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UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION

ROCKY MOUNTAIN DISTRICT
Metal and Nonmetal Mine Safety and Health

Accident Investigation Report
Surface Crushed Stone

Fatal Handtool Accident

Shivwit Pit
Southwest Stone, Incorporated
Gunlock , Washington County, Utah
Mine I.D. No. 42-02129

January 29, 1998

By

Larry O. Weberg
Supervisory Mine Safety and Health Inspector

Ronald S. Goldade
Mine Safety and Health Inspector

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

Robert M. Friend
District Manager

GENERAL INFORMATION

Darin Lee Lancaster, crusher operator/laborer, age 33, was seriously injured at about 2:00 p.m., on January 21, 1998, when he was struck on the forehead by the handle of a sledge hammer he was using to dislodge a rock in the jaw crusher. He died as the result of his injuries on January 29, 1998. Lancaster had a total of five years, four months mining experience, the last four months as crusher operator/laborer at this operation. He had received training in accordance with 30CFR, Part 48.

MSHA learned of the accident on February 18, 1998, upon receipt of an accident report (MSHA Form 7000-1) submitted by Stephen Larkin, office manager for the mining company. An investigation was started the following day.

At the time of the accident, the Shivwit Pit, a portable plant, owned and operated by Southwest Stone, Inc., was located at Gunlock Rock pit near Gunlock, Washington County, Utah. The principal operating official was Donald J. Larkin, president/owner. The plant was normally operated one, eight-hour shift a day, five days a week. Four persons worked at the crushing plant. Lancaster was employed by Southwest Stone, Inc., and the other three persons were employed by Gunlock Rock, LLC. Principal operating officials for Gunlock Rock, LLC, were Donald J. Larkin and Jay R. Leavitt, partners.

The portable plant was at the Gunlock location to produce crushed stone. It had been moved to this site approximately four months prior to the accident. The stone was extracted from a single bench by a bulldozer and pushed to the plant area where a backhoe loaded the stone into the plant feed bin. The material was then crushed, sized, and stockpiled. The finished product was crushed colored stone and was sold by both Southwest Stone Inc., and Gunlock Rock, LLC, to the public as decorative landscape material.

The last regular inspection of this operation was completed on February 13, 1997. Another inspection was conducted in conjunction with this investigation.


PHYSICAL FACTORS INVOLVED

The crusher where the accident occurred was a Kue-Ken jaw crusher, size 105, manufactured by Straub Mfg. Co., Inc. It was driven by a 440-volt, 75-horsepower motor. The operating speed was 368 revolutions per minute and the crusher was rated for crushing material up to 14 inches by 42 inches in an oscillatory motion.

The sledge hammer involved in the accident did not have identifying markings. The handle installed by the manufacturer had been replaced with a one-inch diameter metal pipe that was 34 3/8 inches long. The section of pipe had been welded to the hammer head with two metal gussets for additional strength. A metal pipe coupling was welded to the end of the handle. The overall length of the hammer and handle was 37 inches and the total weight was approximately 14 1/2 pounds.

Access to the top of the crusher was provided by a homemade portable ladder constructed of 1 1/2-inch diameter metal pipe, 9 1/2 feet long and 20 inches wide. The ladder rungs were spaced on 12-inch centers. The ladder was constructed to fit in a location between the crusher and screen deck framework. The distance from the jaw crusher area, where Lancaster was working, to the ground was approximately 8 1/2 feet.


DESCRIPTION OF ACCIDENT

On the day of the accident, Darin L. Lancaster (victim) reported for work at 7:30 a.m., his usual starting time. He met briefly with Jay Leavitt, supervisor, and Bradley Clay, equipment operator. Lancaster started the plant and Clay fed the crusher with the backhoe. Work proceeded normally throughout the morning.

At about 2:25 p.m., Lancaster placed the portable ladder against the side of the jaw crusher and Clay ceased dumping material into the feed bin. Lancaster climbed the ladder and began using the sledge hammer in an effort to dislodge a rock that was caught in the throat of the crusher. The crusher motor was running.

Clay saw the sledge hammer fly out of the jaw chute and over the top of the crusher, landing on the ground about 15 feet away. The end of the hammer handle struck Lancaster on the forehead and knocked him to the ground.

Reed Leavitt, truck driver, Nicholas Bowler, trainee, and Jay Leavitt were conversing nearby. Lancaster fell backward off the ladder and the three men ran to assist him. Jay Leavitt pushed the crusher emergency stop button located at the side of the crusher and Clay ran to the other side of the crusher and pushed another emergency stop button.

Basic first aid was administered to Lancaster at the scene and a call was placed to the local 911 telephone number to obtain emergency assistance. Lancaster was transported by ambulance to a hospital in St. George, Utah, and then flown by helicopter to the

University Medical Center in Las Vegas, Nevada, where he died eight days later as the result of a skull fracture.


CONCLUSION

The direct cause of the accident was the failure to deenergize the drive motor before attempting to dislodge the rock that was hungup in the crusher. Additional contributing factors were:

--- A safe means of access was not provided to the crusher to dislodge rocks that had become stuck. The ladder provided for the victim to use was too short to safely access the crusher throat.
--- The sledge hammer handle had been replaced with a section of metal pipe.
--- A safety belt and line was not available at the site for the victim to use.
--- The victim (and other employees) was not wearing a hardhat. Injuries received from the hammer handle blow and the fall may have been less severe had head protection been worn.
--- The mine operator did not examine each working place for conditions which affected health and safety.


Citation No. 7901950 was issued on February 19, 1998, under the provisions of Section 104(a) of the Mine Act for violation of Standard 50.10:
An accident occurred at this operation at 2:25 p.m., on January 21, 1998, when an employee was struck on the head by a hammer he was using to break rocks in the primary crusher. He died on January 29, 1998. MSHA was not notified of this accident until February 18, 1998.

This citation was terminated on February 20, 1998. The mine operator was instructed to comply with reporting requirements.

Citation No. 7901951 was issued on February 19, 1998, under the provisions of Section 104(a) of the Mine Act for violation of Standard 50.12:

An accident occurred at this operation on January 21, 1998, which resulted in the death of the employee on January 29, 1998. The mine operator failed to preserve the accident scene. The crusher was operated and equipment was removed from the scene prior to a Mine Safety and Health Administration investigation.

This citation was terminated on February 20, 1998. The mine operator was instructed to comply with the requirements of Part 50.12.

Citation No. 7902218 was issued on February 20, 1998, under the provisions of Section 104(d)(1) of the Mine Act for violation of Standard 56.14105:

A serious accident occurred on January 21, 1998, when the crusher operator was struck on the forehead with the handle of a sledge hammer that he was using to dislodge a rock in the jaw crusher. He died on January 29, 1998. The electrically powered crusher was not deenergized before working on the crusher nor blocked against movement. Hangups occurred frequently at this operation. The supervisor was aware of this unsafe procedure and did not initiate corrective action. His knowledge of the hazard and neglect to ensure that safe work procedures were followed constituted more than ordinary negligence. This violation is an unwarrantable failure to comply with the mandatory standard.

This citation was terminated on April 13, 1998. Written lockout procedures were established and posted at the mine. These procedures mandated the steps necessary to properly lockout electrical circuits before working on equipment. Employees were instructed to follow the policy. Locks were provided and accessible to all employees.

Order No.7902219 was issued on February 20, 1998, under the provisions of 104(d)(1) of the Mine Act for the violation of Standard 56.11001:

A serious accident occurred on January 21, 1998, when the crusher operator was standing on a portable ladder while attempting to dislodge a rock in the throat of the jaw crusher. The victim died on January 29, 1998. Frequent hangups necessitated access to the throat of the crusher on a recurrent basis. A means of safe access was not provided to the opening of the crusher in that the ladder was too short for the task, the employee had to stand on the top rungs of the ladder in order to reach the hangups. The victim was struck on the forehead with the end of the handle of the sledge hammer he was using to dislodge the rock. The supervisor was aware of the condition and did not initiate corrective action. This failure constitutes more than ordinary negligence and is an unwarrantable failure to comply with the mandatory standard.

This order was terminated on April 13, 1998. A portable stairway and landing with handrails was provided to access the throat of the jaw crusher. Employees were instructed on the usage of the stairway and landing when working from elevated positions.

Order No. 7902220 was issued on February 20, 1998, under the provisions of 104(d)(1) of the Mine Act for the violation of Standard 56.14205:

A serious accident occurred on January 21, 1998, when the crusher operator was attempting to dislodge a rock in the jaw crusher with a sledge hammer. The victim died on January 29, 1998. The factory installed hammer handle had been replaced with a one-inch diameter metal pipe. While using the hammer to dislodge the rock caught in the throat of the crusher, force generated by the jaw caused the hammer to be propelled from the crusher. The end of the hollow, metal pipe handle struck the victim on the forehead. The sledge hammer had been modified beyond the design capacity intended by the manufacturer. The supervisor was aware of the condition and did not initiate corrective action. This failure constitutes more than ordinary negligence. This violation is an unwarrantable failure to comply with a mandatory standard.

This order was terminated on April 13, 1998. The mine operator established a written policy prohibiting the use of handtools that have been modified beyond safety recommendations of the manufacturer. Employees had been informed of the policy and the policy was posted. All handtools that had been modified were removed from mine property.

Order No. 7902221 was issued on February 20, 1998, under the provisions of 104(d)(1) of the Mine Act for the violation of Standard 56.15005:

A serious accident occurred on January 21, 1998, when the crusher operator was using a sledge hammer to dislodge a rock in the throat of the jaw crusher. He died on January 29, 1998. The victim was standing on a portable ladder, approximately 8 1/2 feet off the ground level, when the end of the sledge hammer handle struck him on the forehead, knocking him to the ground. A safety belt and line was not worn. The supervisor was aware that employees frequently climbed the ladder to dislodge rocks and knew that a safety belt and line was not used nor readily available for employees to use. His failure to ensure that safety belts and lines were used where there was a danger of falling constitutes more than ordinary negligence. This violation is an unwarrantable failure to comply with the mandatory standard.

This order was terminated on April 13, 1998. A safety harness and lanyard was provided for employees to use. The mine operator established written procedures that mandates the use of safety equipment when working from elevated levels where a fall could result in injury. All employees were instructed on the contents of the policy.

Order No. 7902222 was issued on February 20, 1998, under the provisions of 104(d)(1) of the Mine Act for the violation of Standard 56.15002:

On January 21, 1998, a serious accident occurred when the crusher operator was struck on the forehead with a sledge hammer he was using to dislodge a rock caught in the throat of the jaw crusher. He died on January 29, 1998, as a result of the injuries sustained in the accident. The victim was not wearing a hardhat while performing work in an area where head injury hazards existed. The supervisor was at the mine at the time of the accident and was aware that the victim and other workers were not wearing hardhats. His failure to ensure that employees wear hardhats in hazardous areas constitutes more than ordinary negligence. This violation is an unwarrantable failure to comply with the mandatory standard.

This order was terminated on April 13, 1998. The mine operator established a written policy that require employees to wear hardhats. The policy was shared with employees. All persons on mine property were wearing hardhats.

Order No. 7902223 was issued on February 20, 1998, under the provisions of 104(d)(1) of the Mine Act for the violation of Standard 56.18002a:

A serious accident occurred on January 21, 1998, when the crusher operator was attempting to dislodge a rock in the jaw crusher. The victim died January 29, 1998. A person designated by the mine operator had not been examining each work area at least once each shift for conditions which may adversely affect safety. This was evidenced by the unsafe conditions and practices cited during the accident investigation and are as follows:

1) A means of safe access was not provided to the opening of the jaw crusher.

2) A safety belt and line was not worn when working in areas where a hazard of falling existed.

3) Hardhats were not worn in areas where hazards to the unprotected head existed.

4) A handtool had been modified beyond the manufacturer's intended capacity.

5) Additional citations/orders were issued for numerous violations during a concurrent inspection. This failure to examine work areas constitutes aggravated conduct and is an unwarrantable failure to comply with the mandatory standard.

This order was terminated on April 13, 1998. The mine operator established procedures to ensure that inspection of work places will be performed. The program includes record keeping of the inspection. The supervisor was designated as the competent person to inspect work places for conditions that could affect health and safety. Inspection records were reviewed.

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