DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
Rocky Mountain District
Metal & Nonmetal Mine Safety and Health
ACCIDENT INVESTIGATION REPORT
SURFACE NONMETAL MINE
FATAL POWERED HAULAGE ACCIDENT
Harrison-Escalante Pit [I.D. No. 02-00704]
B & R Materials Inc.
Tucson, Pima County, Arizona
February 2, 1995
By
Clarence Ellis
Mine Safety and Health Inspector
Larry Aubuchon
Supervisory Mine Safety and Health Inspector
Originating Office
P.O. Box 25367 DFC
Denver, CO 80225-0367
Robert M. Friend, District Manager
GENERAL INFORMATION
Ronald F. Matthews, front-end loader operator, age 33, was fatally injured at approximately 2:30 p.m., February 2, 1995, when he attempted to replace the berm along the abandoned pit haulage road. He inadvertently traveled over the pit highwall, and the loader fell approximately 30-ft to the pit floor. Matthews had 1 year, 16 weeks total mining experience. All of this time was as a front-end loader operator at this mine.
Douglas McGlothlin, operations superintendent, notified Larry Nelson, MSHA supervisory mine inspector, of the accident at 2:30 p.m., on February 3, 1995. An investigation was started the same day.
The Harrison-Escalante Pit, a multiple bench sand and gravel operation, was owned and operated by B & R Materials. The pit was located within the city limits of Tucson, Pima County, Arizona, along the Pantano Wash. The mine normally operated one, 9-hour shift a day, 5 days a week. A total of 17 employees was employed at the mine. The principal operating official was Roland C. Browne, president.
Sand and gravel was mined at the pit using a dozer to loosen the material, which was loaded onto a belt conveyor by front-end loader for transporting to the crusher, screens and wash plant.
The finished product was stockpiled to be sold to customers in the construction industry.
The last regular inspection was conducted on May 24 and 25, 1994.
MSHA is prohibited by congressionally imposed budget restrictions from enforcing the training requirements of 30 CFR, Part 48, at this operation.
PHYSICAL FACTORS INVOLVED
The accident occurred in the southwest area of the pit at a section of abandoned haulage road that once led to the pit. The abandoned haulage road was sloped downward, toward the pit, at a 15 to 20% grade and ended at the edge of the 30-ft pit highwall.
Approximately 40-ft back from the pit highwall edge, the abandoned haulage road intersected the active haulage road. At this intersection, the abandoned haulage road was bermed-off to prevent vehicle entry. Reportedly, approximately one week before the accident, heavy rains and run-off started washing out the active haulage road. To allow for better drainage, the berm across the abandoned haulage road at the intersection was removed.
A Kolberg screen plant was located approximately 100-ft from the intersection of the active haulage road and the old haulage road at the southeast area of the pit. This screen plant was used to process fill material.
The front-end loader (FEL) involved in the accident was a 1976 International Hough, Model H-80-B, Serial No. 2515, Company No. L-6, equipped with certified ROPS. The L-6 FEL was considered a "spare" loader and was only to be used when any of the other threeFEL's were not in operating condition.
On January 30, 1995, the Kolberg plant operator was operating one of the other Hough Model H-80-B FEL's which the company designated as L-12. Due to problems with the front differential, the L-12 FEL was removed from service.
On January 31, 1995, the Kolberg plant operator operated the spare FEL, designated L-6. At the end of the shift he noted on the equipment check list that the operating service brakes were defective on this L-6 FEL. After maintenance was performed later that day, another entry was made in the equipment check list noting that the maintenance on the L-6 FEL made no improvement to the brakes.
On February 1, 1995, the L-6 FEL was operated by the Kolberg plant operator and again, the FEL operator noted on the equipment check list that the brakes were still defective.
The L-6 FEL was equipped with a combination air-over-hydraulic service brake which employed dual master cylinders to support and actuate the separate front and rear drum type brake shoes. The air actuated park brake system expanded the brake shoe against the drum, which was mounted on the transfer drive shaft.
The L-6 FEL service and park brake systems were inspected and brake components examined at the pit on February 7, 1995. This examination revealed the following:
- The left front master cylinder, which operated the rear wheel brakes, was empty of brake fluid.
- After the left front master cylinder was filled, the actuator cylinder on the right rear wheel brake leaked.
- The right front master cylinder, which operated the front wheel brakes, would not function. The primary retainer cup was defective.
- The park brake shoes were in a "closed" position and would not expand to engage the brake drum. It could not be determined if the park brake was defective prior to the accident.
DESCRIPTION OF THE ACCIDENT
On the day of the accident, Ronald F. Matthews, front-end loader operator (victim), reported to work at 7:00 a.m., his regular starting time. Douglas McGlothlin, operations superintendent, assigned Matthews to operate the Kolberg screen plant, which included operating the L-6 FEL to load customer's trucks and other duties around the plant. Prior to start-up, Matthews serviced the equipment and cleaned-up around the Kolberg plant. At approximately 8:50 a.m., a contract truck driver arrived at the Kolberg plant area for loading. While watching Matthews load his truck, it became obvious to the truck driver that the brakes on the L-6 FEL were defective because Matthews was stopping the loader by shifting the transmission into reverse. After his truck was loaded, he and Matthews discussed the defective brakes.
Matthews continued loading trucks with the L-6 FEL and operating the Kolberg plant. At approximately 1:50 p.m., while loading another truck, the truck driver observed the L-6 FEL running into the side of his truck, another indication that the brakes were defective.
At approximately 2:00 p.m., McGlothlin stopped by the Kolberg plant on his way to the main office and instructed Matthews to replace the berm, closing off the abandoned haulage road. Matthews proceeded to the road intersection area in the L-6 FEL to replace the missing berm.
While operating a FEL at the central area of the pit, Guillermo Gallardo, suddenly noticed a yellow object fall off the 30-ft highwall. Gallardo immediately proceeded to the area, approximately 300-ft away, and upon arrival observed Matthews lying on the ground 5-ft away from the L-6 FEL. Gallardo could not detect a pulse on Matthews. He traveled to the main office and reported the accident. The Tucson Fire Department arrived at the accident site at 2:37 p.m. Matthews was pronounced dead and cause of death was blunt force trauma to the head and upper body.
CONCLUSION
The direct cause of the accident was operating the L-6 FEL with defective brakes. A contributing factor was the absence of a barricade and/or berm at the 30-ft highwall to prevent overtravel. Contributing to the severity of injuries sustained was the failure to wear the seatbelt provided on the FEL.
Investigation of the area where Matthews was instructed to replace the berm revealed that Matthews may have been "back dragging" the roadway with the loader bucket.
VIOLATIONS
The following order was issued during the investigation:
Order No. 4407341, 103 (k)
Issued 2/3/95, at 1430 hours.
A fatal haulage accident occurred on February 2, 1995, at approximately 1430 hours at the Harrison-Escalante Pit. A front-end loader Hough Model H-80 went over the pit wall in the southwest corner of the pit. The area described in Section II, line 15 is restricted to traffic and will not be disturbed until the investigation has been completed. Any activity in the area must be cleared by an inspector or investigator with MSHA.
Terminated 2/9/95, at 1300 hours.
The investigation of the fatal accident that occurred on 2/2/95, is complete. The FEL involved in the accident has been removed from service.
The following citations were issued during the investigation:
Citation No. 4407320, 104 (d) (1)
Issued 2/9/95, at 1300 hours for a violation of 56.14100(c).
A fatal accident occurred on 2/2/95, at approximately 2:30 p.m., when a front-end loader operator over ran the pit highwall. Work was conducted on 1/31/95, to correct the malfunctioning brake system on the Hough Model H-80 B front- end loader, Serial No. 2515 that was involved in the accident.
The operator failed to repair the brake system on the front- end loader. The loader was not tagged or removed from service. On 2/2/95, the Hough loader was allowed to be operated. The operator had full knowledge of the defect in the brake system.
Aggravated conduct higher than normal negligence was shown by the operator allowing the loader to be operated. The condition is unwarrantable. This citation is being issued on 2/9/95, at the completion of the investigation.
Terminated 2/16/95, at 0800 hours.
The loader, Serial No. 2515, has been permanently removed from service. In fact the company insurance has taken control of the loader for salvage.
The hazard has been eliminated.
Citation No. 4407317, 104 (a)
Issued 2/9/95 at 1300 hours for a violation of 50.10.
A fatal accident occurred on 2/2/95, at approximately 2:30 p.m.
The operator failed to report the accident in a timely manner as described in CFR 30, Part 50, Subpart B.
On 2/3/95, at 2:30 p.m., MSHA was notified of the fatal accident. This citation was issued on 2/9/95, at the completion of the investigation.
Terminated 2/9/95, at 1300 hours.
MSHA explained immediate notification procedures to the operator. MSHA was notified of the accident at 2:30 p.m., on 2/3/95.
Citation No. 4407384, 104 (a)
Issued 2/9/95, at 1300 hours for a violation of 56.14130(g).
A fatal accident occurred on 2/2/95, at approximately 2:30 p.m., when a front-end loader operator over ran the pit highwall. It was found that the front-end loader operator (victim) was not wearing the safety belt provided in the loader, Serial No. 2515, Hough Model H-80 B.
The company had a verbal seatbelt policy in place.
This citation was issued on 2/9/95, at the completion of the investigation.
Terminated on 2/9/95, at 1515 hours.
A written seatbelt policy was instituted and Mr. Browne stated it would be enforced.
The following orders were issued during the investigation:
Order No. 4407381, 104 (d) (1)
Issued 2/9/95, at 1300 hours for a violation of 56.14101 (a) (1).
A fatal accident occurred on 2/2/95, at approximately 2:30 p.m., when a front-end loader operator over ran the pit highwall. The Hough loader, Model H-80 B, Serial No. 2515, involved in the accident, was not equipped with a service brake system capable of stopping and holding the equipment with its typical load on the maximum grade it travels. This condition is unwarrantable. Due to the past history of a defective braking system on the front-end loader, aggravated conduct higher than normal negligence was shown by the operator allowing the loader to be operated. This order was issued on 2/9/95, at the completion of the investigation.
Terminated 2/9/95 at 1453 hours.
The equipment was removed from service.
Order No. 4407383, 104 (d) (1)
Issued 2/9/95 at 1300 hours for a violation of 56.9300 (a).
A fatal accident occurred on 2/2/95, at approximately 2:30 p.m., when a front-end loader operator over ran a pit highwall. A berm was not provided for the outer edge of the Kolberg Plant haulage road where the front-end loader operator over ran the pit highwall adjacent to the haulage road. The operator had full knowledge of the condition. This condition is unwarrantable.
Terminated on 2/9/95, at 1305 hours.
A berm was provided.
Respectively submitted by:
/s/ Clarence Ellis
Clarence Ellis
Mine Safety & Health Inspector
/s/ Larry Aubuchon
Larry Aubuchon
Supv. Mine Safety and Health Inspector
Approved by,
Robert M. Friend
District Manager
Related Fatal Alert Bulletin:
[FAB95M05]