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DEPARTMENT OF LABOR MINE SAFETY AND HEALTH ADMINISTRATION South Central District Metal and Nonmetal Mine Safety and Health Accident Investigation Report Surface Nonmetal Mine Fatal Machinery Accident Alamo Gulf Coast Railroad Contractor I.D. ZPW at Beckman Quarry & Plant I.D. No. 41-01335 Redland Stone Products Company San Antonio, Bexar County, Texas July 24, 1997 By Daniel J. Haupt, Supervisory Special Investigator James M. Thomas, Special Investigator Originating Office Mine Safety and Health Administration 1100 Commerce Street, Room 4C50 Dallas, Texas 75242-0499 Doyle D. Fink District Manager GENERAL INFORMATION Joseph W. McCaddon, maintenance consultant, age 71, was fatally injured at about 11:55 a.m. on July 24, 1997, when a locomotive truck assembly fell from the blocking which was supporting it. Two miners working with the victim were injured. McCaddon had fifty years of railroad maintenance experience and was the owner of McCaddon Enterprises. He had been doing contract locomotive maintenance work at the Beckman Quarry and Plant periodically for three years. He had not been trained in accordance with 30 CFR, Part 48. Richard Rodriguez, foreman, Trac-Works, Inc., age 44 sustained a fractured vertebrae and rib. He had 5 years mining experience, 2 months at this mine. He did not have experience at the task being performed and had not been trained in accordance with 30 CFR, Part 48. Epifanio Quiroga, rail car inspector, Alamo Gulf Coast Railroad, age 26 sustained a back muscle pull. He had one and a half years mining experience and no experience at the task being performed. Quiroga had received 8 hours of New Miner training in accordance with 30 CFR, Part 48 on April 25, 1996 and was being trained in the locomotive maintenance tasks by McCaddon. Tom Singley, safety director for Redland Stone Products Company, notified MSHA at 12:45 p.m., on the day of the accident. An investigation was started the same day. The Beckman Quarry & Plant owned and operated by Redland Stone Products Company was located at 17910 IH-10 West, San Antonio, Bexar County, Texas. The senior operating official was David Wenzel, vice president. The plant normally operated two, 8-hour shifts a day, seven days a week. A total of 238 persons, excluding independent contractors, were employed at the mine. Alamo Gulf Coast Railroad, located in San Antonio, Texas, was a subsidiary of Redland Stone Product Company. Alamo Gulf Coast was a short line railroad that was created to inspect, load and move rail cars on the mine property and to the mainline railroad spurs adjacent to the mine. The principal operating official was Ray Tucker, general manager. The railroad operated three 8 hour shifts per day, 7 days a week. Twenty two persons were employed by Alamo Gulf Coast Railroad. Trac-Work, Inc, located in San Antonio, Texas, was hired by Alamo Gulf Coast Railroad to provide track maintenance on the mine property. The principal operating official for Trac-Work was Clarence Bader, area manager. The contractor normally worked one 8 hour shift per day, 5 days a week. The San Antonio branch of Trac-Works, Inc. employed 48 persons with three persons routinely working at the Beckman Quarry & Plant. McCaddon Enterprises, a maintenance consultant, located in Missouri City, Texas, was also hired by Alamo Gulf Coast Railroad to test and perform services on Alamo's three locomotives. Joseph McCaddon and his wife were the sole owners and employees of McCaddon Enterprises. Howell Crane & Rigging, Inc., an independent contractor located in San Antonio, Texas, was contracted by Alamo Gulf Coast Railroad to perform the necessary lifts on July 24, 1997 to replace a locomotive traction motor. The principal official for Howell Crane & Rigging, Inc. was Frank Howell, president. The contractor normally operated one shift per day of 8-10 hours, five days per week. A total of 19 persons were employed with one crane operator at the mine site. Although all three of these contractors were hired by Alamo Gulf Coast Railroad, McCaddon was the only person that knew how to perform the repair on the locomotive. He was therefore directing the work related to changing out the traction motor. Limestone was drilled, blasted, loaded into a mobile crusher with rubber tired front-end loaders. The crushed material was conveyed to the plant where it was sized, washed and stockpiled. The product was sold for road base and general construction. The last regular inspection of this operation was completed on March 3, 1997. Another inspection was conducted following this investigation. PHYSICAL FACTORS INVOLVED The accident occurred in the area known as the number six rail spur that was used only for maintenance of rail equipment. The short spur ran east/west and used standard gauge, 56 � inch track. The locomotive under repair was a General Motors SW1200 Switcher, number 2253, with an approximate weight of 248,000 pounds. The locomotive was equipped with a 12 cylinder, 1200 horsepower diesel engine. Two traction motors were mounted in both of the locomotive's front and rear truck assemblies and provided the torque to eight 40 inch diameter drive wheels. Each traction motor had a axle with wheels that were identified as L (left) and R (right) and whose position under the locomotive was identified by numbering from the front (1) to the rear (4) of the locomotive. The accident involved the rear truck assembly and occurred while the traction motor with wheels R-4 and L-4 was being replaced. The rear truck assembly, which had an 8 foot wheelbase and weighed about 18 tons, had been removed from beneath the locomotive and was approximately 9 feet east of it. Wheels R-3 and L-3 wheels were still on the track rails and wheels R-4 and L-4 were off the rails with R-4 between the rails and L-4 south of the tracks. A new traction motor with wheels was in place under the truck assembly with the L-4 brake straps and axle bearing retainer installed. The R-4 brake strap was on the track beside the wheel and the bearing retainer had not been installed. Six blocks varying in length from 12 to 31 inches (four 4X4 inch oak, one 4X6 inch oak and one 2X4 inch pine) were lying under the truck assembly on the end that fell. The 2x4 had been crushed on one side to about 50% of its original thickness and had split down the center indicating that the blocks were not stacked perpendicular to the bottom of the traction motor. The crushed area of the 2X4 left a mark on the bottom of the motor, 24 inches from the inside of the R-4 wheel and 25 � inches from the inside of the L-4 wheel. The ground surface below the traction motor was course rock between rail ties and was covered with a layer of felt absorbent material. The crane involved in the accident was a 1988 Linkbelt Crane, model HTC-11100, 100 ton, hydraulic truck, Serial Number 65H8-350. The crane was equipped with a computer LED continuous display on the dash which monitored boom angle in degrees, weight in thousands of pound, boom length in feet, radius in feet and maximum weight in thousands of pounds. In addition to monitoring the boom settings, the computer would activate a amber pre-warning light at 95% lift capacity and a red warning light at 100-105% lift capacity. Along with the red warning light, it stops all motion of the crane. The crane did not trip out while performing the lifts and the crane operator said the overload warning (amber or red lights) did not light. The crane had two cable winches, one for the two block 8 part line and the other for the one part line. The 8 part line had been used to lift the locomotive for removal of the truck assembly and the one part line was used to lift the traction motors and truck assembly. When the investigators arrived on July 25, 1997, the truck crane was set up facing west on fully extended outriggers with the left rear outrigger approximately two feet northwest of the R-3 wheel of the truck assembly. The lifting chains and the one part line cable were hooked to the new traction motor lifting eyes and the boom had bleed off (lowered) until the hookball was almost on the ground. Inspection of the crane revealed no visible external oil leaks, however, leak down tests performed on July 25th found the boom cylinders were leaking hydraulic oil internally. A boom cylinder drip test performed on July 29th revealed the two boom cylinder holding valves were defective which would allow the boom to bleed off. The two crane operators, who had operated the crane on the day of the accident and 3 days prior, stated they did not have any problems with their loads bleeding off prior to the accident. A 1992 Ford, F350, long bed maintenance pickup, owned by Trac-Work, Inc. had been backed at an angle between the locomotive truck assembly and crane. The pickup was moved when the accident happened to make room for the ambulance crew. The pickup was returned to approximately the same location when the accident occurred. It was determined the pickup location would create an obstruction to the crane operator's view to the raised end of the truck assembly. DESCRIPTION OF ACCIDENT Joseph W. McCaddon (victim) arrived at the Beckman mine on July 24, 1997, at about 9:30 a.m., approximately two and one half hours late. McCaddon was to supervise the replacement of a locomotive traction motor. One week prior to the accident, while McCaddon was performing a routine 90 day inspection, he found a defect in the traction motor requiring its replacement. He informed Epifanio Quiroga, car inspector for Alamo Gulf Coast that the replacement was needed. Quiroga was inexperienced in locomotive maintenance and had been assigned by Ray Tucker, Alamo Gulf Coast Railroad general manager to work with McCaddon for on-the-job training. McCaddon made a list of materials, including tools and crane requirements for Quiroga and he procured the necessary materials and scheduled for the crane service and the traction motor delivery for 7:00 a.m. on the day of the accident. After McCaddon arrived he told Randall Frazier, crane operator the front of the locomotive, would weigh 50 to 65 tons, the first and heaviest lift to be made. Frazier stated he setup the crane based on the load charts in the cab with the outriggers adjacent to the tracks. Using the 8 part line, the locomotive was lifted by the coupler and Quiroga and Richard Rodriquez, foreman, for Trac-Works, Inc. placed a railroad tie under each side of the front truck assembly equalizer bars. This was to allow the rear of the locomotive to be raised to a sufficient height for removal of the rear truck assembly. The crane was then moved to lift the rear of locomotive by the coupler and the outriggers were fully extended. Once the locomotive was raised the rear truck assembly was pulled out from under the locomotive by Rodriguez with a caterpillar backhoe. Quiroga and Rodriquez cut blocks and placed them under the locomotive and it was lowered to the blocks. The crane was then connected with the one part line to lift the rear of the truck assembly to allow the traction motor and wheels to be pulled out with the backhoe. A flat bed truck carrying the new traction motor was placed by the truck assembly and the replacement motor with axle and wheels was moved from the truck to the rail tracks. The motor being replaced was then put on the truck. The crane was reconnected with the one part line to the rear frame of the truck assembly and it was raised high enough to clear the new traction motor and the backhoe pulled the frame over the new motor. The frame was lowered onto the traction motor and the crane was connected to the traction motor lifting eyes to lift the motor and rear of the frame as a unit. The traction motor needed to be rotated on the wheel axle to make the traction motor air cooling line connection. In lieu of using a hydraulic jack to align the traction motor, McCaddon had it lifted with the crane. After lifting it, he stacked blocks in a single vertical row under the traction motor and signaled the crane operator to lower the truck assembly onto the blocks until the motor rotated sufficiently to make the connections. This left the L-4 and R-4 wheels about 6 inches above the tracks and the L-3 and R-4 wheels on the tracks. McCaddon instructed Quiroga to get under the truck assembly and to remove the remaining section of the inside brake strap bolts that had been left during disassembly. Quiroga and Rodriguez questioned him about the stability of the blocks and he told them it was safe. They agreed to get under the unit because of McCaddon's expertise. Quiroga crawled under the truck assembly between the L-3 and L-4 wheels. He was able to remove the L-4 inside brake strap bolt but the R-4 inside strap bolt was frozen. McCaddon requested a torch and got under the truck assembly by the R-4 wheel to assist Quiroga. Jamie Olquin and Jesus Ortiz, laborers for Trac-Works, Inc. backed the maintenance pickup in between the truck assembly and the crane to provide the torch. Rodriguez crawled under to assist McCaddon and Quiroga with the stuck brake strap bolt. Rodriquez was driving the bolt to the outside with a sledge hammer and punch and McCaddon, who was lying on his back adjacent to the R-4 wheel, would cut sections of the bolt off with the torch. They all were under the truck assembly working on the bolt when the truck assembly shifted to the left and fell off the blocks. The R-4 wheel came down between the tracks striking McCaddon in the head. Rodriguez, who was lying on his side, was trapped under the truck assembly and Quiroga, who was in the process of crawling out between the L4 and L3 wheels, was trapped under the truck assembly equalizer bar. Frazier felt the crane shake when the truck assembly fell and he immediately raised the truck assembly. Quiroga crawled out on the left side. Olquin and Ortiz pulled Rodriguez and McCaddon from under the truck assembly. Quiroga radioed for an ambulance and help. Quiroga and Rodriguez were transported by ambulance to the local hospital. McCaddon was pronounced dead at the scene by the Emergency Medical Technicians at 12:18 p.m. CONCLUSION Allowing employees to work under suspended loads and the failure to properly secure the raised truck assembly from accidental lowering before working under it, were the direct causes of the accident. Failure to use protective head wear contributed to the severity of the accident. VIOLATIONS Citation Number 4447295 Issued on July 24, 1997 under the provisions of Section 103(k). Citation Number 7859403 Issued on August 26, 1997 under the provisions of Section 104(a), for violation of 30 CFR, Part 56.14211c Citation Number 7859405 Issued to Alamo Gulf Coast Railroad on August 26, 1997 under the provisions of Section 104(a), for violation of 30 CFR, Part 56.16009. Citation Number 7859408 Issued on August 26, 1997 under the provisions of Section 104(a), for violation of 30 CFR, Part 56.15002. Citation Number 7859404 Issued on August 26, 1997 under the provisions of Section 104(a), for violation of 30 CFR, Part 56.14211c Citation Number 7859407 Issued on August 26, 1997 under the provisions of Section 104(a), for violation of 30 CFR, Part 56.16009. No citations for violations of 30 CFR, Parts 56.15002, 56.14211c and 56.16009 were issued to McCaddon Enterprises as Joseph McCaddon (victim) was the sole employee/operator of his own company and did not survive the accident. McCaddon's negligence in the accident was at least equal to that of the other companies issued violations. /s/ Daniel J. Haupt /s/ James M. Thomas Approved By: Doyle D. Fink, District Manager Related Fatal Alert Bulletin:  [FAB97M40]
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