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DEPARTMENT OF LABOR MINE SAFETY AND HEALTH ADMINISTRATION Northeast District Surface Nonmetal Mine (Sand & Gravel) Fatal Fall of Material Accident Ambrose Bros., Inc. Cedarapids Portable Model MC-ICS-36 I.D. No. 27-00315 Tamworth, Carroll County, New Hampshire October 7, 1997 By Dennis A. Yesko Supervisory Mine Safety and Health Inspector and Robert A. Dow, Jr. Mine Safety and Health Inspector Northeastern District Office 230 Executive Drive, Suite 2 Cranberry Township, Pennsylvania 16066-6415 James R. Petrie District Manager GENERAL INFORMATION Paul T. Ambrose, retired company president, age 77, was fatally injured on October 7, 1997, at approximately 10:20 a.m., when an unsecured concrete and steel barrier fell on top of him from the rear framework of a portable crusher. Ambrose had retired in 1989, but continued to work periodically at the mine and was directing the relocation of the portable crusher at the time of the accident. Ambrose had a total of 36 years mining experience since starting the company with his brothers in 1961. He had not received training in accordance with 30 CFR Part 48. The local police notified the Concord, New Hampshire office of the Occupational Safety and Health Administration (OSHA) of the accident shortly after it occurred. OSHA sent a compliance officer to investigate, and upon realizing the operation was under MSHA jurisdiction, notified the Agency at 4:17 p.m. on the day of the accident. MSHA started its investigation the following day. The last regular inspection of the portable plant was conducted on October 1, 1997. Another regular inspection was conducted after the conclusion of this investigation. The portable plant was owned and operated by Ambrose Bros. Inc., and located on the site of the Pemi Fish and Game Club in Holderness, Carroll County, New Hampshire. The principal operating official was Robert P. Ambrose, company secretary. The facility normally operated one, 8-hour shift a day, 5 days a week, and employed a total of 2 persons. Ambrose Bros. Inc. was contracted to expand the shooting range at the Pemi Fish and Game Club. Bank run sand and gravel was excavated and transported to the portable plant by front-end loaders. The processed material was sold as road base. PHYSICAL FACTORS INVOLVED The portable crusher involved in the accident was a 1970 Cedarapids jaw crusher, serial number 128X108. The crusher was mounted on a framework of 15-inch I-beams, with semi-truck trailer wheels. The rear of the crusher would normally be pushed against an excavated earthen embankment to allow the front-end loaders to dump directly into the crusher's feed hopper. A large concrete and steel barrier was placed on the framework at the rear of the crusher, to partially support the embankment and to prevent sand and gravel from accumulating around the crusher's wheels. The barrier was constructed of sixteen, 3-inch by �-inch, interlocking steel strips, forming a waffle like structure which was filled with concrete. It measured 20 feet 5� inches long, 4 feet tall, and 3 inches thick, and weighed approximately 4,000 pounds. A steel lifting lug, approximately one foot long with a hole on the end, was permanently attached to the top center edge of the barrier and was used to lift the barrier into position using a chain attached to the bucket of a front-end loader. When located on the crusher, the bottom of the barrier was approximately 39 inches above the ground, and rested atop two 15-inch I-beams which were part of the crusher's framework. The top of the barrier leaned slightly against two, vertical, 6-inch I-beams. It had become normal practice to not secure the barrier in any manner. When the crusher was moved to a new location, the operating procedure was to pull it away from the embankment far enough for a front-end loader to knock the barrier off the supporting I-beams and let it fall to the ground. The lifting lug on the top of the barrier was used only to place the barrier back in position once the crusher had been moved to a new location. On the day of the accident, the crusher had been pulled approximately 41 feet away from the embankment, up a 6 1/2 percent grade. The two front-end loaders used on the property at the time of the accident were a Komatsu model WA450, and a Caterpillar model 966D. DESCRIPTION OF THE ACCIDENT Olif Taylor and Donald R. Draper, front-end loader operators, arrived at the work site at approximately 6:45 a.m., on October 7, 1997. Paul T. Ambrose (victim) arrived at approximately 7:30 a.m., his regular starting time, and instructed Taylor and Draper that the crusher would be relocated. They proceeded to dig out the crusher's rear tandem wheels, and connect a chain from the Komatsu front-end loader to the draw bar on the front of the crusher. At approximately 10:15 a.m., while Draper was using the front-end loader to pull the crusher away from the embankment, a fuel truck arrived and stopped on the access ramp located in front and to the left of the crusher. Ambrose had the men halt their activities so the front-end loaders could be fueled. Taylor pulled the Caterpillar loader in front of the fuel truck. He was fueling the loader when he saw Ambrose walking towards the rear of the crusher with a shovel in hand. Moments later, Taylor heard a noise towards the rear of the crusher. He looked over and saw Ambrose on the ground with the steel and concrete barrier on top of him. At the same time, Draper, who was standing on the fuel tank of the Komatsu loader located in front of the crusher, caught a glimpse of the falling barrier. Draper called out to Ambrose, but received no response. Both men immediately rushed to his aid and found Ambrose on the ground at the rear of the crusher, with his left shoulder and back pinned under the top left side of the barrier. Taylor checked for vital signs and found none. Draper immediately called the company shop using a 2-way radio in the Komatsu loader. Barry Cotton, company coordinator, received the call and immediately called 911. Neither Draper nor Taylor attempted to lift the barrier off of Ambrose. Emergency responders arrived at the scene at approximately 10:32 a.m. They checked Ambrose for vital signs and, finding none, they secured the area until the local medical examiner arrived. The medical examiner pronounced Ambrose dead at the scene, and the barrier was lifted to remove Ambrose's body. CONCLUSION The primary cause of the accident was failure to secure the barrier to prevent it from creating a falling hazard to persons walking near it. A contributing factor was the 6 � percent incline that the portable crusher was sitting on, which shifted the barrier's center of gravity making it more unstable. VIOLATIONS Citation No. 7702165 Issued on October 8, 1997, 8:20 a.m., under the provision of section 104 (a), for violation of 30 CFR 56.9201: //s// Dennis A. Yesko Supervisory Mine Safety and Health Inspector //s// Robert A. Dow, Jr. Mine Safety and Health Inspector Approved by: James R. Petrie, District Manager Related Fatal Alert Bulletin:  [FAB97M55]
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