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UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION

Northeast District
Metal and Nonmetal Mine Safety and Health


Accident Investigation Report
Dredge Operation


Fatal Accident



Tuckahoe Sand & Gravel (company)
Tuckahoe Sand & Gravel (mine)
Tuckahoe, Cape May County, New Jersey
Mine I.D. No. 28-00558

October 27, 1997


by

Dale R. St. Laurent
Supervisory Mining Engineer

and

Joseph H. Bosley
Mine Safety and Health Inspector


Mine Safety and Health Administration
Northeastern District
230 Executive Drive, Suite 2
Cranberry Township, PA 16066-6415

James R. Petrie
District Manager



GENERAL INFORMATION



Edwin L. Harris, dredge operator, age 50, died at about 3:00 p.m., on October 27, 1997, while traveling from a dredge to shore in a work boat. Harris had a total of 16 years mining experience, all at this mine, the past 10 years as a dredge operator. He had not received training in accordance with 30 CFR Part 48.



MSHA was notified at about 4:30 p.m. on the day of the accident by a telephone call from the plant manager. An investigation was started the following day.



The Tuckahoe Sand & Gravel mine, a dredging operation, owned and operated by Tuckahoe Sand & Gravel company, was located near Tuckahoe, Cape May County, New Jersey. The principal operating official was Ronald Carusi, aggregate manager. The mine normally operated two, 8-hour shifts a day, 5 days a week. A total of 20 persons was employed.



Sand and gravel was extracted by dredging from ponds. Three dredges extracted and pumped the material to the processing plant on shore where it was screened, sized, and stockpiled. The finished products were used at the company-owned concrete plants and sold for use as aggregate.



The last regular inspection of this operation was completed August 27, 1997. Another inspection was conducted following this investigation.

Physical Factors Involved



The accident occurred at the No. 2 dredge pond, which was one of three separate ponds. The size of the No. 2 dredge pond was approximately 2,300 feet long by 1100 feet wide and the average depth was 40 to 45 feet. The work boat involved in the accident was a Lowe, Delta Model No. 1436L, aluminum flat-bottomed "jon boat," powered by a 2.5-horsepower Nissan 2-cycle outboard motor. It was approximately 14 feet long, and its maximum width measured about 36 inches across the bottom and 50 inches across the gunwales. The height measured 16 inches from the bottom to the gunwales. Freeboard was 6 to 8 inches at the rear of the boat with one person on board, and 8 to 10 inches when empty. The boat was equipped with three seats, each foam filled to provide floatation. The boat was examined, and no leaks or damage were evident. A cutout plastic jug used for bailing rainwater, and a nearly full, half gallon plastic gasoline container were found in the boat.



The company had purchased three identical Lowe "jon boats," including this one, for servicing their dredges. They were purchased new in June 1997, from a local boat dealer and were manufactured by Outboard Marine Corporation (OMC), Aluminum Boat Group, Lebanon, Missouri. The manufacturer listed the maximum carrying capacities, per U.S. Coast Guard regulations, as "3 persons or 350 lbs.," and "530 lbs. persons, motor, gear." The maximum motor capacity was 15 horsepower. Several company employees who had used the boats reported that they were "skittish" when getting in or out, and that large men had to be extra careful not to upset them. The manufacturer had posted a warning label inside the boat to remain seated while operating.



The Nissan outboard motor was pull-started with a retractable cord and weighed about 30 pounds. It was a direct drive unit, and the propeller would immediately begin turning when the engine started. The motor had no reverse, and was designed to be mounted on the transom so that it could be turned 360 degrees in the water. Controls consisted of a stop button, manual choke, and sliding throttle lever, all located on the motor. Speed ranges were estimated to be 2-3 mph at the throttle's lowest setting and 8-10 mph at the highest setting. The motor was also equipped with a safety tether strap intended to be attached to the operator. When the tether strap was pulled, such as if someone fell out of the boat, it would shut off the motor. The tether strap was found wrapped around the motor and apparently was never used. The motor was tested following the accident, and it started and ran normally.



Boarding platforms were located immediately in front of the winch on both sides of the dredge. The platforms measured about 2 feet wide, and were about 18 inches below the main deck level and 18 inches above the water at the rear area of the dredge.



The company provided two types of approved personal flotation devices: U.S. Coast Guard Type V, work vests, and Type II, horse-collar style. Work vests were assigned to each employee and could be buckled around persons with up to a 52-inch chest size, although they would not be able to expand their chest. Several employees stated that they did not wear the vests because of the poor fit. The horse-collar style devices were used as unassigned spares. One of these was found floating in the water inside the work boat used by Harris. Reportedly, it stayed in the boat and was rarely worn. No life jackets were found on the dredge.



The company did not have a formal policy requiring the wearing of life jackets. Several employees stated that they, along with members of mine management, frequently rode in the boats, and worked elsewhere around the pond without wearing life jackets. Reportedly, a life jacket had been assigned to Harris, which had his name written on it. However, it could not be found following the accident. A company official stated that all available life jackets had been provided to the police and rescue units and the current whereabouts of some of them were unknown, including Harris's.



Weather conditions at the time of the accident were fair, about 60 degree Fahrenheit, with a light breeze. The water temperature was estimated to be in the low 50-degree Fahrenheit range.

Description of Accident



On the day of the accident, Edwin Harris (victim) reported for work about 6:50 a.m., his regular starting time. He stopped at the office and was instructed by Albert Knoll, plant manager, to operate the No. 2 dredge. Harris drove his personal truck to the boat landing, and took the work boat to the dredge. He operated the dredge without any unusual incident until shortly before the end of his work shift at 3:00 p.m.



Steve Shaw, plant operator, was assigned to relieve Harris and drove his truck to the boat landing. Shaw parked next to Harris's truck and from shore, observed Harris walk down the stairway from the dredge's pilot house, then to the pump house for a moment, he then walked toward the front of the dredge. Shaw did not see Harris after that, as his view of the boarding platform and the boat Harris used was blocked. After a few minutes, when Harris failed to reappear, Shaw decided to bail out the other work boat, which was beached at the landing, and motor out to the dredge.



Shaw came around the stern of the dredge and saw Harris's boat slowly going around in circles about 10 to 12 feet from the dredge. The motor was running and there was no sign of Harris. His lunch box was floating in the water near the boat, which contained about 6 inches of water inside. The motor was turned 90 degrees sideways, which caused the boat to circle. Reportedly, a free tiller would soon turn the motor sideways from the prop torque and the boat would begin to circle. Shaw stated that upon subsequent examination, the throttle was in the "start" position, and the manual choke was in the open (run) position.



Shaw pushed Harris's boat against the dredge and reached over and shut the motor off. After quickly searching, he radioed to shore that Harris was missing. He then climbed back into his boat and continued searching. A few minutes later, Shaw picked up James Schweibing, plant operator, in his boat and they returned to the dredge to continue searching for Harris.



Albert Knoll, plant manager, was on the No. 1 dredge when he heard Shaw's call and sent the No. 1 dredge operator to help search for Harris. Knoll then went to the plant office, picked up Ronald Carusi, aggregate manager, and drove to the pond. Several rescue teams arrived with boats and divers a short time later.



Harris weighed about 260 pounds, and reportedly, was a poor swimmer, but not afraid of the water. His body was found about 7:00 p.m. by divers in water about 50 feet deep, and 20 to 30 feet from the dredge, just forward of its boarding platform. Harris was wearing work pants, a T-shirt, a flannel shirt, and work boots, but no life jacket.



The Certificate of Death issued by the county medical examiner listed the immediate cause of death as "cardiac arrhythmia due to hypertensive cardiovascular disease(?)," question mark included. It also listed under OTHER SIGNIFICANT CONDITIONS - CONTRIBUTING TO THE DEATH BUT NOT RELATED TO THE UNDERLYING CAUSE as: "Blunt force trauma to the head with facial contusions." Although the medical examiner did not find water in the victim's lungs and did not list drowning as either an "immediate" or "other" cause, he stated to MSHA investigators that he could not completely rule out death by drowning as the immediate cause.

Conclusions



As stated above, the county medical examiner was not able to conclusively determine the cause of Harris's death. However, the small size and light construction of the boat and the direct-drive characteristic of the motor may have caused the boat to move as soon as it was started, causing Harris to lose his balance and fall into the water. Contusions found on Harris's head may have been caused by his striking the side of the boat or dredge when he fell. The failure to wear a life jacket contributed to the severity of the accident.

Violations



Order No. 4434602
Issued on October 28, 1997, under the provisions of Section 103(k) of the Mine Act prohibiting activity and work around the dredge until MSHA investigators determined the cause of the fatality and presence of any hazards. This order was terminated on October 29, 1997, upon completion of MSHA's investigation.



Citation No. 7703124
Issued on November 5, 1997, under the provisions of Section 104(d) of the Mine Act for violation of 30 CFR: 56.15020:

A fatal accident occurred at this operation on October 27, 1997, when the operator of the No. 2 dredge fell into the water from a 14-foot jon boat and presumably drowned. He was returning to shore at the end of his work shift and was not wearing a life jacket. In the area of the accident, the pond was approximately 50 feet deep. Employees reported that it was common practice not to wear life jackets when working where there was a danger of falling into the water. Mine management also stated that they had traveled on the work boats to the dredges without wearing life jackets, and had seen many instances of miners not wearing them. The failure of the mine operator to enforce the wearing of life jackets or belts where there is a danger of falling into water represents a serious lack of reasonable care and an unwarrantable failure to comply with the standard.

This citation was terminated on January 12, 1998, after company management reissued life jackets to all employees; established a formal policy requiring that life jackets be used at all times where there was a danger of falling into water; purchased a larger, heavier duty, boat to replace the one involved in the accident; conducted training, through the state police, on the proper use of personal floatation devices and small vessel safety; and, conducted 8 hours of refresher safety training to all employees.

Recommendations



The two remaining 14-foot jon boats be replaced with heavier duty boats designed for industrial use. Their light duty construction does not appear suitable for use at this operation.



The direct-drive motors should be replaced with motor/drive units that must be started in "neutral."



//s// Dale R. St. Laurent
Supervisory Mining Engineer


//s// Joseph H. Bosley
Mine Safety and Health Inspector


Approved by: James R. Petrie, District Manager


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Fatal Alert Bulletin Icon [FAB97M58]