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UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
Metal and Nonmetal Mine Safety and Health

Report of Investigation

Surface Nonmetal Mine
(Cement)

Fatal Fall of Person Accident

September 23, 2002

Parsons Steel Erectors, Inc. (FF6)
Tucson, Pima County, Arizona

at

Rillito Plant
Arizona Portland Cement
Div California Portland Cement Co.
Rillito, Pima County, Arizona
I.D. No. 02-01138

Accident Investigators

Dale D. Teeters
Mine Safety and Health Inspector

David D. Estrada
Mine Safety and Health Inspector

Isabel R. Williams
Mine Safety and Health Specialist

Steven J. Vamossy
Civil Engineer

Michael P. Stark
Civil Engineer

Originating Office
Mine Safety and Health Administration
Rocky Mountain District
P.O. Box 25367, DFC
Denver, CO 80225-0367
Irvin T. Hooker, District Manager


OVERVIEW

Rillito Plant, a cement manufacturing plant, owned and operated by Arizona Portland Cement, a Division of California Portland Cement Company, was located near Rillito, Pima County, Arizona. The principal operating official was David Bittel, plant manager. The plant was normally operated three, 8-hour shifts a day, seven days a week. Total employment was 161 persons.

Cement was produced at the plant by four kilns; three were operating on the day of the accident. Kilns 1, 2, and 3 were direct-fired and kiln 4 was indirect-fired. The kilns used coal/coke as the main source of fuel. Limestone utilized in the process was received at the plant by conveyor belt.

A major shut down was planned in order to replace a large section of the K-4 kiln. Several contractors were on-site to perform specific tasks related to the kiln replacement. The shut down began at 7:00 a.m., on the day of the accident.

Parsons Steel Erectors, Inc., an independent contractor, was contracted to remove roofing over the K-4 kiln. Parsons Steel Erectors, Inc., was located in Tucson, Pima County, Arizona. The principal operating official was Joe Parsons, vice-president. Parsons Steel Erectors, Inc., normally operated one, 8-hour shift a day, 5 days a week. The contractor employed seven persons at this site.

The last regular inspection of this operation was completed on March 8, 2002.

DESCRIPTION OF ACCIDENT

On the day of the accident, Clifford J. Dunagan, (victim) reported for work at 6:30 a.m., his normal starting time. Joe Hall, foreman, instructed Dunagan to proceed to the roof above the K-4 kiln to begin removing sections of the roof. Dunagan used the pre-heater tower elevator and accessed the east end of the roof from the third floor. Hall accessed the roof using the JLG manlift positioned on the ground near the northeast end of the roof. Hall walked diagonally on the roof to the apex where he and Dunagan discussed the procedure for preparing the roof for disassembly.

Hall and Dunagan worked together on the roof for about 30 minutes removing screws from four vents and two ridge caps. Hall then instructed Dunagan to begin removing screws from the roof sheeting near the north eave. Hall worked his way up the roof pitch on foot to the apex removing screws from the sheeting. The JLG manlift was moved by Hall and positioned along the eave as the men worked from west to east. No tie-off points for lifelines had been established on the roof. Both men walked in direct line above the manlift as they worked, using the manlift handrails as fall protection.

Work on the roof proceeded normally until about 8:15 a.m., when Hall heard a yell, turned and saw Dunagan fall from the roof. Hall ran down the tower stairs to the concrete pad below the roof. An employee of Arizona Portland Cement was already at the scene and had called for assistance.

Emergency medical assistance arrived within a few minutes. Dunagan was pronounced dead at the scene at 8:36 a.m. Death was attributed to multiple injuries to the head and torso due to blunt impact.

INVESTIGATION OF ACCIDENT

MSHA was notified of the accident at 8:35 a.m., on the same day, by a telephone call from Francis Obregon, safety supervisor for Arizona Portland Cement, to Benny Lara, supervisory mine safety and health inspector. 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 mine management and employees.

DISCUSSION

  • The accident occurred at the roof above the northeast end of K-4 kiln. The roof consisted of sheet metal sections that were fastened with screws to the frame. The eave of the roof was about 46 feet above the concrete floor where the manlift was positioned. The pitch of the roof was 1v-4h. The roof was covered with dry, caked-on, hard dirt material that had accumulated over 3 years.


  • The victim was wearing a full body safety harness.


  • The contractor had safety lines available in the tool room at the job site trailer, but had not provided secure tie-off locations prior to commencing work on the roof. Employees past training discussed the requirements to be tied off when working in elevated positions.


  • The equipment involved in the accident was the 600S JLG (Model 2002), Serial No. 0300067940, manlift. The manlift had a maximum platform height of 60 feet and maximum capacity of 1000 lbs.


  • The platform basket was 38 inches wide and 96 inches long. The basket top handrail was 43.5 inches high. The manlift basket was placed snug to the eave of the roof.


  • The manlift was operated by the foreman who repositioned it along the eave of the roof as he and the victim used electric screw guns to remove screws from the sheet metal roof.


  • The contractor's standard procedure was to work in line with the manlift basket and to rely on the manlift handrails as fall protection with the manlift placed snug against the roof. Evidence of removed screws, approximately 30 inches to the east of the manlift basket, indicated work was performed beyond the edges of the basket.


  • Weather at the time of the accident was warm, clear and calm. There was no evidence that the victim's ability to perform his job at the time of the accident was impaired.
  • CONCLUSION

    The accident occurred because the victim was not restrained by a safety line while working from the elevated roof.

    The following root causes were identified: failure to properly analyze the task and implement safe job procedures to eliminate hazards; failure to install secure tie-off locations; and failure to require the use of safety belts and lines.

    ENFORCEMENT ACTIONS

    The following violations were issued to Parsons Steel Erectors, Inc.:

    Order No. 7949588 was issued on September 23, 2002, under the provisions of Section 103(k) of the Mine Act:
    A fatal accident occurred at this operation on September 23, 2002, when a contract iron worker fell while working on the roof of the K-4 kiln. This order is issued to ensure the safety of all persons at this operation. It prohibits all activity at the K-4 kiln; including travelways, on both sides of the No. 4 kiln along the floor level and on the upper deck. This also includes the JLG manlift, Serial No. 0300067940, which was parked in the area and being used at the time of the accident. The mine operator shall obtain prior approval from an authorized representative of the Secretary for all actions to recover and/or restore operations to the affected area.
    This order was terminated on September 27, 2002. Conditions that contributed to the accident have been corrected and normal mining operations can resume.

    Citation No. 6297724 was issued on October 28, 2002, under the provisions of Section 104(d)(1) of the Mine Act for violation of 30 CFR 56.15005:
    A fatal accident occurred at this mine on September 23, 2002, when a contractor employee fell about 46 feet while working on the roof above the K-4 kiln. The victim was positioned about 3 feet away from the work basket of his mobile manlift removing screws near the eave of the roof. Tie off locations had not been installed on the roof and although the victim was wearing a fall protection harness, he was not secured to a line to prevent a fall. Failure to ensure that safety lines were provided and being used by the contractor employees constitutes more than ordinary negligence and is an unwarrantable failure to comply with a mandatory standard.
    This citation was terminated on September 28, 2002. The mine operator provided extensive training in the use of fall protection and in the use of the fall protection system the operator installed for this project.

    Related Fatal Alert Bulletin:
    Fatal Alert Bulletin Icon FAB02M28




    APPENDIX A


    Persons Participating in the Investigation

    Parsons Steel Erectors, Inc.
    Joe M. Parsons ............. vice-president
    David Caesar Ramirez ............. foreman/safety officer
    Snell & Wilmer L.L.P.
    Charles P. Keller ............. attorney
    Arizona Portland Cement Div California Portland Cement Co.
    David N. Bittel ............. plant manager
    Francis R. Obregon ............. safety supervisor
    Wm. Russell Hawks, P.E. ............. plant engineer
    George S. Tomita, P.E. ............. chief civil engineer
    State of Arizona
    Tim Evans ............. deputy mine inspector
    Wesley A. Cruea ............. deputy mine inspector
    AFL-CIO Iron Workers
    Gene Ryan ............. business representative/organizer local union 75
    Paper Allied Industries Chemical Energy Workers (PACE)
    Ronald M. Laguna ............. safety representative PACE local 80296
    Mine Safety and Health Administration
    Dale D. Teeters ............. mine safety & health inspector
    David D. Estrada ............. mine safety & health inspector
    Isabel R. Williams ............. mine safety & health specialist
    Steven J. Vamossy ............. civil engineer
    Michael P. Stark ............. civil engineer
    APPENDIX B

    Persons Interviewed

    Parsons Steel Erectors, Inc.
    Joe M. Parsons ............. vice-president
    David Caesar Ramirez ............. foreman/safety officer
    Joe Hall ............. foreman/ironworker
    David T. Young ............. ironworker
    Wayne Bogart ............. foreman/ironworker
    Mark W. Hambrock ............. ironworker
    Jim M. Frey, Jr. ............. foreman/ironworker
    William L. Pryor ............. ironworker
    Arizona Portland Cement Div California Portland Cement Co.
    David N. Bittel ............. plant manager
    Francis R. Obregon ............. safety supervisor
    Lawrence A. Duke ............. production control supervisor
    Steve M. Nason ............. kiln utility worker
    J.T. Thorpe
    Rosemary A. Rogers ............. foreman
    R.E. Lee Mechanical Contracting, Inc.
    Albert J. Castillo ............. foreman
    AFL-CIO Iron Workers
    Gene Ryan ............. business representative/organizer local union 75
    Paper Allied Industries Chemical Energy Workers (PACE)
    Ronald M. Laguna ............. safety representative PACE local 80296