T, 215-horsepower diesel engine. The maximum lift capacity of the crane was 35 tons. The four wire rope cables connecting the hoist to the hoisted platform were 3/8-inch in diameter, each with a capacity of 3.76 tons when rigged at an angle of 70 degrees. Each cable was approximately six feet in length.
� At the time of the accident, the floor of the hoisted platform was approximately twelve feet below the bottom of the cyclone. The top handrail of the system platform was approximately 5 feet below the floor of the hoisted platform. The distance from the top handrail of the system platform to the pit floor was approximately 54 feet.
� The hoisted platform was of unknown origin and age. It was acquired when the plant was purchased in 1994. Steel plates welded to the corners of the handrails provided anchor points for rigging to the crane. The floor of the platform was 4� feet by 2� feet in size. Two-inch pipe was used to construct uprights and handrails, and 1�-inch steel grating for the floor. The distance between the 4-inch high toeboard and the bottom of the handrail was 37-5/8 inches. There was no midrail and the sides of the platform were open. According to ANSI (American National Standards Institute) standard A10.28-1998:
Perimeter protection shall consist of:
1) a top rail approximately 42 inches above the floor
2) a toeboard at least 4 inches high, and
3) a midrail approximately halfway between the top and the toeboard.
The area from the floor to the midrail should be enclosed by the use of solid construction, expanded metal, or metal mesh with openings no greater than one-half inch.� At the time of the accident, the crane operator was outside of the cab, handing a bucket of water to the victim. It is an unsafe practice for the crane operator to leave the controls of the crane while persons work from a hoisted personnel platform.
� The hoisted platform was not tied off or anchored at the time of the accident. A safe practice is for a mobile platform to be tied or otherwise fastened to fixed anchor points to hold it steady when transferring materials or persons onto or off the platform.
� The victim was not wearing approved fall protection at the time of the accident. The crane operator stated that he failed to notice that Rodriguez was not wearing fall protection while he was on the mobile platform. On the morning of the accident, the victim was seen loading a belt and lanyard on the maintenance truck used to travel to the work site. A Miller model D26 safety belt and Miller flat nylon shock-absorbing lanyard were found on the bed of the truck immediately following the accident.
� Management officials for Texas Mining LP stated that they had a policy requiring safety belts and lines to be worn by employees when working where there was a danger of falling. Interviews confirmed that miners were aware that they should wear fall protection when working from an elevated position. However, the operator's written policy at the time of the accident regarding fall protection did not address work from hoisted platforms. It stated only that "safety belts and lanyards will be worn at all times when working over open crushers, bins, chutes, pockets, etc. except when the use would create a hazard to the employee or others and safety belts and lanyards should be inspected before using.
� The wind was calm, and the weather dry, clear, and above freezing on the day of the accident.
The root cause of the accident was the failure to provide safe working conditions and establish safe work procedures for the hoisting of personnel. A contributing factor to the severity of the accident was the failure to tie-off while working from an elevated personnel platform.
Texas Mining LP. dba/Oglebay Norton Industrial Sands
Order No. 7890907 was issued On November 17, 2000, under provisions of Section 103(k) of the Mine Act:
A fatal accident occurred at this operation on November 17, 2000, when three miners were working on the silt cyclone discharge equipment at the pit. This order is issued to assure the safety of all persons at this operation. It prohibits all activity at the equipment platform and the use of the 35 ton Todano [sic] crane and man basket being used there until MSHA has determined that it is safe to resume work in the area. The mine operator shall obtain prior approval from an authorized representative for all actions to recover and/or restore operations to the affected area.This order was terminated on December 18, 2000, after it was determined that the mine could safely resume normal operations.
Citation No. 7865332 was issued on December 11, 2000, under the provisions of Section 104(a) of the Mine Act for violation of 30 CFR 56.11027:
A fatal accident occurred at this operation on November 17, 2000, when an employee fell 59 feet from a hoisted personnel platform at the tailings cyclone discharge system at the pit. The platform was not substantially constructed with a guard rail system enclosing the space between the handrail and the toeboard.This citation was terminated on December 14, 2000, after the operator permanently removed the personnel platform from mine property.
Citation No. 7865333 was issued on December 11, 2000, under the provisions of Section 104(a) of the Mine Act for violation of 30 CFR 56.15005:
A fatal accident occurred at this operation on November 17, 2000, when an employee fell 59 feet from a hoisted personnel platform at the tailings cyclone discharge system at the pit. The victim was not tied off with a safety belt and line.This citation was extended until January 12, 2001, to allow the operator time to establish a fall protection program for all employees exposed to a danger of falling, including written policy and procedures, comprehensive training, and supervisory oversight of this program.
Related Fatal Alert Bulletin:
FAB2000M46
A. Persons Participating in the Investigation
B. Persons Interviewed
Persons Participating in the Investigation:
Texas Mining LP.dba/
Oglebay Norton Industrial Sands
Larry Henderson . . . . . . . . . . . . . . . . . . . . regional managerMine Safety and Health Administration
Mike Peel . . . . . . . . . . . . . . . . . . . . . . . . . plant superintendent, Brady Plant
Gene Matthews . . . . . . . . . . . . . . . . . . . . . plant superintendent, Voca Pit and Plant
Ron Jordan . . . . . . . . . . . . . . . . . . . . . . . . plant manager, Brady Plant
Andy Siersma . . . . . . . . . . . . . . . . . . . . . . manager - environmental, health & safety
Ralph Rodriguez . . . . . . . . . . . . . . . . . . . . supervisory mine safety and health inspector
Danny R. Ellis . . . . . . . . . . . . . . . . . . . . . . mine safety and health inspector
Kevin L. Busby . . . . . . . . . . . . . . . . . . . . .mine safety and health inspector
Laman J. Lankford . . . . . . . . . . . . . . . . . . mine safety and health specialist
Stephen B. Cole . . . . . . . . . . . . . . . . . . . . mechanical engineer
Persons Interviewed:
Oglebay Norton Industrial Sands
Larry Henderson . . . . . . . . . . . . . . . . . regional manager
Mike Peel . . . . . . . . . . . . . . . . . . . . . . plant superintendent, Brady Plant
Gene Matthews . . . . . . . . . . . . . . . . . . plant superintendent, Voca Pit and Plant
Ron Jordan . . . . . . . . . . . . . . . . . . . . . plant manager, Brady Plant
Jim Ellison . . . . . . . . . . . . . . . . . . . . . . trucking manager
John W. Potter . . . . . . . . . . . . . . . . . . maintenance work crew leader
Hamie Cortes . . . . . . . . . . . . . . . . . . . mechanic/welder
Joe Bara . . . . . . . . . . . . . . . . . . . . . . . mechanic/crane operator
Sam Johnson . . . . . . . . . . . . . . . . . . . mechanic