DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
Western District
Metal and Nonmetal Mine Safety and Health
ACCIDENT INVESTIGATION REPORT
SURFACE SAND AND GRAVEL MINE
FATAL MACHINERY ACCIDENT
Carr Trucking Company, Inc., Contractor ID WEQ
Sun Valley Mine, ID No. 04-01736
CALMAT Company
Sun Valley, Los Angeles County, California
September 18, 1995
By
Timothy B. Hannifin III
Mine Safety and Health Inspector
David Kerber
Mine Safety and Health Inspector
Western District Office
3333 Vaca Valley Parkway, Suite 600
Vacaville, California 95688
Fred M. Hansen
District Manager
GENERAL INFORMATION
Jose Juan Gomez, a 21 year old equipment operator for a contractor trucking company, was fatally injured September 18, 1995, at approximately 9:05 a.m., when the rubber-tired dozer he was operating went over a berm and into a water-filled pit. Hired August 25, 1995, Gomez had worked a total of 25 hours during the three week period prior to his death. There was no information available concerning his previous work experience as he had recently relocated from Mexico.
The MSHA San Bernardino Field Office was notified of the accident by H.D. "Hal" Salem, Corporate Safety Director, CalMat Co., at 11:15 a.m., September 18. An investigation was started the following day.
The accident occurred at the Sun Valley Mine, Sheldon Pit, which was owned and operated by CalMat Co. The operation, located in Sun Valley, CA., was approximately 24 miles northwest of Los Angeles, CA. The mine had 43 employees working one of three overlapping 11 hour shifts, six days a week.
Material was extracted from the pit with front-end loaders. It was then crushed and transported to the primary plant via conveyor belts.
Carr Trucking Co., Inc., the victim's employer, was hauling waste material, consisting of rock and dirt, into the Sheldon Pit from the Metro-Link, a subway development project in Los Angeles. The material was dumped at various locations and, depending on the dump site, pushed or piled by Carr Trucking Company, Inc. employees and equipment.
Principal operating officials for Carr Trucking Co., Inc., were:
Elliott Carr, President
Steven Barber, Operations Manager
The last regular inspection at this operation was completed
June 14, l995.
PHYSICAL FACTORS INVOLVED
The rubber-tired dozer involved in the accident was an open-cab, 1973 Caterpillar, model 824B, serial no. 36H1204. The vehicle was equipped with a roll-over protective structure. Seat belts were provided but not in use.
A mechanical engineer with MSHA Denver Safety and Health Technical Center inspected the dozer once it had been retrieved from the pit. He found no service brake or steering defect that could have contributed to the vehicle's having gone out of control.
The accident occurred on the main roadway going into the Sheldon Pit. The road was 36 feet wide, with an elevated conveyor belt extending up the right side and a 42-inch high by 8-foot wide berm on the left. The properly bermed and fairly smooth road was covered with a thin layer of loose gravel. The average grade was 14%. The road was primarily used by empty trucks coming out of the pit, and by service and maintenance vehicles.
On the day of the accident the weather was clear and dry.
DESCRIPTION OF THE ACCIDENT
Jose Juan Gomez, equipment operator, arrived at the main office at 6:00 a.m., his regular starting time. Steven Barber, operations manager, assigned him to operate a Caterpillar 980C front-end loader. He was to move material that had been brought on site and dumped and, should the need arise, push trucks out of the pit. At about 8:30 a.m., after performing routine maintenance on mine equipment, Gomez and Eliceo Herrera, a mechanic, went to the truck shop where the front-end loader was located. On the way they observed two trucks unable to climb the pit roadway.
On arrival at the shop, Herrera and Gomez attempted to start the 980C front-end loader. The batteries were low and it would not start. They then drove back to the office where the Caterpillar 824B rubber-tired dozer was parked and started it. Gomez drove the dozer forward down the roadway, turned around, and pushed one of the trucks up the road until it gained traction. He then backed down the road in reverse. Cecil Evans, a truck driver, observed the dozer approaching him. He stated that he could see it gaining speed and swerving while Gomez appeared to be struggling with the steering wheel. The dozer took a hard left turn, just in front of Evans' truck, went over a berm, and fell approximately 70 feet to the water below.
Evans ran up the road and advised Valentin Baltazor, another truck driver, of the accident. Baltazor contacted the dispatcher, Merci Rozas, who then called 911 at approximately 9:05 a.m.
Robert Owen, of CalMat Co., Mario Moreno, a sub-contractor to Carr Trucking Co., Inc, and Bernard Hedgepeth, a vendor making a delivery to the site, made several unsuccessful attempts to rescue Gomez from the water.
Gomez was removed from approximately 25 feet of water, and
from underneath the blade of the dozer, by the Los .Angeles City
Fire Department dive team. He was pronounced dead at the scene
at 1:45 p.m. Death was due to "blunt instrument trauma."
CONCLUSION
The accident appears to have occurred because the operator,
lacking experience and training in the task that he was assigned
to perform, lost control of the vehicle.
VIOLATIONS
Order No. 4357950, 103(k), issued 9/19/95.
A rubber-tired dozer went over a berm and into a pit filled with water. This order is to secure the area in and around the accident site until an investigation can be made by MSHA to determine the cause of the accident.
Citation No. 4357954, 104(a), Section 56.14101(a)(3)
The parking brake on the Caterpillar rubber-tired dozer, involved in a fatal accident, was not being maintained in a functional condition as it was disconnected.
Citation No. 4357955, 104(a), Section 56. 14100(d)
There was no documentation to show that defects found during equipment inspections were being reported and corrected.
Citation No. 4358357, 104(a), Section 56.14100(b), Issued 12/11/95
The Caterpillar rubber-tired dozer, involved in a fatal accident, was missing the orientation and guide plate for the gear and directional selector. Being unable to tell which gear, or position, the selector was in could present a hazard to the operator.
Citation No. 4358358, 104(a), Section 56.4130(g), Issued 12/11/95
The equipment operator, involved in a fatal accident, was not wearing a seat belt.
Citation No. 4358359, 104(a), 56.9101, Issued 12/11/95
The operator of a rubber-tired dozer, involved in a fatal accident, failed to maintain control of the vehicle.
Respectfully submitted by:
/s/ Timothy B. Hannifin III
Mine Safety & Health Inspector
/s/ David Kerber
Mine Safety & Health Inspector
Approved by:
Fred Hansen
Manager, Western District
Related Fatal Alert Bulletin:
[FAB95M31]