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UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION


ROCKY MOUNTAIN DISTRICT

Accident Investigation Report
Surface Nonmetal Mine


Fatal Powered Haulage Accident


Crusher 1
Mine I.D. No. 05-03802
Roaring Fork Aggregates, Inc.
Carbondale, Garfield County, Colorado


July 19, 1997


By

William Tanner, Jr.
Supervisory Mine Safety & Health Inspector

Michael S. Okuniewicz
Mine Safety & Health Inspector



Rocky Mountain District
P.O. Box 25367, DFC
Denver, CO 80225-0367


Robert M. Friend
District Manager

GENERAL INFORMATION



Terry LeeRoy Vroman, front-end loader operator, age 19, was fatally injured on July 19, 1997, at approximately 12:30 p.m., when he was pinned between the cross member of the lift-arm assembly and the canopy of the skid-steer loader he was operating. Vroman had a total of 1 year and 7 months experience as a front-end loader operator, all at this operation. He had not received training in accordance with 30 CFR, Part 48.



John Charles Martin, president/safety director, notified MSHA of the accident by telephone on July 19, 1997, at 7:08 p.m. An investigation was started the following day.



Crusher 1, owned and operated by Roaring Fork Aggregates, Inc., was located about 2 miles east of Carbondale, Garfield County, Colorado, along Highway SR82. Sand and gravel was mined from a multiple-bench pit. The material was transported to the crushing/screening plant with a front-end loader. Plant equipment consisted of a feed bin, vibra feeder, jaw and cone crushers, screen plant, and conveyor belts. The finished products were stockpiled and sold to contractors and to the public.



Total mine employment was 15 persons working one, 8-10 hour shift per day, 6 days a week. At the time of the accident, 3 employees were on the property.



Principal operating officials for Roaring Fork Aggregates, Inc. were:
John Charles Martin, President/Safety Director
Bernard Russel Johnson, Superintendent
William Wiley Rice, Supervisor



The last regular inspection of this operation was conducted on July 9, 1997.

PHYSICAL FACTORS INVOLVED



Involved in the accident was a 1994 Melroe Bobcat skid-steer loader, Model 7753, I.D. No. 507631492, purchased on July 16, 1996. The loader had 356 hours of use when purchased by the company and was powered with a diesel engine rated at 46 horsepower. It was equipped with rollover protection, and the operating capacity of the loader was rated at 1,700 pounds.



The loader was equipped with a safety seat bar which was installed by the manufacturer as a safety feature. If operating properly, when the equipment operator was not in the seat and the bar was pushed forward or in the raised position, all hydraulic systems were locked out and all components of the equipment controlled by the hydraulic system were inoperable.



Tramming was accomplished by pushing forward on the lever handles to go forward or pulling back on the handles to reverse direction. Two foot pedals activated the hydraulic flow to the lift and tilt cylinders of the bucket or forklift attachments.



The mining company had fabricated a hoe-type attachment from used grader blades to perform clean-up under conveyors and other equipment. It was approximately 7 feet in length. The hoe was designed to be attached to the bucket and forklift mounting plate on the loader and weighed approximately 200 pounds.



The skid-steer loader and the accident site were inspected during the investigation. The following conditions were observed:
1. The magnetic/electrical safety sensor located in the seat-bar assembly was intentionally disabled and bypassed.

2. The shut-off solenoid was defective and bent causing the loader's engine not to shut off when the ignition key was turned to the off position.

3. The steering linkage was out of adjustment, bent, and worn which caused the loader to creep while in neutral position.

4. The spring-loaded interlocks that control the locking and unlocking functions of the control pedals were out of adjustment and allowed the lift-arm function of the loader to operate when in a lock position.

5. The seatbelt was tucked behind the seat with extraneous material on it.

6. Manufacturers' safety and warning decals were in place and readable in the operator's compartment.

7. The operator's handbook was in the cab.

8. The park brake was functional but needed adjustment.

9. The lift-arm bypass switch for the hydraulics was not operational.

10. Operating hours on the loader was 1514 hours. Safety defects were not recorded.

DESCRIPTION OF ACCIDENT



Terry LeeRoy Vroman (victim) reported for work at 6:00 a.m., his normal starting time and met with James Russel Walton, leadman. Walton started the plant and instructed Vroman to feed the plant with a front-end loader. Work proceeded normally throughout the morning.



After lunch, Vroman began operating the Bobcat skid-steer loader using the hoe attachment to clean-up under the jaw crusher. At approximately 12:30 p.m., Walton observed Vroman backing the loader from the jaw crusher. Walton could see that the hoe attachment had partially disengaged from the loader.



Walton observed Vroman reaching out of the operator's compartment toward the attachment's locking latches. He looked away for a few seconds, then saw Vroman pinned between the lift-arm assembly and the top of the operator's cab. Walton immediately ran to assist. He climbed through the back of the loader and activated the left foot pedal, which lowered the boom.



Vroman was helped out of the loader. He walked to his truck and was driven by Walton to the local hospital, 12 miles away. Vroman, still conscious, was admitted to the hospital. He died at 1:45 p.m., as the result of cardiac arrest caused by internal bleeding and injuries.

CONCLUSION



The hoe attachment had disengaged from the skid-loader. The victim raised the safety seat-bar and leaned out of the cab, reaching over the lift boom arm to reset the latching device. His foot contacted the foot pedal, causing the boom to raise, pinning him between the cross member of the boom and the canopy of the cab.



The accident was caused by: 1. The safety seat bar had been intentionally bypassed, allowing the hydraulic system, including the tramming functions, to be operational when the loader operator was not in the operator's seat.

2. The mine operator had no mobile equipment inspection program in place at the mine site to assure that equipment which had safety defects was removed from service.

3. Employees were not indoctrinated in safety rules and safe work procedures when hired.

4. The miner left the operator's seat to adjust a shop fabricated component on the equipment, placing himself in an unsafe position.

VIOLATIONS



Order No. 4673594
Issued at 12:00 p.m., July 20, 1997, under the provisions of Section 103(k) of the Mine Act:

At approximately 12:30 p.m., on July 19, 1997, the Bobcat skid-steer loader operator was fatally injured at this mining operation. This order is issued pursuant to Section 103(k) of the 1977 Mine Act to ensure the safety of miners until a systematic evaluation of the conditions and safety practices is conducted, and a determination is made that hazards similar to those that caused or contributed to the accident have been eliminated.

This order was terminated on August 19, 1997.



Citation No. 4662450
Issued under the provisions of Section 104(d)(1) on August 7, 1997, for violation of 30 CFR 56.14100(c):

A fatal accident occurred on July 19, 1997, at about 12:30 p.m., when a loader operator was pinned between the lift-arm crossbar and the top of the cab of the Melroe Bobcat skid-steer loader, I.D. No. 507631492, that he was operating.

The loader has defects that affected safety and was not taken out of service or placed in a designated area posted for that purpose. A) The electric sensor for the safety seat bar assembly was intentionally rendered inoperable. The purpose of the sensor was to deactivate the hydraulic system to prevent movement of the loader and hydraulic cylinders when the operator was not in the proper position, which is the operator's seat. A supervisor and other employees had used this loader on numerous occasions and were aware of the inoperative safety seat bar. This accident would not have occurred had the safety feature been operable. B) The manual bypass control knob on the loader was also inoperative.

The loader had warning decals posted in the operator's cab in addition to the proper procedures for safe operation that were outlined in the Operation and Maintenance Manual. The employees who operated this loader stated they did not conduct safety inspections prior to operating this loader.

The mine operator engaged in aggravated conduct constituting more than ordinary negligence and the violations stated above were unwarrantable failures on the part of the operator.



Order No. 4662451
Issued under the provisions of Section 104(d)(1) on August 7, 1997, for violation of 30 CFR 56.14100(a):

An accident resulting in a fatality occurred on July 19, 1997, at about 12:30 p.m., when a loader operator was pinned between the lift-arm crossbar and the top of the cab of the Melroe Bobcat skid-steer loader, Model No. 7753, I.D. No. 507631492. A defect affecting safety existed on the loader which was a contributing cause of the accident. The loader was not inspected prior to being placed in operation. The loader had warning decals posted in the operator's cab and warnings were noted in the operator's manual indicating the proper procedures for inspecting the safety devices before placing the loader in operation. A supervisor and employees indicated that they did not inspect the loader on the shift when the accident occurred nor prior shifts when they operated the loader. The mine operator engaged in aggravated conduct constituting more than ordinary negligence. This violation is an unwarrantable failure.



Order No. 4662452
Issued under the provisions of Section 104(d)(1) on August 7, 1997, for violation of 30 CFR 56.18006:

A fatal accident occurred at 12:30 p.m., on July 19, 1997, when a loader operator was pinned between the lift-arm crossbar and the top of the cab of the Melroe Bobcat skid-steer loader, I.D. No. 507631492. The victim had not been indoctrinated in safety rules and safe work procedures which may have prevented this accident in that he would have recognized the inherent dangers of not taking equipment with safety defects out of service. The supervisor and employees stated that no indoctrination on safety rules and safety work procedures was done. The mine operator engaged in aggravated conduct constituting more than ordinary negligence. This violation is an unwarrantable failure.




//s// William Tanner, Jr.
Supervisory Mine Safety & Health Inspector


//s// Michael S. Okuniewicz
Mine Safety & Health Inspector


Approved by: Robert M. Friend, District Manager


Related Fatal Alert Bulletin:
Fatal Alert Bulletin Icon [FAB97M39]