DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
Metal and Nonmetal Mine Safety and Health
Report of Investigation
Surface Nonmetal Mine
(Sand and Gravel)
Fatal Powered Haulage Accident
March 29, 2002
Tri-County Sand and Gravel, Inc.
Elba, Hall County, Nebraska
ID No. 25-00979
Rodney D. Gust
Mine Safety and Health Inspector
Chrystal A. Dye
Mine Safety and Health Inspector
Eugene D. Hennen
Steven J. Miller
Mine Safety and Health Specialist
Mine Safety and Health Administration
Rocky Mountain District
P.O. Box 25367, DFC
Denver, CO 80225-0367
Russell L. Coufal, truck driver, age 53, was fatally injured on March 29, 2002, when he was caught between the frame and bed of a haul truck. Coufal was assisting two other employees locate a problem with the control cable for the truck's hydraulic lift system.
The accident occurred because of maintenance problems with the power-take-off control cable. The failure to secure a raised truck bed prior to working under it caused the accident.
Coufal had one-year mining experience, all at this mine as a truck driver. He had not received training in accordance with 30 CFR, Part 46.
Elba Pit, a sand and gravel operation, owned and operated by Tri-County Sand and Gravel, Inc., was located 10 miles northwest of St. Paul, Howard County, Nebraska. The principal operating official was Kyle R. Wolinski, president. The mine was normally operated one, 8-hour shift a day, five days a week. Total employment was 12 persons.
Sand and gravel was extracted from the pit with a floating dredge. Material was pumped to the plant where it was sized and stockpiled.
The last regular inspection of this operation was completed on August 29, 2001. Another regular inspection was completed on April 16, 2002.
DESCRIPTION OF ACCIDENT
On the day of the accident, Russell L. Coufal (victim) reported for work at 8:20 a.m., approximately 20 minutes later than his normal starting time. Coufal performed his normal duties as a truck driver which consisted of hauling sand from the pit stockpile to the batch plant stockpile. At about 8:30 a.m., Kyle R. Wolinski, president, operated a front-end loader to load Coufal's truck.
Work proceeded normally until about 9:15 a.m. Coufal dumped a load of sand and returned to be loaded again when he realized that the power-take-off (PTO) for the hoist hydraulic pump was stuck in the engaged position. Coufal contacted Wolinski and explained that the PTO had stuck in the on position. Wolinski parked his loader, climbed onto the truck running board and started working the PTO control knob inside the cab of the truck. Coufal crawled under the truck and used a hammer to tap on a lever near the hydraulic pump. Donald Morrow, plant operator, and Brandon Headrick, laborer, stopped on their way back from starting the dredge pump. Morrow asked Wolinski if the PTO had stuck again. Wolinski replied "Yes". Morrow then crawled under the truck and used a hammer to tap on the PTO lever mounted on the PTO housing. Coufal, observing Morrow, told Morrow that he had been tapping on the wrong lever. When Morrow turned to tell Wolinski that he should be able to push in the PTO control knob, the truck bed began to raise. As Morrow turned back around, he observed Coufal standing behind the truck cab leaning over the frame and pulling on the bed lift hydraulic control valve. The raised bed suddenly dropped and caught Coufal between the truck bed and frame.
Morrow directed Wolinski to raise the bed. Once the bed was raised, Morrow removed Coufal and provided assistance.
Emergency personnel were summoned and arrived at the accident site a few minutes later. The victim was transported to a local hospital. He died a short time later due to crushing injuries to the chest.
INVESTIGATION OF ACCIDENT
MSHA was notified of the accident at 10:34 a.m., on March 29, 2002, by a telephone call from Shelley Wolinski, vice president of Tri-County Sand and Gravel, Inc., to Richard Laufenberg, acting assistant district manager. An investigation was started the same day. An order was issued pursuant to Section 103(k) of the Mine Act to ensure the safety of miners.
MSHA's accident investigation team traveled to the mine, made a physical inspection of the accident site and equipment involved, interviewed persons, and reviewed documents relative to the job being performed by the victim. The investigation was conducted with the assistance of the mine management and mine employees. The miners did not request nor have representation during the investigation.
� The accident occurred near the sand stockpile about 40 feet east of the slurry access road.
� The haul truck involved in the accident was a Mack, Model P685 LST, VIN No. 5132. The truck was equipped with a Model ENDT675 six-cylinder Mack engine rated at 237 horsepower mated to a six-speed Model 1076 Maxi torque transmission. The truck had originally been equipped with a flat-bed without a hoist lift cylinder.
� The rear dump bed mounted on the truck had a 10-cubic yard capacity and was removed from a 1960 Ford truck.
� The truck was equipped with a three-stage telescopic lift cylinder that was removed from a 1973 Clement tag-along trailer, Serial No. 3TTDB455237C. A test was conducted to determine stroke rate of the hydraulic lift cylinder. With the truck bed loaded, engine set at low idle, and the control knob placed in full lift position, there was a delay of approximately 16 seconds before the hydraulic lift cylinder began to lift the bed. The lift cylinder was bled to determine if the delayed action was caused by air in the hydraulic cylinder. After bleeding the cylinder, the delay time was reduced to less than two seconds.
� A test was conducted to determine drop rate of the loaded truck bed. With the engine speed set at low idle, the bed was raised 10 inches. The control knob was placed in a full drop position and the bed dropped to a horizontal resting position in less than one second.
� Personnel at Tri-County Sand and Gravel, Inc., installed the hydraulic pump and control valve assembly on the truck involved in the accident. The assembly was manufactured by Commercial Intertech. The Part No. was C101D-25. The assembly was mounted inside of the left frame rail between the front of the bed and to the rear of the cab.
� A control lever mounted horizontally between the seats in the operator's cab actuated the hydraulic control valve. A push/pull cable connected the control lever to the hydraulic control valve. When the control lever was pulled up, the bed of the truck raised. When the control lever was pushed down, the bed lowered. The design and operation of the hydraulic control valve was found to be functioning properly.
� The hydraulic pump was driven by a drive shaft connected to a Chelsar PTO, that was mounted on the side of the transmission. A control knob, connected to a push/pull cable assembly located to the left of the steering wheel, engaged or disengaged the PTO. Visual examination of the PTO push/pull cable assembly showed that the cable rod connected to the control knob was bent. Testing of the push/pull cable assembly showed that the control knob would only push inward until the bent portion of the rod began to enter the cable housing. The employees stated that for a period of two weeks prior to the accident everyone knew it was hard to disengage the PTO for the hydraulic pump.
� The PTO control lever was activated by hand to determine if it functioned without binding. With the cable removed, the lever was easily actuated with one finger. No sticking or binding of the PTO control lever was found.
� A new PTO push/pull cable was purchased and installed on the truck. With the new cable installed, the PTO was easily engaged and disengaged using the control knob in the operator's cab.
� The victim had not received the full 24-hours of New Miner training as required by 30 CFR, Part 46.5(d). It was determined that the training deficiency did not contribute to the cause of the accident.
The root cause of the accident was the failure to establish procedures that required prompt maintenance of the defective power take off control cable.
The cause of the accident was failure to secure the raised bed of the truck prior to performing work under it.
Order No. 6286892 was issued on March 29, 2002, under the provisions of Section 103(k) of the Mine Act:
A fatal accident occurred at this operation on March 29, 2002, when the bed of the 1968 Mack haul truck fell on the victim, causing fatal injuries. This order is issued to ensure 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 for all actions to recover persons, equipment and/or return affected areas of the mine to normal operations.This order was terminated on April 8, 2002, after it was determined that this area of the mine could resume normal operations.
Citation No. 6269118 was issued on April 9, 2002, under the provisions of Section 104(a) of the Mine Act for violation of 30 CFR 56.14211(c):
A fatal accident occurred at this operation on March 29, 2002, when a truck driver was pinned between the bed and the frame of a haul truck. The bed of the truck was not secured to prevent accidental lowering before the truck driver worked between the raised bed and the frame.This citation was terminated on April 23, 2002, after a proper blocking device was installed to prevent accidental lowering of the truck bed.
Related Fatal Alert Bulletin:
Persons Participating in the Investigation
Tri-County Sand and Gravel, Inc.
Kyle R. Wolinski ......... presidentMine Safety and Health Administration
Allen Ingerle ......... co-owner
Edna M. Ingerle ......... bookkeeper
Chrystal A. Dye ......... mine safety and health inspector
Rodney D. Gust ......... mine safety and health inspector
Eugene D. Hennen, P.E. ......... mine safety and health mechanical engineer
Steven J. Miller ......... mine safety and health specialist
Tri-County Sand and Gravel, Inc.
Kyle R. Wolinski ......... president/co-owner
Allen Ingerle ......... co-owner/truck driver
Donald Morrow ......... plant operator
Brandon Headrick ......... laborer