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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 Mill
(Trona)

Fatal Powered Haulage Accident

August 06, 2002

Rail Link, Inc. (JVU)
Jacksonville, Duval County, Florida

at

General Chemical Mill
General Chemical Corporation
Green River, Sweetwater County, Wyoming
I.D. No. 48-01497

Accident Investigators

John R. King
Mine Safety and Health Inspector

Iredell J. Rogers
Mine Safety and Health Inspector

John Turner
Mine Safety and Health Specialist

Benjamin Gandy
Mining 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

On August 6, 2002, Jerry L. Ridgeway, switchman, age 50, was fatally injured when he was crushed between a parked railcar and a railcar being moved on an adjacent track.

The accident occurred because adequate clearance was not provided between the parked railcar and the cars being moved on the adjacent track.

Ridgeway had a total of 29 years and 13 weeks mining experience, four years and 13 weeks as a switchman at this operation. Ridgeway had received training in accordance with 30 CFR, Part 48.

GENERAL INFORMATION

General Chemical Mill, a trona mill, owned and operated by General Chemical Corporation, was located in Green River, Sweetwater County, Wyoming. The principal operating official was Peter J. Kalivas, vice-president of manufacturing. The mill was normally operated three, 8-hour shifts a day, seven days a week. Total employment was 243 persons.

Ore was delivered from the company's underground trona mine to the mill where it was screened, crushed, and heated in large kilns known as calcinators. It was then dissolved into a soda ash liquid, filtered and evaporated to form soda ash crystals. The product was dried and screened to customer specifications and conveyed to storage bins at the product load-out facility. The soda ash was loaded into railcars or semi-trucks and shipped to customers.

Rail Link, Inc., an independent contractor, was contracted to move railcars at the mill site. Rail Link, Inc. was located in Jacksonville, Duval County, Florida. The principal operating official was James N. Davis, vice-president field operations. Rail Link, Inc. normally operated two, 10-hour shifts a day, five days a week. The contractor employed four persons at this site.

The last regular inspection of this operation was completed on May 6, 2002.

DESCRIPTION OF THE ACCIDENT

On the day of the accident, Jerry L. Ridgeway (victim), reported for work at 9:30 p.m., his normal starting time. DeWayne H. Herren, crew leader, assigned Ridgeway to switch railcars and Shane Fulghum, switchman/locomotive engineer, to operate the locomotive. William E. Shay, switchman (trainee), was assigned to the crew and was being trained as a switchman. Herren provided the switch crew with a list of railcars to be moved to different locations in the rail yard.

Work switching railcars in the yard proceeded normally until about 11:30 p.m. Herren then assigned the crew to reposition two railcars at the cold ash load-out facility. Herren directed Fulghum to proceed to the cold ash load-out with two locomotives attached to 22 railcars. The railcars were positioned in front of the locomotives and Ridgeway was assigned to open the MARV rail switch on the running rail to allow the train access to the No. 12 track crossover for entry to the cold ash load-out rail. Herren and Shay then proceeded to walk to the cold ash load-out with the intent of training Shay on coupling procedures.

Ridgeway opened the MARV rail switch and was directed by Herren to ride the front railcar ladder stirrup, on the left (south) side of the car. Fulghum was then directed by Ridgeway to push the railcars towards the cold ash load-out. Fulgham proceeded as directed and moved the 22 railcars up the line (west) towards the cold ash load-out. The established procedure was for the switchman to stay in contact with the engineer by radio when out of sight. The train moved forward approximately five car lengths at which point Fulgham could not see Ridgeway and attempted to call him on his radio. When Ridgeway did not respond, Fulgham stopped the train. Herren and Shay then attempted to contact Ridgeway on the radio. After receiving no response, they walked along both sides of the train and found Ridgeway laying on his back, unconscious, between the rails of No. 12 crossover track.

Emergency medical assistance was summoned and Ridgeway was transported to a local hospital where he was pronounced dead at approximately 1:05 a.m., on August 7, 2002. Death was attributed to trauma due to crushing impact to the chest and abdomen.

INVESTIGATION OF THE ACCIDENT

MSHA was notified of the accident at 1:30 a.m., on August 7, 2002, by a telephone call from Edward A. Bostick, General Chemical Corporation's safety and security administrator, to Danny Frey, 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 examination of the 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 management and employees.

DISCUSSION

  • The accident occurred at the No. 12 track crossover, 116 feet from the MARV switch.


  • The victim was riding on the stirrup of the ladder on the left side of westbound railcar No. GACX 48158 traveling on the running rail. He was crushed between it and railcar No. CEFX 13305 positioned at the west-end of No. 12 track.


  • Railcar No. GACX 48158 and No. CEFX 13305 were covered hopper cars, each with a gross weight of 122,000 pounds.


  • Clearance between the two railcars at the No. 12 track crossover was 3-1/2 inches at the stirrup and 11 inches at the top of the railcars.


  • A reenactment of the movement of the train on the running rail was conducted. The railcars yawed (move from side to side) as they approached the No. 12 track traveling from east to west at four miles per hour. Clearance between the railcars was less than the clearance during static position of the railcars. Several railcars were observed striking the parked No. CEFX 13305 railcar.


  • Sodium vapor lights were positioned along the north side of the rail yard. The victim carried a Starlight (Model 292) star headlight and illumination lamp.


  • The victim carried a Motorola (Model HT 1000) handie-talkie, 3 channel, FM radio, operated on B-channel. The radio was used to communicate with other members of the switch crew.


  • All equipment inspected by MSHA Technical Support and a railcar maintenance company representative was found to be fully functional.


  • The insufficient clearance was noted on the previous shift.
  • CONCLUSION

    The root cause of the accident was the failure to initiate prompt corrective action when it was first discovered the parked railcar was too close to the adjacent track. The accident occurred because adequate clearance was not provided between the parked railcar and the cars being moved on the adjacent track.

    ENFORCEMENT ACTIONS

    The following violations were issued to Rail Link, Inc.:

    Order No. 7914506 was issued on August 7, 2002, under the provisions of Section 103(k) of the Mine Act:
    A fatal accident occurred at this operation on August 6, 2002, when a miner who was switching railcars was crushed between the moving railcar he was riding and a stationary railcar on an adjacent track. This order is issued to ensure the safety of all persons at this operation. It prohibits all activity at the rail switch yard between switch 12 and 13 until MSHA has determined that it is safe to resume normal mining operations an the area. 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 August 7, 2002. Conditions that contributed to the accident have been corrected and normal milling operations can resume.

    Citation No. 7935758 was issued on September 5, 2002, under the provisions of Section 104(d)(1) of the Mine Act for violation of 30 CFR 57.9103:
    On August 6, 2002, a switchman was fatally injured when the railcar on which he was riding passed too close to the parked railcar (CEFX 13305). Railcar (CEFX 13305) was left on a sidetrack without adequate clearance for traffic to pass on an adjacent track. The switch crew leader was aware of the inadequate clearance between the railcar parked on the sidetrack and railcars moving on the adjacent cut through between switches 12 and 13. Failure to ensure adequate clearance on the cut through between switches 12 and 13 and the railcar parked on the sidetrack, prior to moving railcars, constitutes more than ordinary negligence and is an unwarrantable failure to comply with a mandatory standard.
    This citation was terminated on September 23, 2002. All switch locations where close clearance problems can exist have been marked with yellow paint on the rails. Procedures are in place for these close clearance locations stating that no portion of the railcar other than the coupler may extend beyond the yellow close clearance marking and training has taken place.

    Order No. 7935756 was issued on September 5, 2002, under the provisions of Section 104(d)(1) of the Mine Act for violation of 30 CFR 57.18002(a):
    On August 5, 2002, a switch crew leader observed that a railcar had been left on a sidetrack without adequate passing clearance for railcars moving on the adjacent cut through between switches 12 and 13. No action was taken to correct this unsafe condition. The next day, a switchman was fatally injured when the railcar on which he was riding passed too close to the parked railcar. The failure to initiate corrective action constitutes more than ordinary negligence and is an unwarrantable failure to comply with a mandatory standard.
    This citation was terminated on September 23, 2002. All competent persons designated by the operator have been retrained in the importance of correcting conditions which may adversely affect safety and health.

    Related Fatal Alert Bulletin:
    Fatal Alert Bulletin Icon FAB02M21




    APPENDIX A


    Persons Participating in the Investigation


    General Chemical Corporation
    David A. Graham ......... manager-safety and occupational health
    Joseph Jelaca ......... safety engineer
    Keith A. Mullins ......... mine safety supervisor
    Edward A. Bostick ......... safety and security administrator
    Peter J. Kalivas ......... vice-president of manufacturing
    William Kuehl ......... production supervisor - surface
    Rail Link, Inc.
    James N. Davis ......... vice-president field operations
    Jack N. Brown ......... chief compliance officer
    Patrick A. Duling ......... site manager
    United Steelworkers of America, Local 15320
    Donald L. Tyler ......... co-chair union safety committee
    United Steelworkers of America, Local 15320
    Terry Gordon ......... manager
    State of Wyoming
    Donald G. Stauffenberg ......... state inspector of mines
    Hector A. Castillon ......... deputy inspector of mines
    Mine Safety and Health Administration
    John R. King ......... mine safety and health inspector
    Iredell J. Rogers ......... mine safety and health inspector
    Benjamin Gandy ......... mining engineer
    John R. Turner ......... mine safety and health specialist

    APPENDIX B

    Persons Interviewed

    General Chemical Corporation
    Tasha L. Urbatsch ......... emergency medical technician
    William Kuehl ......... production supervisor - surface
    Rail Link, Inc.
    James N. Davis ......... vice-president field operations
    Jack N. Brown ......... chief compliance officer
    Patrick Duling ......... site manager
    DeWayne H. Herren ......... crew leader
    Shane E. Fulghum ......... switchman/engineer
    William E. Shay ......... switchman trainee
    Lamar J. Johnson, III ......... assistant manager