DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
Report of Investigation
Surface Nonmetal Mine
Fatal Powered Haulage Accident
September 10, 2002
Highland Enterprises Crusher I
Highland Enterprises, Inc
Lewiston, Nez Perce County, Idaho
Mine I.D. No. 10-01911
John D. Pereza
Mine Safety and Health Inspector
John C. Kathmann
Mine Safety and Health Specialist
James L. Angel
Eugene D. Hennen
Mine Safety and Health Administration
2060 Peabody Road, Suite 610
Vacaville, CA 95687
Lee D. Ratliff, District Manager
On September 10, 2002, Wayne C. Reuter, truck driver, age 57, was fatally injured when he lost control of the haul truck he was operating. The truck over-traveled the road edge, went approximately 550 feet, struck a tree and rolled onto its side. The victim was thrown from the operator's cab.
The accident occurred due to the truck's braking systems not being maintained in functional condition
Reuter had 25 years mining experience. He had received training in accordance with 30 CFR, Part 46.
Highland Enterprises Crusher 1, a portable surface crushed stone operation, owned and operated by Highland Enterprises, Inc., was located in Lewiston, Nez Perce County, Idaho. The principal operating official was Marvin A. Hairston, manager. The plant was normally operated one, 8-hour shift a day, 5 days a week. Total employment was four persons.
The portable plant had been relocated to this site about 2 days prior to the accident. Upon completion of the required set-up activities, the plant commenced operation on the day of the accident. Rock was mined from a single bench quarry by drilling and blasting. A bulldozer then pushed the blasted rock into a primary feed hopper. The material was crushed and sized to a finished product and was sold for use in the construction industry.
The last regular inspection of this operation was completed on August 14, 2002.
On September 10, 2002, Wayne C. Reuter (victim) reported for work at 6:30 a.m. his normal start time. Reuter spoke with foreman Richard James, prior to starting his work activities, regarding the final setup of the plant and hauling finished material.
At about 11:30 a.m., Reuter proceeded to haul one truckload of material to the finished material stockpile. James observed the truck approaching the load-out conveyor when it suddenly left the road. The truck traveled downhill through a field crossing a ditch, a road, and an embankment and struck a tree. Chad Reuter, Plant Oiler, witnessed the truck leaving the roadway and proceeded to the area and found the victim lying on the ground unconscious. As Reuter ran toward the plant, he met James and informed him about the victim's injuries. James immediately called 911, retrieved a first aid kit, and attended to the victim. A short time later emergency medical service arrived at the scene and pronounced the victim dead. Death was attributed to traumatic injury to the head.
MSHA's Boise, Idaho, field office was notified of the accident at 8:15 a.m. on September 11, 2002, by a telephone call from Andy Hairston, manager. An investigation began the same day. MSHA's accident investigation team traveled to the mine, made a physical inspection of the accident scene, interviewed employees, reviewed training records, and reviewed conditions and work procedures relevant to the accident. MSHA conducted the investigation with the assistance of mine management and employees.
The accident occurred on the plant haul road near the load-out conveyor. This road was also used to access the mine. The road at this location was 16 feet wide with a grade of approximately 8 percent. The drop-off on the elevated edge of this road ranged from 4 feet to 10 feet. The point at which the truck left the roadway had a drop-off measuring approximately 5 feet. Berms were not constructed at any location on this haulage road.
Upon leaving the roadway, the truck traveled approximately 550 feet through three distinct areas. The first section was a field 100 feet long, with grades ranging from 12 to 16 percent. This section was separated by a ditch measuring 6 feet in depth. The truck traveled through the ditch, climbed the bank and proceeded forward entering the second section. At this point it crossed another road and traveled 250 feet through an open area with grades ranging from 10 to 16 percent. The truck then entered the third section where it traveled over an embankment for another 125 feet, struck a tree, and overturned.
The truck involved in the accident was a 1980 Volvo, Model 861, VIN No. 56733, articulated dump truck with one axle on the front tractor unit and two axles on the dump trailer unit. The truck capacity was 20 tons and it weighed 28,356 pounds empty. The company purchased the truck on August 1, 2002.
The service brakes were split into a separate circuit for the tractor unit axle and a separate circuit for the two axles on the dump trailer unit. The service brakes were applied and released using the foot brake pedal (treadle valve) located in the cab.
The parking brake, which consisted of the spring portion of the four dump trailer unit brake chambers, could be applied and released manually with the parking brake control located in the cab to the right of the operator's seat. The parking brake application and release was also controlled automatically by transmission position. With the parking brake control in the released position, placing the transmission in neutral automatically applied the parking brake. When placing the transmission in gear the park brake would automatically release. With the parking brake control in the applied position, the transmission position would not affect the function of the parking brake. The parking brake system was not directly linked into the service braking system and loss of air pressure to the service braking system did not result in automatic application of the parking brakes.
The system that automatically applied the parking brake once the transmission was placed in neutral was not functional.
The tractor unit axle was equipped with air over hydraulic disc brakes on each wheel with two brake calipers on each disc. A single air over hydraulic unit (air chamber/hydraulic master cylinder assembly) supplied the two tractor unit axle brakes. The air over hydraulic unit master cylinder on the tractor unit was found to have a defective seal. No braking force was provided by the tractor unit axle brakes.
The dump trailer unit was equipped with air-applied, s-cam shoe-type service brakes. On the dump trailer unit rear axle, the mechanism that held the bar connecting the brake chambers to the slack adjusters was bent, causing a bind on this mechanism when the brakes were applied. On the rear axle right side, the brake shoes had approximately three-sixteenths of an inch of lining thickness. Part of the wear surface of the drum was shiny and part was rusty which indicated the brake shoes were making partial contact with the drum when the brakes were applied. The linings on the left side of the rear axle were severely worn. Rivets in the linings had been wearing against the drum and most of the friction material had fallen off. When the park brake was applied there was a gap of one-eighth of an inch between the shoes and the drum. Rust on the entire wear surface of this drum also indicated the brake shoes did not come in contact with the drum when either the parking brake or service brake was applied.
On the dump trailer unit forward axle the brake shoe linings on both the left and right brakes were approximately one-quarter of an inch thick. The brake drum and brake shoe linings on the right front were oil soaked.
The air hose connecting the service brake relay valve to the forward axle brake chambers had a hole approximately 2 inches long. Failure of this hose resulted in a complete loss of air pressure to all four brakes on both axles of the dump trailer.
There was no record of defects for the truck.
The victim was not wearing the seat belt provided in the truck. The seat belt latch and straps were dirty indicating it was a practice not to wear the seat belt when operating this truck. The company did not have a written seat belt policy in place.
The company had an approved MSHA training plan and training had been given to the victim. Although the victim had been task-trained in the use of the truck, there was no operator's manual for the truck onsite.
A root cause analysis was conducted. The following causal factors were identified:
Causal Factor: The defective brakes on the truck were not repaired.
There were problems with the braking system for both the tractor and the trailer portions of the truck. There was a defective master cylinder on the front brake system. The brake linings were worn on one wheel of the trailer and the brake drum and lining were soaked in oil on another wheel of the trailer. Additionally, there was a mechanical bind on the slack adjusters due to a bent connecting mechanism.
Corrective Action: A plan should be developed and implemented for pre-operational inspections for mobile equipment. Employees should be trained on conducting effective pre-operational exams on mobile equipment and the proper procedure for reporting any safety defects. A plan should be in place to ensure that all defects are recorded and corrected in a timely manner.
Causal Factor: A berm was not provided along the elevated edge of the haul road that the truck typically travels.
Corrective Action: Berms should be provided along the edge of roadways where a drop-off exists of sufficient grade or depth to a cause a vehicle to overturn or endanger persons in equipment. Work areas should be inspected each shift to ensure hazards are eliminated.
Causal Factor: The operator of the truck was not wearing his seatbelt.
Corrective Action: The company should train their employees on wearing their seatbelts, monitor their employees to ensure the training was effective and require that seatbelts be worn when operating all mobile equipment.
The accident occurred because the truck's braking systems had not been maintained in functional condition. The following root causes were identified: failure to implement a safety process; failure to promptly correct safety defects; and the failure to inspect mobile equipment thoroughly prior to operating it. The failure to construct a berm on the elevated outer edge of the plant roadway and the failure to require mobile equipment operators to wear seat belts were contributing causes.
Order No. 6333534 was issued on September 11, 2002, under the provisions of 103(k)1 of the Mine Act.
A fatal accident occurred at the Highlands Enterprises Portable Crusher on September 10, 2002. A miner was operating a Volvo BM 860 haul truck from the product-loading hopper to the lower stockpile area. The truck went off an elevated roadway that was adjacent to the product-loading bin, and traveled on its wheels several hundred feet through rough terrain and stopped after colliding with a large tree. This order is issued to assure the safety of all persons at this operation. It prohibits all activities associated with product loadout, including the Volvo BM 860 haul truck, until MSHA has determined that it is safe to resume normal operations. 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 September 23, 2002, when conditions which led to the accident no longer existed and normal operations could resume.
Citation No. 6333533 was issued on September 17, 2002, under provisions of Section 104(d)1 of the Mine Act for a violation of 30 CFR 56.14101(a)3:
A fatal accident occurred at this mine on September 10, 2002 when a Volvo haul truck (serial # 56733) over-traveled the edge of an elevated roadway and struck a tree. All braking systems on the truck were not maintained in a functional condition. The defects included, but were not limited to: a defective seal on the master cylinder for the front air over hydraulic braking system, which rendered the system inoperative; and a crack existed in the brake fluid reservoir for the front system. The left rear wheel on the rear braking system had a gap of one-eight of an inch between the shoes and the drum; the right rear shoes were making minimal contact with the drum; the right rear middle brake drum and shoes were saturated with an accumulation of oil. Additionally, the automatically operated neutral brake system was not functioning. The mine operator engaged in aggravated conduct constituting more than ordinary negligence in that it was aware of problems with the braking systems on the truck and instructed the truck to be driven over grades. This is an unwarrantable failure to comply with a mandatory safety standard.This citation was terminated on November 18, 2002, when the vehicle was removed from the property.
Order No. 6333534 was issued on September 17, 2002, under the provisions of 104(d)1 of the Mine Act for a violation of 56.9300(a):
A fatal accident occurred at this mine on September 10, 2002, when a Volvo haul truck over-traveled the edge of an elevated roadway and struck a tree. Berms or guardrails were not provided for the plant roads. There were more than 100 feet of the elevated roadway where this truck was normally operated. A dropoff from between 4 and 10 feet existed along this elevated roadway edge. The mine operator engaged in aggravated conduct constituting more than ordinary negligence by knowingly allowing a vehicle to operate on this unbermed roadway where dropoffs exist. This is an unwarrantable failure to comply with a mandatory safety standard.This order was terminated on October 17, 2002, when the plant roads were bermed as necessary.
Order No. 6333535 was issued on September 17, 2002, under the provisions of 104(a) of the mine Act for a violation of 56.14131(a):
A fatal accident occurred at this mine on September 10, 2002, when a Volvo haul truck over-traveled the edge of an elevated roadway and struck a tree. The operator of the truck was not wearing the seat belt provided and was found lying outside the truck. The physical condition of the seat belt indicated it had not been worn for a period of time.This citation was terminated on November 21, 2002, when the company provided additional training in the use of seat belts for the mine employees.
Related Fatal Alert Bulletin:
Persons Participating in the Investigation
Marvin A. Hairston .......... manager
Richard M. James .......... foreman
Kenneth S. Leighton .......... regional product support manager, Volvo North America, Inc.
Ben J. Mosley .......... mechanical technician, Clyde West Volvo
Mine Safety and Health Administration
John D. Pereza .......... mine safety and health inspector
John C. Kathmann .......... mine safety and health specialist
James L. Angel .......... mechanical engineer
Eugene D. Hennen .......... mechanical engineer
Marvin A. Hairston .......... manager
Richard M. James .......... foreman
Chad E. Reuter .......... plant oiler
Mark C. Reid .......... bulldozer operator
Nez Perce County
Lt. Wade L. Ralston .......... Nez Perce County Sheriff's Department
Sgt. William R. Madison .......... Nez Perce County Sheriff's Department
Robert M. Whitlock .......... Nez Perce County coroner
St Joseph's Hospital, Lewiston, Idaho
Dr. Robert W. Cihak .......... medical examiner