DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
District 9
ACCIDENT INVESTIGATION REPORT
(Surface Coal Mine)
Fatal Machinery Accident
Kayenta Mine, (ID NO. 02-01195)
Peabody Western Coal Company
Kayenta, Navajo, Arizona
Page Steel Company, Inc. (ID NO. KAF)
Kayenta, Navajo, Arizona
December 18, 1996
by
Ted E. Farmer
Supervisory Coal Mine Safety and Health Inspector
and
Dennis O. Robertson
Coal Mine Safety and Health Inspector (Electrical)
Originating Office - Mine Safety and Health Administration
P. O. Box 25367 DFC, Denver, Colorado 80225-0367
John Kuzar, District Manager
ABSTRACT
On Monday, December 18, 1996, at about 4:30 p.m., a machinery accident occurred. Justin Lamb, a scrap processor for Page Steel Company, Inc., was struck by a piece of steel that was cut from a truck body at the CDK yard, Kayenta Mine. Page Steel Company, Inc. was salvaging steel from old haul trucks at the mine. Lamb suffered fractures of the tibia and fibula of the right leg that required surgery at the Flagstaff Regional Medical Center, Flagstaff, Arizona. He died while at the hospital on December 21, 1997, at 5:55 a.m. of a systemic fat embolism complicating fractures of right tibia and fibula. The accident occurred because the portion of the axle beam being cut was not secured in a manner to prevent movement.
GENERAL INFORMATION
The Kayenta Mine is a surface coal mine operated by Peabody Western Coal Company. The mine is located about 20 miles south of Kayenta, Navajo County, Arizona, off Route 160. The mine was opened in 1972, and presently is a multi-seam operation. The coal seams range from 2 feet to 12 feet in thickness and the overburden depth is from 60 feet to 100 feet. The mine employs 422 persons, of which 76 are salaried. Operations are on three daily production shifts, five days a week. Draglines remove overburden on three shifts per day, five to seven days a week. Rubber-tired front-end loaders are utilized to load coal into 250-ton capacity bottom-dump haul trucks for transportation to a preparation plant for crushing. The coal is then transported on an overland belt conveyor to a unit train loadout facility for transportation to customers. The mine produces an average of 21,836 tons of coal per day.
The principal officials at the mine are:
Scott Williams..............................General Manager
Bob Boone...................................Production Manager
William K. Bippus.........................Manager of Safety & Training
The Page Steel Company, Inc. is located at 2040 Industrial Drive, Page, Coconino County, Arizona and has a yearly contract with the Kayenta Mine to salvage metal from outdated equipment. Page Steel Company, Inc., does not have a continuing presence at the mine. Their contract is based on demand. The company operates as an independent contractor and employs 48 persons, of which 3 are salaried.
Principal officials at Page Steel Company, Inc. are:
Doug Gardner...................................President
Harvey Gardner...............................Vice President
Cleo Lamb........................................Foreman
DESCRIPTION OF THE ACCIDENT
Page Steel Company, Inc. purchased two Bryan, three Rimpull and two Terex 150-ton bottom-dump trailers; one 10,000-gallon Dart water truck, one 10,000-gallon 796B Caterpillar water truck, two 100-ton Dart end-dump trucks and two Dart tractor's from the Kayenta Mine for salvage. The salvaging operations were done on mine property at the CDK yard ("bone yard") by two employees, Cleo Lamb, Foreman, and Justin Lamb, Scrap Processor. The two employees started salvaging operations on November 11, 1996.
Between November 11 and December 18, 1996, Cleo and Justin Lamb salvaged five trucks and one trailer.
On December 18, 1996, at approximately 7:30 a.m., Cleo and Justin Lamb arrived at the CDK yard to begin their shift. They worked without incident until the lunch hour. Cleo Lamb had cut on the second trailer being salvaged, and Justin Lamb was cutting on the third trailer with an oxygen and acetylene torch.
After lunch they started preparations to load a flatbed trailer that was due later in the day. Using a 5,000-pound lifting capacity Electro-Magnet attached to a crane, they began to clean up their work area and stack the metal that they had been cutting. At approximately 4:30 p.m., Justin proceeded to cut an axle beam in two pieces, that the Electro-Magnet could not lift. When the axle beam was cut through, both sections rolled to the left. The beam on the right landed on Justin's right leg. Justin was transported by mine ambulance to the Kayenta Public Health Service in Kayenta, Arizona, and then flown to the Flagstaff Medical Center, in Flagstaff, Arizona. Justin suffered fractures of the tibia and fibula of the right leg that required surgery. On December 21, 1996, at about 5:55 a.m., Justin Lamb died at the hospital. The autopsy showed he died of a systemic fat embolism complicating fractures of the right tibia and fibula.
PHYSICAL FACTORS INVOLVED IN THE ACCIDENT
- Due to the nature of Justin Lamb's initial injuries,
immediate notification to MSHA was not required in
accordance with 30 CFR 50.10 and the accident scene was not
preserved. Accident scene details were reconstructed
through the statement of Cleo Lamb, who witnessed the
accident.
- According to Cleo Lamb, the part of the axle beam that was
cut was approximately 10 feet long, 2 feet thick, and 6
inches wide. An oxygen-acetylene torch was used to perform
this task.
- An autopsy was conducted by the Coconino County Medical
Examiner. The medical examiner stated that Justin Lamb's
manner of death was accidental and that he died of a
"systemic fat embolism complicating fractures of the right
tibia and fibula."
- CDK yard is located on the main entrance road to the Kayenta
mine office.
- Salvaging operations continued and the accident scene was
not preserved. Because of the different models of bottom
dump trailers, it could not be determined which model of
trailer was being salvaged at the time of the accident.
- Cleo Lamb was Justin Lamb's father.
- Page Steel Company, Inc., purchased the trucks and trailers
separately from their salvaging contract with the Kayenta
Mine.
- Training in salvaging operations was given to Justin Lamb by
Cleo Lamb. No exact time of training or experience could be
gathered. The Lambs had worked for years in salvaging
operations.
The last date of MSHA approved Annual Refresher Training for Cleo Lamb was November 30, 1994. Justin Lamb had not received MSHA approved, "Training for Newly Employed, Experienced Miners".
- Justin Lamb was positioned between the two axle beams, cutting the axle in two pieces. When the beam was cut through, it rolled on its side and caught Justin's right leg as he was retreating to a safe location. Cleo Lamb used the 5,000-pound lifting capacity Electro-Magnet to lift the beam off Justin's leg.
CONCLUSION
The accident occurred because the two parts of the axle beam being cut were not secured in a manner to prevent movement. A contributing factor was where Justin Lamb positioned himself while cutting the axle beam.
ENFORCEMENT ACTIONS
No violations were issued that related to the accident. Part 48 violations were cited, however they did not contribute to the accident.
Respectfully submitted by:
Ted E. Farmer
Supervisory, CMS&H Inspector
Dennis O. Robertson
CMS&H Inspector (Electrical)
Approved by:
Archie D. Vigil
Assistant District Manager
for Inspection Programs
John A. Kuzar
District Manager
Related Fatal Alert Bulletin:
FAB96C37