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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 (Sand & Gravel) Fatal Power Haulage Accident Shallow Ford Construction Company, Incorporated Utley Pit Salado, Bell County, Texas Mine I.D. No. 41-03964 September 30, 1997 Originating Office Mine Safety and Health Administration 1100 Commerce Street, Room 4C50 Dallas, Texas 75242-0499 Doyle D. Fink District Manager GENERAL INFORMATION Michael Charles Green, scraper operator, age 44, was fatally injured at about 3:00 p.m. on September 30, 1997, when the scraper he was operating rolled over, throwing him from the seat and pinning him under the rollover protective structure (ROPS). The victim had a total of 26 weeks mining experience, all at Shallow Ford's Utley Pit and Miller Pits. He had three years experience operating a scraper. He had not received training in accordance with 30 CFR Part 48. MSHA was notified at 5:30 p.m. on the day of the accident by telephone call from Timothy D. Counts, aggregate operations & marketing manager for the mining company. An investigation was started the following day. The Utley Pit, a sand and gravel mine, owned and operated by Shallow Ford Construction Co., Inc., was located on Toll Bridge Road near Salado, Bell County, Texas. The principal operating official was Bob Spiegel, president. The mine was normally operated one eight-hour shift a day, five days a week and employed three persons. Green and Richard Holster, a coworker, worked at this pit on an as needed basis. The pit foreman, Charles Drake, supervised the Utley Pit and the Miller Pit, which was located nearby. He divided his time accordingly. At the time of the accident, Drake was at the Miller Pit. Sand and gravel was extracted from a single bench in the pit by an excavator and processed at another location. The final product was utilized for road base material. The mine had opened about 6 months prior to the accident and had not been inspected by MSHA. A regular inspection was conducted following this investigation. PHYSICAL FACTORS INVOLVED The equipment involved in the accident was a four-wheel-drive, 1986, Caterpillar Scraper, Model 627-B, powered by two, 225-HP engines. This model was equipped with an eight-speed semi-automatic transmission. Top speed was 34 MPH. The scraper was equipped with seat belts and ROPS. The seat belts and tethers were worn and in need of replacement, but were functional. The victim was not wearing the seat belt. An inspection of the scraper following the accident revealed no defects affecting safety in steering or braking capability.This scraper had previously been overturned at the Miller Pit, when Green drove the scraper over the outer edge of a stockpile. He was wearing a seat belt and was not injured. Damage to the scraper was minimal. The stockpile, where the accident occurred, consisted of topsoil and was located adjacent to the haulage road from the stripping area to the reclaim area. It had been developed during the startup six months prior. The stockpile was approximately 200 feet long, 80 feet wide, and constructed with two levels; one 10 feet high and the other 5 feet high. The ends were sloped to ground level to accommodate entry and exit. The slope between the upper and lower levels of the stockpile was approximately 32 degrees and was not compacted. Tire tracks indicated that the scraper had been driven onto the stockpile numerous times. When the scraper overturned, it had been driven gradually off the top level onto the lower level leaving tracks 14 to 22 inches deep in the slope. The left rear trailer tire struck an imbedded rock and slid down the slope causing the scraper to rollover on its side. The weather on the day of the accident was clear skies with temperatures in the mid 90's. DESCRIPTION OF ACCIDENT On the day of the accident, Michael Green (victim) reported for work at the main office in Temple, Texas shortly before 7:00 a.m., his regular starting time. He received his work assignment from Charles Drake, pit foreman, to strip overburden at the Utley Pit. When Green arrived at the pit about 20 minutes later, Richard Holster, scraper operator, was already onsite. They began removing overburden from the stripping area and dumping at the reclaim area, a distance of approximately one-quarter mile. At about noon, Holster and Green went to town for lunch, returning after about one half hour and resumed stripping. Later, Holster noticed that Green had made several trips onto the stockpile without any apparent reason to do so. Holster assumed that Green was going up on the stockpile momentarily where it was cooler. Prior to the accident, Holster last saw Green at about 2:55 p.m. taking a water break on the roadway. Upon returning from the stripping area he saw Green's scraper turned over on its side on the lower level of the stockpile. Holster drove to the accident scene and found Green conscious with his left leg and arm pinned under the ROPS structure. After offering assurances to Green, he drove back to the stripping area where Kevin Elkins and Wayne Trojan were working. The three men returned to the scraper. Elkins made several attempts to notify the main office and secure help by radio. He finally made contact with a truck driver who relayed the call. Radio communications had been problematic in the past. Upon arrival at the accident site the three men found that Green's left arm and leg were partially amputated. Having no medical supplies with them, they applied tourniquets made of torn shirts and knotted with sticks and attempted to dig him free. Green was still conscious and alert when local authorities, emergency services and Shallow Ford supervisory personnel arrived at about 3:34 p.m. He lost consciousness when he was withdrawn from the scraper at 3:59 p.m. He was transported by ambulance to a local hospital where he was pronounced dead at 4:43 p.m. CONCLUSION The primary cause of the accident was failure to maintain control of the scraper due to driving from the upper level of the stockpile onto the slope to the lower level. Failure to wear seat belts contributed to the severity of the accident. Lack of a designated person to take charge in case of an emergency and ineffective emergency communications were also contributing factors. VIOLATIONS Citation Number 4453327 was issued on September 30, 1997 under the provisions of Section 103(k):On 9/30/97, a fatality occurred when a Caterpillar 627B scraper ran over the top soil storage pile and overturned. This order is issued to ensure the safety of any persons in the area /vicinity of this equipment. The operator shall obtain the approval of a representative of the Secretary of Labor of any plan to recover or remove materials or return the affected area to normal prior to such work commencing.This order was terminated on October 2, 1997 after it was determined that the mine could return to normal operation. Citation Number 7858233 was issued on October 2, 1997 under the provisions of Section 104(d)(1), for violation of 30 CFR, Part 56.18013: A fatal accident occurred at this operation on September 30, 1997, when a Caterpillar 627 B Scraper turned over on its side, throwing the operator from his seat pinning him under the ROPS structure. A suitable communication system had not been provided at this mine to obtain assistance in the event of an emergency. Ineffective communications caused a delay in reaching emergency services following the accident which delayed emergency assistance and transportation for the victim. Failure to provide adequate emergency communications constitutes more than ordinary negligence. This is an unwarrantable failure to comply with a mandatory standard.This citation was terminated on February 12, 1998, after a telephone had been installed in the office at the mine site. Order Number 7858234 was issued on October 2, 1997 under the provisions of Section 104(d)(1), for violation of 30 CFR, Part 56.18009: A fatal accident occurred at this operation on September 30, 1997, when a Caterpillar 627 B Scraper turned over on its side, throwing the operator from his seat and pinning him under the ROPS structure. A competent person designated by the mine operator was not in attendance to take charge during this emergency. The foreman was at another mine site, approximately eleven miles away. After his being notified of the accident, it took approximately twenty-five minutes for him to arrive. Failure by the mine operator to ensure that a competent person is in attendance to take charge in case of an emergency constitutes more than ordinary negligence. This is an unwarrantable failure to comply with a mandatory standard.This order was terminated on February 12, 1998, after all employees, including the leadman, were trained and designated to take charge at the mine in the absence of the regular supervisor if an emergency situation occurs. Citation Number 7858286 was issued on September 30, 1997 under the provisions of Section 104(a), for violation of 30 CFR, Part 56.9101: A fatal accident occurred at this operation on September 30, 1997, when a Caterpillar 627 B Scraper turned over on its side, throwing the operator from his seat and pinning him under the ROPS structure. The operator did not maintain control of the scraper and traveled over the edge of the 5 foot high topsoil stockpile.This citation was terminated on March 26, 1998, after all equipment operators were given instruction in the hazards associated with operating mobile equipment and on safe operating procedures. Citation Number 7858287 was issued on September 30, 1997 under the provisions of Section 104(a), for violation of 30 CFR, Part 56.14130(g): A fatal accident occurred at this operation on September 30, 1997, when a Caterpillar 627 B Scraper turned over on its side, throwing the operator from his seat and pinning him under the ROPS structure. The victim was not wearing a seat belt. This citation was terminated on March 26, 1998 after all employees were given instruction in safe operation of equipment including the wear of seat belts. The company has implemented seat belt enforcement procedures of their seat belt policy with disciplinary provision for not wear seat belts. Citation Number 7858288 was issued on October 1, 1997 under the provisions of Section 104(a), for violation of 30 CFR, Part 56.20011: A fatal accident occurred at this operation on September 30, 1997, when a Caterpillar 627 B Scraper turned over on its side, throwing the operator from his seat and pinning him under the ROPS structure. Barricades or warning signs had not been posted at the south end of the topsoil stockpile where the accident occurred. Load-out of topsoil on the north end had created a vertical drop of ten foot that would not be apparent to equipment operators approaching from the south.This citation was terminated on March 26, 1998 after signs were posted and all employees received instruction on identifying and posting of hazardous areas. Citation Number 7858289 was issued on October 1, 1997 under the provisions of Section 104(a), for violation of 30 CFR, Part 50.10: A fatal accident occurred at this operation at 3:00 p.m. on September 30, 1997, when a Caterpillar 627 B Scraper turned over on its side, throwing the operator from his seat and pinning him under the ROPS structure. MSHA was not notified until 5:30 p.m. This citation was terminated on October 1, 1997, after the mine management received instruction in the part 50.10 immediate reporting requirements. Related Fatal Alert Bulletin:  [FAB97M54]
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