Skip to content
UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION

COAL MINE SAFETY AND HEALTH

REPORT OF INVESTIGATION

Underground Coal Mine
(Surface Area)

Fatal Powered Haulage Accident
February 27, 2002

Savage Industries Inc. (ZP4)
Salt Lake City, Utah

at

Pinnacle Mine
Andalex Resources, Inc.
Price, Carbon County, Utah
I.D. No. 42-01474

Accident Investigators

Jerry O. D. Lemon
Coal Mine Safety & Health Inspector

John Turner
Educational Field Services Specialist

Ronald Medina
Mechanical Engineer

Originating Office
Mine Safety and Health Administration
District 9
P.O. Box 25367
Denver, Colorado 80225-0367
Allyn C. Davis, District Manager

Report Release Date: June 10, 2002


OVERVIEW


On Wednesday, February 27, 2002, at about 5:05 p.m., Bryon Snow, age 43, a coal truck driver employed by Savage Industries Inc., an independent contractor trucking company, was fatally injured at the Pinnacle Mine while loading his Kenworth, double-trailer truck with coal. Snow had 1 year 9 weeks experience with Savage Industries operating coal haul trucks. There were no witnesses to the accident. It appears that the rear trailer was not properly positioned beneath the coal spreader chute and about 3 to 4 tons of coal spilled down the right side of the rear trailer. Snow, after becoming aware of the spill, pulled the truck forward, set the tractor parking brakes, and got out of the truck. The tractor and trailers then started to move forward down an 8 to 9 percent grade toward the main road. Snow apparently ran after the truck and attempted to get in and stop it. The truck traveled downgrade, left the road, and entered the left drainage ditch. It stopped after traveling approximately 200 feet. The back trailer struck the hillside along the ditch and turned on its side. Snow was thrown from the truck, ran over, and fatally crushed by the tires. He was found lying on the ground about 1 foot from the left dual tires on the rear trailer. This was Snow's first trip to the Pinnacle Mine to load and transport coal.

Based on information gathered during the investigation, it is likely the direct cause of the accident was that the trailer parking brakes were not applied before the driver got out of the truck. Brake holding tests indicated that only the tractor parking brakes were set. This allowed the loaded coal truck to runaway uncontrolled. Contributing factors included improper alignment of the rear trailer under the coal spreader chute that allowed coal to spill, and the grade of the roadway at the loadout. Root causes of the accident included inadequate hazard training for Snow regarding the Pinnacle Mine loadout, insufficient pre-job briefing and practice in the task under supervision, and the habit of only setting the tractor parking brakes.

The service and parking brake systems were inspected and met the criteria established by the Commercial Vehicle Safety Alliance (CVSA) for trucks in service on public highways. Grade holding capability tests were conducted at the loadout facility. The parking brake system could hold the loaded vehicle on this grade if the parking brakes on the tractor and trailers were applied. However, the tractor parking brakes alone could not hold it on the grade. The service brake could also stop and hold the loaded vehicle on this grade. Equipment defects were not found to be a contributing factor to the accident.

GENERAL INFORMATION


The Pinnacle Mine is an underground coal mine located on the Airport Road, 10 miles north of Price, Carbon County, Utah. The mine, operated by Andalex Resourses, Inc., produces bituminous coal, and employees 47 persons. The mine has 2 production and 1 maintenance shifts per day, 5 days per week. The average mining height is about 72 inches, and an average of 2,059 tons of coal is mined per day.

Savage Industries Inc., an independent contractor trucking company, transports approximately 2,100 tons of coal per day from the Pinnacle Mine to the Wildcat Train Loadout facility. Savage Industries has offices and a shop near Wellington, Utah, and corporate offices in Salt Lake City, Utah. Kenworth and Mack tractors with double trailers are used to haul the coal. These trailers hold about 22 tons of coal each. The tare weight of the tractor and trailer combination is between 39,000 and 41,000 pounds. The average total weight of the loaded trucks is about 128,500 pounds. At the time of the accident, three trucks were used to haul coal from the Pinnacle Mine.

The last regular safety and health inspection by the Mine Safety and Health Administration was completed on December 14, 2001, and one was ongoing at the time of the accident. The Non-Fatal Days Lost (NFDL) Incidence rate (not including office workers) for the mine is 0.00. The NFDL rate for the Nation for underground mines is 7.28. The rate for Savage Industries Inc. is 1.49, and the National rate for all contractors is 3.20.

The principle officers at the Pinnacle Mine at the time of the accident were:
Samuel C. Quigley .......... Vice-President of Operations
David D. Pilling .......... General Mine Superintendent
Thomas R. May .......... Safety Manager
The principle officers at Savage Industries Inc. at the time of the accident were:
John Savage .......... Senior Vice-President
Jeffrey Chesler .......... Vice-President Mountain Region
David Sorrells .......... Operations Manager
Reese Blackhurt .......... Director of Safety
Eric Adamson .......... Vice-President of Safety
James Phillips .......... Coal Truck Driver Supervisor
DESCRIPTION OF THE ACCIDENT
On Wednesday, February 27, 2002, Brian Snow started his shift at approximately 4:05 p.m., at Savage Industries' Coal Service Operations shop, located on the Nine-Mile road near Wellington, Utah. Snow conducted a pre-operational check on his Kenworth coal haul truck and then traveled to the Pinnacle Mine coal loadout. He followed John D. Wimmer in his coal truck to the mine. Robin Beason left the shop after Snow in a third haul truck.

Wimmer arrived at the Pinnacle Mine and loaded his truck without incident. He then parked the truck, secured the brakes, and walked to Snow's truck. He stood on the truck's running board to instruct Snow in loading his first load at the mine. Snow loaded the first trailer without incident. Wimmer then left and started toward the Wildcat Train Loadout facility.

Wimmer received a radio call from Snow when he was about a mile from the mine. Snow thought he was getting more coal loaded in the rear trailer than he should. He thought he was getting a double feed. Wimmer told him to shut off the feed belt. That was his last conservation with Snow. Information indicates that Snow pulled his truck forward, set the tractor parking brakes, and got out of the truck to shut off the belt and check the coal that had spilled. After Snow exited the truck, it started moving forward, down an approximate eight to nine percent grade. Snow apparently ran after the truck and attempted to get in and stop it.

The truck continued down the road and turned into the left drainage ditch alongside the main road. The rear trailer hit the hillside beside the drainage ditch, turned over on its left side, and threw coal out on the hillside. The truck then came to a stop with the engine running, the transmission in neutral gear, and both parking brake buttons pulled out. The truck stopped with the rear trailer in the ditch and the tractor on the roadway surface. The truck traveled approximately 200 feet from the loadout.

Beason arrived at the accident scene at 5:08 p.m., a few minutes after the accident occurred. He found Snow on the ground approximately a foot from the left rear dual tires of the back trailer. He immediately notified the Savage Industries dispatcher, who called the 911 County emergency number. The Carbon County Ambulance was dispatched at 5:20 p.m, and arrived at the accident scene at 5:30 p.m. Officers with the Carbon County Sheriff's department and the Highway Patrol also arrived at the scene. The ambulance crew examined Snow and detected no vital signs. His body was removed from the site and transported to Salt Lake City, Utah, for autopsy.

INVESTIGATION OF THE ACCIDENT


MSHA was immediately notified of the accident. Terry Anderson, Coal Mine Safety and Health Inspector, was dispatched to the accident site, arriving at 6:00 p.m. Anderson issued a Section 103(k) order and made a preliminary examination of the accident scene.

On Thursday, February 28, 2002, at 8:00 a.m., the accident investigation was started with a pre-investigation conference at the Pinnacle Mine training room. The accident investigation team consisted of Jerry O.D. Lemon, lead investigator and Coal Mine Safety and Health Inspector, Price, Utah; John R. Turner, Educational Field Services Specialist, Castle Dale, Utah; and Ronald Medina, Mechanical Engineer, Technical Support, Tridelphia, West Virginia. Officials and employees with Andalex Resources, Inc. and Savage Industries, Inc. assisted in the investigation. Todd N. Curtis, Utah State Highway Patrol Trooper, assisted in the brake examinations on the truck involved in the accident.

The investigation team proceeded to the accident scene, took measurements, photographs, and secured the truck and front trailer. The tractor was started and the brake air pressure checked, which was about 120 p.s.i. No air pressure was leaking off, and, from visual observation, all the brakes were functioning. The rear coal trailer was righted, inspected, and positioned on the paved road surface. Additional brake checks were made, and no significant defects were found.

The truck and trailers were moved to the lower, flat loadout area, where the coal was dumped from both trailers. The truck and trailers were blocked in place and all brakes were checked. The truck and trailers sustained four flat tires, two bent tire rims, and one broken spring assembly on the rear trailer. MSHA permitted Savage Industries to make necessary repairs on the springs, tires, and rims. The truck and trailers were taken to the loadout, loaded with coal, positioned about ten feet down grade from the loadout, and only the tractor parking brakes were set. In this test, the tractor parking brakes were insufficient to hold the tractor and loaded trailers on the grade. This test was repeated and yielded the same results. Based on the tests and investigation, the Section 103(k) Order was terminated on March 1, 2002.

DISCUSSION


1. The accident occurred at the Pinnacle Mine truck coal loadout facility. The grade immediately down from the loadout was approximately 8 to 9 percent. The haulroad was about 30 feet wide. The road from the loadout was paved with asphalt and was maintained in good condition.

2. The truck loadout consisted of a concrete floor beneath an elevated steel structure containing a coal spreader chute. The reclaim conveyor belt from the surface coal stockpile dumped coal directly into the chute. The steel structure was supported by four vertical steel columns. Trucks pulled onto the concrete floor beneath the chute to be loaded. The facility was constructed in 1981.

3. The coal loading process was automatic and did not require the driver to leave the truck. An electric light beam, which activated the coal feed, was located on the second steel column on the driver's side of the loadout. The beam projected across the path of the approaching haul trucks. It was approximately 10 feet off the ground and hit the top of the coal trailers. When a trailer broke the beam, a red warning light, located on the steel column below the electric light beam, was activated. This light remained lit the entire time the beam was broken. After the light beam was broken for 8 seconds, a warning bell sounded, and a few seconds later, the reclaim belt conveyor began to run and deliver coal to the spreader chute. A white light, which was mounted on a conduit pole, located 10 feet past the red light, lit while the reclaim belt was running. The belt conveyor started automatically and continued until a preset tonnage of 22 tons was loaded. When the belt stopped, the white light went off, signaling the driver to pull forward. The cycle was repeated for the second trailer. An emergency shut-off switch was located on the driver's side of the loadout on the steel column below the electric light beam.

4. Truck drivers must position the trailers directly under the spreader chute in both directions, i.e. from front to back and side to side. This was done visually. Over time, ruts and humps developed in the asphalt located past the concrete floor where the tractor's tires were positioned during loading operations. Experienced drivers used these humps/ruts to properly position the trailers beneath the spreader chute.

5. The complete tractor trailer combination consisted of a Kenworth Model 900B Tractor and two Beall 34 cubic yard trailers. The Kenworth tractor was equipped with a six cylinder, Model N14-460E, Cummins engine, and an eight-speed Eaton-Fuller Road Ranger transmission. The complete tractor-trailer had 11 axles, three on the tractor and the rest on the two trailers.

6. SERVICE BRAKE SYSTEM: The service brake system consisted of an air operated, two shoe, internal expanding drum type arrangement at each wheel. Each brake chamber on axles 2, 3, 5, 6, 10, and 11 was composed of two separate chambers coupled together into one unit to serve two separate functions. The forward chamber provided service braking capability and the rear chamber provided parking brake capability. The brake chambers on the rest of the axles were single chambers that only provided service brake capability. When compressed air entered the service brake chambers, the push rods extended from the chambers and applied the service brake.

7. SERVICE BRAKE SYSTEM INSPECTION: Three defects were found - one brake chamber had an audible air leak when the service brake was applied, and the brakes at two wheels were out of adjustment. The audible brake chamber air leak was on axle 2 on the right side, and the out of adjustment brakes were on axle 7. The air compressor maintained 120 psi of reservoir pressure, despite the audible air leak, when the service brake was fully applied and the engine was at low idle. The type 30 brake chamber on the 7-left position had a push rod travel of 2-1/8 inches, and was therefore 1/8 inch beyond the brake adjustment limit. The type 24, long stroke brake chamber on the 7-right position had a push rod travel of 2-1/2 inches, and was therefore 1/2 inch beyond the brake adjustment limit. Based on the criteria established by the Commercial Vehicle Safety Alliance (CVSA), the percentage of defective brakes on the vehicle did not exceed the allowed 20 percent limit so the vehicle was still suitable for highway use. The above defects did not affect the parking brake performance. The CVSA North American Uniform Out-of-Service Criteria are nationally recognized by the trucking industry for highway trucks and are used by MSHA to determine brake adequacy.

8. PARKING BRAKE SYSTEM DESIGN: The rear portion of the brake chambers on axles 2, 3, 5, 6, 10, and 11 provided parking brake capability. Without compressed air in the parking brake portion, a self-contained spring expanded. This extended the push rod and applied the parking brake. The parking brake on the tractor and trailers could be applied manually from the operator's cab using a pair of push-pull control buttons. The park brake also applied automatically from loss of air system pressure.

9. PARKING BRAKE SYSTEM INSPECTION: The parking brake system operated as designed using two push-pull control buttons on the dashboard. Pulling out the right side button caused the tractor parking brakes on axles 2 and 3 to apply, and simultaneously caused the trailer button to pop out, applying the trailer brakes on axles 5, 6, 10, and 11. Pulling out the right side button (parking brake) while simultaneously holding in the left side button (trailer supply) resulted in application of only the tractor parking brakes on axles 2 and 3. Lastly, pulling the left side button out (trailer supply) caused the trailer parking brakes on axles 5, 6, 10, and 11 to apply. When interviewed, truck drivers stated that, commonly on flat ground, the drivers pulled the right button out, depressing the left button, and only the tractor brakes were set. The advantage to only setting the tractor parking brakes was that it took a few seconds less to release just the tractor brakes rather than releasing both the tractor and trailer parking brakes. Interviews also indicated that drivers had been instructed to set all parking brakes when they got out of their trucks, regardless of grade.

10. PARKING BRAKE AND SERVICE BRAKE TESTS: Grade holding capability tests were conducted at the loadout facility involved in the accident. The tractor-trailer combination was loaded to approximate the full load at the time of the accident. When tested, the parking brake system held the loaded vehicle on the grade at the loadout if the parking brakes on both the tractor and trailers were applied. However, the tractor parking brakes alone did not hold the truck on the grade. The grade holding ability of the trailer parking brakes alone was also tested and found to be sufficient to hold the vehicle on the grade. The service brake could also stop and hold the loaded vehicle on this grade.

     Moving tests showed that if the truck was allowed to coast and build up some speed from the loadout point and the yellow parking brake button was pulled out (without holding in the red button) the tractor and trailer parking brakes applied after a short time delay. The delayed response was the time it took for the air to release in the braking system and allow the springs to apply the parking brakes. Once the parking brakes finally applied, the truck came to a quick stop. However, the short delay would allow the truck to move a considerable distance. Since both the tractor and trailer parking brake buttons were found in the out position, the parking brakes probably set-up near where the truck eventually stopped. This would indicate that Snow had reached the runaway truck and pulled out the trailer parking brake button.

11. TRAILER BRAKE CONTROL: The hand-operated trailer brake control lever was located on the right side of the steering column. It operated as described in the maintenance manual. Movement of the control handle back, applied the trailer service brakes; movement forward, released them. The control was spring loaded and returned to the brake released position when released.

12. TRUCK CONDITION: Emergency response personnel reported that upon arriving at the accident scene, the engine was running, the tractor doors were closed, the transmission was in neutral, and both the parking brake button and the trailer air supply button were out (brake applied position).

13. GROSS VEHICLE WEIGHT: The combined gross vehicle weight rating of the tractor and both trailers, as specified by the manufacturers, was 152,000 lbs. The total gross vehicle weight of the loaded tractor-trailer combination at the time of the accident was approximately 128,000 lbs. The load was therefore within the allowed rating for the truck. Each trailer was normally loaded to 22 tons of coal.

14. The throttle pedal and steering system, were evaluated and no defects were found. A seat belt was provided for the driver and it latched when the two ends were buckled.

15. The brake inspections and tests were conducted by MSHA and Utah State Highway Patrol Trooper Todd Curtis. Trooper Curtis' Driver Vehicle Examination Report, documenting his findings is in Appendix C.

16. The damage done to the tractor and trailers due to the accident were: the right back up light mounted near the operator's door was broken off; several tire rims were bent; four tires were flat on the trailers; and a leaf spring unit was broken on the left rear coal trailer. There were some minor dents in the rear trailer and the left front tractor bumper was bent.

17. Approximately three to four tons of coal were on the loadout floor that had spilled over the rear right side of the rear trailer.

18. A truck wheel chock was located in a holder on the loadout concrete wall on the driver's side of the truck. It had not been used to block the truck or trailer wheels.

19. Coal, scattered on the roadway, appeared to have been shaken off the rear trailer during the runaway. This coal covered an area approximately 22 feet wide by 35 feet long. Truck tire tracks were present through this coal and on the haulroad, as shown in the Sketch. Snow's hard hat was found in the center of the road adjacent to the rear trailer impact spot with the hillside.

20. The victim was found lying in the drainage ditch with his head about one foot from the rear trailer left dual tires. Evidence indicated that he was run over by the rear tires. The victim's rubber mallet and his trip sheets were found just in front of the rear trailer axles.

21. The emergency shut-off switch at the loadout was not pushed. The double load, that the Snow thought he was getting, was coal spilling from the normal loading cycle. He did not have the rear trailer properly aligned under the coal spreader chute, and about three to four tons of coal spilled over the right rear side of this trailer.

22. Snow had approximately one year and nine weeks of experience as a truck driver for Savage Industries. The Kenworth truck involved in the accident was assigned to Snow. It was the truck that he normally operated. Snow had received experienced miner training, annual refresher training, and task training as a truck driver according to Part 48 requirements. Savage Industries had a comprehensive "Savage Driver Training Certification Checklist" that itemized in detail the task training that was provided to truck drivers. Snow completed this training on December 22, 2000. Item 3, page 1 of the Checklist addresses use of truck parking brakes. This item states, "If the truck is loaded and the driver leaves the vehicle, both park valves should be pulled." Thus, both the tractor and trailer parking brakes are required to be set when the driver leaves the truck.

23. Wimmer was assigned to train Snow on the coal loading procedures at the Pinnacle Mine loadout. He stood on the running board and instructed Snow during the loading of the first trailer. He then left the loadout prior to the second trailer being loaded.

ROOT CAUSE ANALYSIS


A root cause analysis was performed on the accident. The following causal factors and root causes were identified:

1. Causal factor - This was Snow's first trip to the Pinnacle Mine loadout. Root causes - Human Performance Difficulties indicated that Snow received inadequate instructions on the loadout procedures; insufficient practice/repetitions under the direction of an experienced person; that no written procedures were in place for the loadout procedures: and that the pre-job briefing was inadequate.

2. Causal factor - Snow received inadequate hazard training on the loadout procedures. Root cause - Human Performance Difficulties indicated inadequacies in the instructions and walk-through provided to Snow on the loadout.

3. Causal factor - Snow improperly set the parking brakes by only applying the tractor parking brakes. Root cause - Information indicated that Snow was overwhelmed by the coal spillage and was in a hurry when he exited the truck. This, and the habit of only setting the tractor brakes when on level ground, led to Snow not setting all brakes. Instruction on setting parking brakes needs improvement.

4. Causal factor - Snow did not block the wheels when he exited the truck. Root cause - Again, by being overwhelmed and in a hurry, Snow did not take the time to block the tires, even though a chock was available at the loadout. The analysis indicates additional training is needed on blocking wheels.

5. Causal factor - No sign was installed at the loadout to warn of the steep grades. Root cause - Lack of a warning sign for the steep grades contributed to Snow not recognizing this condition/hazard. The analysis indicates a warning sign/display is needed at the loadout.

CONCLUSION


Based on information gathered during the investigation, it is likely the direct cause of the accident was that the trailer parking brakes were not applied before the driver got out of the truck. Brake holding tests indicated that only the tractor parking brakes were set. This allowed the loaded coal truck to runaway uncontrolled. Contributing factors included improper alignment of the rear trailer under the coal spreader chute that allowed coal to spill, and the grade of the roadway at the loadout. Root causes of the accident included inadequate hazard training for Snow regarding the Pinnacle Mine loadout, insufficient pre-job briefing and practice in the task under supervision, and the habit of only setting the tractor parking brakes.

The service and parking brake systems were inspected and met the criteria established by the Commercial Vehicle Safety Alliance (CVSA) for trucks in service on public highways. Grade holding capability tests were conducted at the loadout facility. The parking brake system could hold the loaded vehicle on this grade if the parking brakes on the tractor and trailers were applied. However, the tractor parking brakes alone could not hold it on the grade. The service brake could also stop and hold the loaded vehicle on this grade. Equipment defects were not found to be a contributing factor to the accident.

ENFORCEMENT ACTIONS


1. Section 103(k) Order No. 7612234 was issued on February 27, 2002, to ensure the safety of all persons until an investigation could be completed and the mine deemed safe. The order stated, "The surface truck loadout facility of the Pinnacle Mine has experienced a fatal truck haulage accident. This order is issued to assure the safety of any person or persons until an examination or investigation is made. Only those persons selected from Company Officials, State Officials, the miners representative and other persons who are deemed by MSHA to have information relevant to the investigation may enter or remain in the affected area."

2. Section 104(a) Citation No. 7615672 was issued on June 5, 2002, for a violation of 77.1607(n). The citation stated, "The Kenworth Model 900B tractor (Company No. S-935) and two Beall 34 cubic yard trailers involved in a fatal powered haulage accident at the Pinnacle Mine truck loadout on February 27, 2002, were left unattended on a grade without the full parking brake system, as provided by the manufacturer to hold the loaded truck and trailers on a grade, not set. The wheels were not blocked nor turned into a berm or bank. This allowed the truck to runaway approximately 200 feet down a grade. The truck driver was fatally injured by the left rear tires on the back trailer, as a result of this violation."

3. Section 104(a) Citation No. 7615673 was issued on June 5, 2002, for a violation of 48.31(a)(3), Hazard Training. This citation stated, "Brian Snow, coal truck operator, did not receive adequate hazard training on the safe operating procedures for loading coal trucks at the Pinnacle Mine loadout. This was Snow's first trip to this loadout. He was not instructed through an entire loading cycle at the loadout, and he appeared unaware of the hazard that the steep slope from the loadout presented."

Related Fatal Alert Bulletin:
Fatal Alert Bulletin Icon FAB02C08




APPENDIX A


List of Persons Participating in the Investigation

SAVAGE INDUSTRIES INC. OFFICIALS
John Savage ............. Senior Vice-President
Jeffrey Chesler ............. Vice-President Mountain Region
David Sorrells ............. Operations Manager
Reese Blackhurt ............. Director of Safety
Eric Adamson ............. Vice-President of Safety
James Phillips ............. Coal Truck Driver Supervisor
SAVAGE INDUSTRIES INC. EMPLOYEES
John D. Wimmer ............. Truck Driver
Robin R. Beason ............. Truck Driver
James Charles Mitchell ............. Truck Driver
ANDALEX RESOURCES INC. OFFICIALS AND EMPLOYEES
Samuel C. Quigley ............. Vice-President of Operations
Thomas R. May ............. Safety Manager
Kent Pilling ............. Consultant
John Lewis ............. Senior Mining Engineer
STATE OF UTAH
Ronald P. Parkin ............. State Mine Inspector
Todd N. Curtis ............. Trooper, State Highway Patrol
CARBON COUNTY SHERIFF'S DEPARTMENT
Rick Adams ............. Deputy Sheriff
Roy Robinson ............. Sergeant
MINE SAFETY AND HEALTH ADMINISTRATION
Jerry O.D. Lemon ............. Coal Mine Safety & Health Inspector, Lead Investigator
John Turner ............. Educational Field Services Specialist
Terry Anderson ............. Coal Mine Safety & Health Inspector
Ronald Medina ............. Mechanical Engineer, Technical Support, Tridelphia, WV
Donald Durrant ............. Coal Mine Safety & Health Inspector
APPENDIX B


List of persons interviewed: SAVAGE INDUSTRIES INC. EMPLOYEES
John D. Wimmer ............. Coal Truck Driver
Robin R. Beason ............. Coal Truck Driver
James Charles Mitchell ............. Coal Truck Driver
James Phillips ............. Coal Truck Driver Supervisor
.