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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
(Limestone)

Fatal Powered Haulage Accident
November 18, 1999

Strunk Brothers Company (IR2)
Princeton, Bureau County, Illinois
at
Emerson Quarry
Frank N. Butler Company
Emerson, Whiteside County, Illinois
I.D. 11-00400

Accident Investigators

Russell T. Jarvi, Jr.
Supervisory Mine Safety and Health Inspector

William G. Dethloff III
Mine Safety and Health Inspector

Dennis Ferlich
Mechanical Engineer

Lawrence G. Wilson
Civil Engineer

Originating Office
Mine Safety and Health Administration
North Central District
515 West First Street, Room 333
Duluth, MN 55802-1302
Felix A. Quintana, District Manager


OVERVIEW


On November 18, 1999, Dean E. Dirksen, scraper operator, age 38, was fatally injured when the scraper he was operating lost power, rolled backward down the ramp and over the high wall to the quarry floor.

The accident occurred because the braking systems of the scraper were not maintained in safe operating condition. A berm of at least mid-axle height was not provided along the elevated ramp adjacent to the quarry high wall.

Dirksen had a total of four years experience as an equipment operator and had worked two months at this mine site. He had not received training in accordance with 30 CFR, Part 48.

GENERAL INFORMATION


Emerson Quarry, a surface limestone operation, owned and operated by Frank N. Butler Company, was located in Emerson, Whiteside County, Illinois. The principle operating officials were Donald F. Butler, Sr., president; Steve Decker, vice president and general manager; Dan Foltyniewicz, risk manager; and Joe Reaver, quarry foreman. The mine was normally operated one, 8-hour shift, five days a week. Total employment was six persons. Limestone was mined from a multi-bench quarry. It was crushed and conveyed by overland conveyors to the plant where it was screened, washed, and stockpiled for sale as construction aggregate.

The victim was employed by Strunk Brothers Company. Strunk Brothers Company, an independent contractor located in Princeton, Illinois, was hired to remove and haul overburden from the quarry to dump sites. The principle operating official was Richard Brown, owner. They employed nine persons on one, 8-hour shift, five days a week.

The last regular inspection of Emerson Quarry was completed on April 29, 1999.

DESCRIPTION OF THE ACCIDENT


On the day of the accident, Dean Dirksen (victim) reported for work at 7:00 a.m., his normal starting time. Dirksen and two other scraper operators were assigned to haul overburden from the northwest section of the quarry to a dump site at the south end of the quarry.

At about 1:30 p.m., Dirksen's loaded scraper was ascending the ramp from the loading point on his way to the dump site. As the scraper approached the top of the ramp, it stopped. The scraper rolled backward and traveled over the elevated edge of the ramp, coming to rest on the bench below.

James A. Cavallini, contractor excavator operator, observed a scraper traveling down the ramp and thought it was one returning from the dump. He swung the excavator back into the bank to prepare material for loading. When he swung back toward the ramp area, he saw the scraper going over the high wall. He ran to his truck and drove to the quarry office to summon emergency assistance.

Joseph Reaver, Emerson Quarry foreman, was working in the quarry with three of his men when he heard a loud crash. He proceeded to the accident scene and attempted to assist Dirksen. The scraper's tractor had overturned and the cab was partially submerged in mud. A front-end loader was used to upright the scraper in order to remove Dirksen.

Emergency personnel arrived and transported the victim to the local hospital where he was pronounced dead. Death was attributed to massive skull fracture and chest trauma.

INVESTIGATION OF THE ACCIDENT


At about 1:33 p.m., on November 18, 1999, Jay Bell, mine safety and health inspector, Peru, Illinois field office, was notified of the accident by a telephone call from Steve Decker, vice president and general manager for the Emerson Quarry. An investigation was started the next day. An order was issued pursuant to Section 103k of the Mine Act to ensure the safety of the miners until the affected area of the mine could return to normal operations. MSHA conducted an investigation with the assistance of Strunk Brothers Company personnel and Frank N. Butler Company personnel. The miners did not request nor have representation during the investigation.

DISCUSSION


1. The accident occurred on the ramp from the stripping site at the northwest section of the quarry. The ramp was about 320 feet long, 45 feet wide, and constructed of well-compacted earth. The lower section of the ramp bordered the high wall on one side. The ramp gradually turned away from the high wall as it continued at a 17 percent grade toward the quarry perimeter.

2. The berm along the elevated outer edge of the ramp was missing for a distance of about 65 feet. The distance from this elevated edge of the ramp to the bench below was about 51 feet.

3. Evidence indicated the loaded scraper stopped as it neared the crest of the ramp, rolled backward for a distance of about 180 feet, and traveled over the un-bermed edge, landing on the bench below.

4. A left-hand traffic pattern was used in the area where the accident occurred. There was no precipitation at the time of the accident and the ramp surface was dry and relatively smooth.

5. The scraper involved in the accident was a 1976 Caterpillar model 631D wheel tractor scraper. The scraper weighed about 93,000 pounds with a 21 cubic yard capacity, giving it a gross vehicle weight of about 168,280 pounds.

6. The scraper was powered by a Caterpillar Model 3408, eight-cylinder, turbo charged diesel engine. The transmission had a single-lever control, semi automatic power shift transmission with eight forward gears. A torque convertor multiplies torque in first, second, and reverse gears, and the third through eighth gears are direct. The steering was fully hydraulic articulated steering. Emergency steering was not included.

7. The rollover protection structure was intact and visibly undamaged. The steering wheel was slightly damaged.

8. The seat had separated from the pedestal which anchored it to the floor. No tether straps were installed to provide additional means to secure the seat. The seat belt was present and was being worn. Reportedly, the first employee on the scene cut the seat belt to remove the victim from the seat.

9. The park brake knob appeared to be applied (knob pulled outward). The emergency brake knob was in the applied position. The key was missing from the ignition. The transmission shift lever was in third gear.

10. The service brake system was air-operated and consisted of s-cam actuated drum type expanding shoe brakes on each of the four wheels. Air applied emergency brakes, supplied by a separate air reservoir, operating the same air chambers as the service brakes, were present on all four wheels. The service brakes were actuated using a foot pedal. The emergency brakes could be applied manually by positioning a knob on the dash in the operator's cab or automatically from loss of service air system pressure. The brake air chambers provided for each wheel were type 50 single-chamber rotochambers. A wet-disc parking brake was located internal to the transmission.

11. The push rod travel of all brake chambers was measured with approximately 110 p.s.i. of air pressure supplied to the air chambers. The maximum specified push rod stroke for type 50 rotochambers was 3 inches.

12. The push rod stroke for the right rear axle brake measured 3-3/4 inches. The right rear axle brake drum wear surface was shiny and clean, indicating lining to drum contact. Although the condition of the drum and brake linings showed some braking force was generated, the braking force was compromised by the brakes being 3/4 inch out of adjustment.

13. The push rod stroke for the left rear axle brake measured 3-7/8 inches. The left rear axle brake drum wear surface and brake lining were coated with dirt and rust, indicating no lining to drum contact. The wheel could be rotated by hand when the brakes were applied. The brake was 7/8 inch out of adjustment. No braking force was generated by this brake.

14. The push rod stroke for the right front axle brake measured 3-7/8 inches. The right front axle brake drum wear surface and the brake lining were coated with grease. The area inside the brake shoes was coated with grease. The brake was 7/8 inch out of adjustment. No braking force was generated by this brake.

15. The push rod stroke for the left front axle brake measured 3-5/8 inches. The left front axle brake drum wear surface was shiny and clean in appearance with some heat checks, indicating lining to drum contact. The rear section of the top brake lining had a crack extending across the width of the lining through the rivets. This crack extended through the lining thickness and was visible from the edge of the lining. A piece of the lining approximately 3 inches long by 7 inches wide was broken off the front section of the top brake lining. Although the condition of the drum and brake linings showed some braking force was generated, the braking force was compromised by the brakes being 5/8 inch out of adjustment.

16. The transmission was removed from the machine. Visual examination of the components that could be seen without disassembling the transmission showed no broken parts. The transmission was turned by hand and found to rotate freely with no audible signs of damage. The differential output gear was rotated by hand and the final drive gears rotated easily with no audible or visual signs of damage.

17. The fuel strainer and fuel filters were separated from the engine. The strainer and fuel filter were removed from the housing and visually examined for dirt and contamination. The strainer and bowl were relatively clean. The fuel line between the injector pump and fuel injectors was removed. A small amount of fuel was present in some of the lines.

CONCLUSION


The primary cause of the accident was management's failure to maintain the scraper in safe operating condition. The service braking system and the parking brake were not maintained to allow the driver to control the scraper. Contributing factors were management's failure to assure that adequate pre-operation inspections had been conducted on mobile equipment to identify safety defects and failure to assure that berms of mid-axle height were provided to the outer edge of the haul ramp. Failure to assure that seat tether straps were installed contributed to the severity of the accident.

ENFORCEMENT ACTIONS


Strunk Brothers Company

Order No. 7838219 was issued on November 18, 1999, under provisions of Section 103(k) of the Mine Act:
A fatal accident occurred at the Emerson Quarry on November 18, 1999, when a contractor scraper operator was ascending the hill and inadvertently went backwards down the hill and over a 51-foot high wall, causing fatal injuries. This order is issued to assure the safety of persons at this operation until the mine or affected areas can return 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 December 8, 1999, after it was determined that the mine could safely resume normal operations.

Order No. 7838239 was issued on December 8, 1999 under provisions of Section 104(d)(1) of the Mine Act for violation of 30 CFR 56.14101(a)(1):
A fatal accident occurred at this mine on November 18, 1999, when a loaded scraper was ascending a ramp, lost power, rolled backwards, and traveled over the edge of the quarry bench. The service brakes on the scraper were not capable of stopping and holding the scraper on this ramp. Failure to provide adequate service brakes is a serious lack of reasonable care constituting more than ordinary negligence and is an unwarrantable failure to comply with a mandatory safety standard.
This citation was terminated on December 8, 1999. The scraper has been taken out of service and disassembled.

Order No. 7838240 was issued on December 8, 1999, under provisions of Section 104(d)(1) of the Mine Act for violation of 30 CFR 56.14101(a)(2):
A fatal accident occurred at this mine on November 18, 1999, when a loaded scraper was ascending a ramp, lost power, rolled backwards, and traveled over the edge of the quarry bench. The parking brake was not capable of holding the scraper on this ramp. Failure to provide adequate parking brakes is a serious lack of reasonable care constituting more than ordinary negligence and is an unwarrantable failure to comply with a mandatory safety standard.
This order was terminated on December 8, 1999. The scraper was taken out of service and disassembled.

Order No. 7838241 was issued on December 8, 1999, under provisions of Section 104(d)(1) of the Mine Act for violation of 30 CFR 56.14101(a)(3):
A fatal accident occurred at this mine on November 18, 1999, when a loaded scraper was ascending a ramp, lost power, rolled backwards, and traveled over the edge of the quarry bench. The following defects to the braking systems existed on this scraper: the left front wheel had a 3-inch by 7-inch piece of the brake shoe missing; the right front wheel brake shoe and drum were coated with grease; the brakes on all four wheels of the scraper were out of adjustment. The continued operation of this scraper constituted more than ordinary negligence and is an unwarrantable failure to comply with a mandatory safety standard.
This order was terminated on December 8, 1999. The scraper has been taken out of service and disassembled.

Order No. 7838242 was issued on December 8, 1999, under provisions of Section 104(d)(1) of the Mine Act for violation of 30 CFR 56.9300(b):
A fatal accident occurred at this mine on November 18, 1999, when a loaded scraper was ascending a ramp, lost power, rolled backwards, and traveled over the edge of the quarry bench. A berm was not provided for a distance of 65 feet on the elevated edge of this ramp where a drop-off existed. Failure to provide a berm of mid-axle height is a serious lack of reasonable care constituting more than ordinary negligence and is an unwarrantable failure to comply with a mandatory safety standard.
This order was terminated on December 8, 1999. The use of the ramp has been discontinued and the access has been blocked with large berms.

Order No. 7838243 was issued on December 8, 1999, under provisions of Section 104(d)(1) of the Mine Act for violation of 30 CFR 56.14100(a):
A fatal accident occurred at this mine on November 18, 1999, when a loaded scraper was ascending a ramp, lost power, rolled backwards, and traveled over the edge of the quarry bench. Three separate safety defects existed on this scraper and were cited as causes of the accident. The mine operator did not require the equipment operator to perform a pre-operation inspection on this scraper. This is a serious lack of reasonable care constituting more than ordinary negligence and is an unwarrantable failure to comply with a mandatory safety standard.
This order was terminated on December 8, 1999. The scraper was taken out of service and disassembled.

Citation No. 7838244 was issued on December 8, 1999, under provisions of Section 104(a) of the Mine Act for violation of CFR 30 56.14100(d):
The operator failed to maintain records of mobile equipment defects in regards to the braking systems on the #22 Caterpillar 631D scraper, s/n 27W535, not being functional.
This citation was terminated on December 8, 1999. The scraper was taken out of service and disassembled.

Order No. 7838246 was issued on December 15, 1999, under provisions of Section 104(d)(1) of the Mine Act for violation of 30 CFR 56.14130h:
A fatal accident occurred at this mine on November 18, 1999, when a loaded scraper was ascending a ramp, lost power, rolled backwards, and traveled over the edge of the quarry bench. The tether straps provided by the equipment manufacturer to secure the seat to the floor of the operator's cab had been removed. Failure to provide seat tether straps is a serious lack of reasonable care constituting more than ordinary negligence and is an unwarrantable failure to comply with a mandatory safety standard.
This order was terminated on December 15, 1999. The scraper was taken out of service and disassembled.

Frank N. Butler Company

Order No. 7838245 was issued on December 8, 1999, under provisions of Section 104(d)(1) of the Mine Act for violation of 30 CFR 56.9300(b):
A fatal accident occurred at this mine on November 18, 1999, when a loaded scraper was ascending a ramp, lost power, rolled backwards, and traveled over the edge of the quarry bench. A berm was not provided for a distance of 65 feet on the elevated edge of this ramp where a drop-off existed. Failure to provide a berm of mid-axle height is a serious lack of reasonable care constituting more than ordinary negligence and is an unwarrantable failure to comply with a mandatory safety standard.
This order was terminated on December 8, 1999. The use of the ramp has been discontinued and the access has been blocked with large berms.

Related Fatal Alert Bulletin:
Fatal Alert Bulletin Icon FAB99M49

APPENDIX A

Persons Participating in the Investigation

Strunk Brothers Company

Thomas Brown, shop supervisor Steve Joiner, equipment operator
Frank N. Butler Company
Joseph Reaver, quarry foreman
Mine Safety and Health Administration
Russell T. Jarvi, Jr., supervisory mine safety and health inspector
William G. Dethloff, III, mine safety and health inspector
Dennis Ferlich, mechanical engineer
Larry Wilson, civil engineer
APPENDIX B

Persons Interviewed

James Cavallini, excavator operator
Patrick Nichols, track dozer operator/mechanic
Daniel Myers, scraper operator
Darrell Corcran, scraper operator