MINE SAFETY AND HEALTH ADMINISTRATION
Northeast District
Metal and Nonmetal Mine Safety and Health
Accident Investigation Report
Surface Nonmetal Mine
(Cement)
Fatal Powered Haulage Accident
Lehigh Portland Cement Company
Union Bridge, MD Mine
Union Bridge, Carroll County, Maryland
I.D. No. 18-00017
July 1, 1998
by
Carl A. Onder
Supervisory Mine Safety and Health Inspector
Robert L. Carter
Mine Safety and Health Inspector
Leonard C. Marraccini
Supervisory Physicist
George Durkt Jr.
Industrial Hygienist
Originating Office:
Northeastern District Office
230 Executive Drive, Suite 2
Cranberry Township, Pennsylvania 16066-6415
James R. Petrie
District Manager
Ronald L. Stewart, serviceman, age 41, was fatally injured at about 1:15 p.m. on July 1, 1998, when the powered sweeper he was operating was struck by a train. Stewart had a total of seven years mining experience, all as a serviceman at this operation. He had received training in accordance with 30 CFR Part 48.
MSHA was notified at 1:41 p.m. on the day of the accident by a telephone call from the safety and training supervisor for the mining company. An investigation was started the same day.
The Union Bridge, MD mine, a surface quarry and milling operation, owned and operated by Lehigh Portland Cement Company, was located at Union Bridge, Carroll County, Maryland. The principal operating official was David H. Roush, plant manager. The plant was normally operated three, 8-hour shifts a day, 7 days a week. A total of 138 persons was employed.
Limestone and shale were extracted by drilling and blasting from multiple benches in the quarry. Broken stone was loaded by front-end-loaders onto haul trucks and transported to the mill where it was crushed and sized. The processed stone was blended with sand and mill scale, which were purchased from outside suppliers, and conveyed to rotary kilns. The clinker from the kilns was ground to produce cement and the finished product was stored in silos. Cement was bulk loaded from the silos and shipped to customers by truck and rail.
The last regular inspection of this operation was completed on March 11, 1998. Another inspection was conducted following this investigation.
The accident occurred at the south end of rail load-out Tunnel-H, which was one of four located beneath the cement storage silos. This tunnel was 292 feet long and 26 feet 10 inches wide. It narrowed to 23 feet 10 inches where several vertical pillars projected along the sides. The tunnel was well lighted. The southeast corner of the silo was posted with a sign stating, "DANGER RAILROAD CROSSING." A sign was also posted above each tunnel stating, "DANGER DON'T RIDE CARS NO CLEARANCE." There were no warnings outside the tunnel to alert mobile equipment operators of the restricted clearance when trains were moving inside.
The train involved in the accident consisted of five covered hopper cars connected to a diesel- electric locomotive. The locomotive was an 80-ton, General Electric, powered by two 335-HP Cummins diesel engines. The hopper cars were bottom-discharge and measured 10 feet 8 inches wide and 42 feet long. When positioned inside the tunnel, the clearance was 6 feet 7 inches between the sides of the rail cars and the pillars. There were no signal lights on the last car of the train. Just prior to pushing the cars into the tunnel, the train was positioned with its locomotive and the first hopper car outside the north end of the tunnel with four of the cars inside the tunnel. The locomotive was pushing with its front connected to the string of five cars. The engineer was sitting on the left side in the cab.
The mobile sweeper involved in the accident was a Tennant, Model 830, used to clean roadways and hard surfaces around the plant. It was 5 feet 8 inches wide and 14 feet long. The vehicle was equipped with an air-conditioned cab and the operator's seat was positioned on the right side. The right front of the sweeper was struck by the left rear corner of the lead hopper car as the train was pushed into the tunnel. The collision occurred on the west side of the tunnel, about 70 feet from the south end. After impact, the sweeper was pushed about 32 feet. It was stopped by one of the pillars along the west side of the tunnel. The sweeper was found in gear and had been running when struck by the train.
Rail cars were loaded automatically from the control room located mid-way along the west side of Tunnel-H. The control room was elevated and had a 4-by 6-foot window facing east, and a door with a window facing north. The site where the accident occurred could not be seen from within the control room.
Although the locomotive engineer reportedly sounded the horn at least twice prior to movement of the train, there was no signal or method to warn which direction it was moving. Following the accident, noise measurements were taken to determine if the sweeper operator could have heard the train's horn. The accident scene was recreated using the same locomotive and an identical sweeper. The results of the tests indicated that it was unlikely the sweeper operator could have heard the locomotive's horn from within the cab of the sweeper. The cab windows were closed at the time of the accident. The victim was not wearing hearing protection, and the sweeper's radio/cassette player was off.
On the day of the accident, Ronald Stewart (victim) reported for work a few minutes before his normal starting time of 7:00 a.m.. Stewart was working on light duty status as a result of a fractured left index finger and had been assigned by Larry Lesher, maintenance relief foreman, to operate the sweeper. Earlier in the week, Lesher had instructed Stewart to clean roadways and hard surfaces around the plant. Reportedly, Stewart had operated the sweeper on numerous prior occasions.
At about 1:00 p.m., Randy Brown, silo laborer, was closing the hatch covers on the hopper cars in Tunnel-H, when he noticed that the car coupled to the locomotive was outside the tunnel and beyond reach of the tether line used to provide safe access to the top of the cars. Brown reported the problem to James Hammond, bulk loader operator, who called Larry Brooks, locomotive engineer, and asked him to push the cars back into the tunnel.
Before moving the train, William Frye, brakeman, adjusted the coupling between the locomotive and the first car. Brooks then called Hammond to make sure the tracks were clear. Brooks and Frye were on the left side of the locomotive and could not see the right side of the train (west side of the tunnel). Frye had not walked to the lead car to determine if the area in front of the train was clear.
Brown and Hammond were in the control room when they received the call from Brooks. Brown reportedly told Hammond the tunnel was clear, and Hammond said he also checked by looking out the control room window. The control room, however, lacked windows on the south side and visibility along the southwest side of the tunnel was limited.
After receiving confirmation from Hammond that the tunnel was clear, Brooks reportedly sounded the horn at least twice and began pushing the cars into the tunnel. As the train advanced, Brooks noticed that there was no slack in the cars and he asked Frye if he had left the brakes on. After stopping the train, Brooks heard on the radio that it had struck a sweeper in the tunnel.
Kenneth Roche, truck driver, was outside his truck in Tunnel-J when he heard the collision. Roche walked to the south end of Tunnel-H where he saw that the sweeper had been struck by the train, pinning Stewart inside the cab. Roche notified company personnel in Tunnel-J of the accident, and a call was placed to local emergency response personnel. While awaiting their arrival, Daniel Zile, millwright and EMT, checked Stewart for vital signs and found none. The local emergency rescue squad arrived a few minutes later. It took them about two hours to extricate Stewart from the cab. Stewart was pronounced dead at the scene by the local medical examiner.
It could not be determined if Stewart had entered the tunnel before or after the train began to move. Stewart was last seen, shortly before the accident, sweeping in Tunnel-J.
The primary cause of the accident was failure to utilize methods to alert mobile equipment operators to stay out of areas with restricted clearance and rail traffic. Contributing factors were failure to establish procedures to warn persons of the direction of train movement, and failure to provide a warning signal which was audible inside the cab of the sweeper.
Order No. 4436032 was issued on July 1, 1998, under the provisions of Section 103(k) of the Mine Act:
A serviceman was fatally injured at this mine on July 1, 1998, when the sweeper machine he was operating was hit by a train. This order is issued to assure the safety of the personnel in the area until the area affected can be returned to normal mining operations as determined by an authorized representative of the Secretary. The operator shall obtain approval from an authorized representative for all actions to recover persons, equipment, and/or restore operations in the affected area.This order was terminated on July 2, 1998, when it was determined that the affected area could safely return to normal operation.
Citation No. 7714808 was issued on August 5, 1998, under the provisions of section 104(d)(1) of the Mine Act for violation of 30 CFR 56.9306:
A serviceman was fatally injured at this operation on July 1, 1998, when the powered sweeper he was operating was struck by a train that was backing up inside a rail load-out tunnel. Warning devices were not installed to alert persons operating mobile equipment of the restricted clearance hazard. Failure to provide these warning devices constitutes more than ordinary negligence and is an unwarrantable failure to comply with a mandatory safety standard.This citation was terminated on August 19, 1998, after the company: (1) installed strobe lights and stop lights to signal when trains are moving in the tunnel; (2) posted warning signs explaining the signal lights; and, (3) installed a bay window in the load-out control room to provide the bulk loader operator with a better view of the tunnel.
Order No. 7714809 was issued on August 5, 1998, under the provisions of section 104(d)(1) of the Mine Act for violation of 30 CFR 56.9100(a):
A serviceman was fatally injured at this operation on July 1, 1998, when the powered sweeper he was operating was struck by a train that was backing up inside a rail load-out tunnel. The mine operator had not established rules to warn individuals of the direction of movement of its trains. Further, the train had begun to back-up without determining that the area behind it was clear. Failure to provide for the safe movement of trains on the mine site constitutes more than ordinary negligence and is an unwarrantable failure to comply with a mandatory safety standard.This order was terminated on August 5, 1998, after the company: (1) installed strobe lights and stop lights to signal when trains are moving in the tunnel; (2) positioned a brakeman at the end of the train (lead car) when pushing rail cars into the tunnel; (3) established procedures to sound two blasts on the locomotive's horn before pushing cars and one blast before pulling; and, (4) trained company personnel on these procedures.
Citation No. 7714810 was issued on August 5, 1998, under the provisions of section 104(a) of the Mine Act for violation of 30 CFR 56.14214(c):
A serviceman was fatally injured at this operation on July 1, 1998, when the powered sweeper he was operating was struck by a train that was backing up inside a rail load-out tunnel. The train's warning signal was not audible above the surrounding noise level.This citation had not been terminated at the time this report was published.
Related Fatal Alert Bulletin:
FAB98M27