MINE SAFETY AND HEALTH ADMINISTRATION
NORTH CENTRAL DISTRICT
Metal and Nonmetal Mine Safety and Health
Underground Nonmetal Mine
Fatal Powered Haulage Accident
September 29, 1999
Gunther-Nash Mining Construction Company (B08)
St. Louis, St. Louis County, Missouri
Skyline Construction Mine No. 1
Bruening Rock Products, Incorporated
Knoxville, Marion County, Iowa
Ralph D. Christensen
Supervisory Mine Safety and Health Inspector
William T. Owen
Mine Safety and Health Inspector
Eugene D. Hennen, P.E.
Mine Safety and Health Administration
North Central District
515 West First Street, Room 333
Duluth, MN 55802-1302
Felix A. Quintana, District Manager
On September 29, 1999, Joseph Isidore, laborer, age 29, was fatally injured when he was pinned under the boom of a rough-terrain forklift. Isidore was in the process of hauling a 265-gallon container of water on the forks from the bottom of a decline slope. It was determined by another employee that he was operating the forklift in an unsafe manner and he was asked to park the machine.
The accident occurred when Isidore attempted to exit the operator's compartment of the forklift on the interior boom side and inadvertently contacted the boom control lever, lowering it down on him.
The day of the accident was Isidore's second work shift at this underground construction project. He had no previous mining experience. It was stated that he had operated various pieces of mobile equipment in the past. Although shaft and slope construction workers are not covered by the existing provisions of Part 48, the contractor had trained the victim in accordance with 30 CFR, Part 48.
The Skyline Construction Mine No. 1, a decline slope construction project, owned and operated by Bruening Rock Products, Incorporated, was located at Knoxville, Marion County, Iowa. The principal operating official was Gregory A. Bruening, vice president.
The victim was employed by Gunther-Nash Mining Construction Company, located at 2150 Kienlen Avenue, St. Louis, Missouri. The principal operating official was Thomas A. Braxmeier, Jr., vice president-operations. The mine operated three, 8-hour shifts per day, seven days a week. Total employment was 24 persons.
This construction company had been contracted to develop a decline slope to an underground limestone formation. Material was extracted by a continuous miner and hauled by a side-dump front-end loader to a hopper underground. A conveyor, located along the left side of the decline slope, was used to transport the material to the surface where it was discarded.
The last regular inspection of the operation was completed on September 22, 1999.
DESCRIPTION OF THE ACCIDENT
On the day of the accident, Joseph Isidore (victim) reported for work at 12:00 a.m., his normal starting time. Patrick Lowe, foreman, informed Isidore that he needed to haul water containers, called "totes", out of the decline with the forklift. Isidore had received instruction and practiced operating the forklift on the previous shift. Lowe assigned Isidore with Oscar McLamb, an experienced operator, to brief him on the forklift pre-inspection checks and operation. Lowe went underground and, later on, McLamb came down with a front-end loader and Isidore followed with the forklift. After some miscellaneous tasks at the bottom of the decline, Isidore walked over to the sump pump area with Lowe. One plastic tote was full and a second one was half full. Isidore picked up the full tote with the forklift. Lowe guided Isidore to get the tote to the right height for travel. Lowe watched Isidore proceed up the decline with no problem. When Isidore returned, Lowe operated the forklift and picked up the second tote that was full. Lowe instructed Isidore how to install a spray bar on the tote, which was used to water the roadway as the forklift backed up the decline. Lowe continued up the decline, watering the road as he went while Isidore watched. When he finished, he returned with the empty tote and parked the forklift.
After lunch, Isidore was assigned to work on other tasks at the bottom of the decline. Toward the end of the shift, McLamb observed Isidore on the forklift having trouble trying to pick up a full tote. He went over and tried to guide Isidore on various ways to pick it up. Because the tote was in a tight area, McLamb got on the forklift and picked up the tote while Isidore watched. McLamb then parked it against the rib and turned it back over to Isidore. About 6:30 a.m., Jon McCarty, mechanic, and Harrison Bingham, electrician, were at the bottom of the tunnel. They wanted a ride out of the decline and sat on the fuel tank on the opposite side of the operator's compartment of the forklift, waiting for it to be driven to the surface.
Shortly after, Isidore got on the forklift and started backing up the decline. The forklift traveled within 6 inches of an electrical power center located just below the conveyor feed hopper. McCarty shouted to Isidore that he was too close to the left side going up the decline. Isidore steered the forklift toward the opposite side of the decline, missing the conveyor feed hopper by a few inches in the process. McCarty again shouted to Isidore that he now was going into the airline, and to park the forklift.
Isidore parked the forklift on the right side of the decline, about 2 feet from the opposite wall and 19 inches from the airline, and set the park brake. McCarty then observed Isidore get out of his seat and proceed to climb out of the operator's compartment by ducking under the boom. McCarty shouted to him to stop, but it was too late. Isidore inadvertently caught the boom control lever with his body and lowered the boom, pinning himself. McCarty quickly tried to move the lever back to raise the boom but was unable to do so. Several employees arrived at the scene to assist and emergency medical personnel were summoned. The boom hydraulic lines were disconnected to facilitate raising the boom with a front-end loader to remove the victim.
Emergency personnel then transported the victim to a local hospital where he was pronounced dead. Death was attributed to asphyxia due to traumatic compression.
INVESTIGATION OF THE ACCIDENT
MSHA was notified at about 7:25 a.m. on the day of the accident by a telephone call from Albert Dudzik, project manager, to Ronald Goldade, supervisory mine safety and health inspector. An investigation was started the same day. Upon arrival at the mine, MSHA's accident investigation team issued an order under the provisions of Section 103(k) of the Federal Mine Safety and Health Act of 1977 to ensure the safety of the miners until the affected area and equipment could be returned to normal operations. The investigation was conducted with the assistance of the mine employees. The miners did not request, nor have representation during the investigation.
1. The accident occurred 1,170 feet down the decline. The decline sloped at about 12 percent and was advanced to 1,906 feet. It was approximately 25 feet wide and 19 feet high, with an arched back.
2. A 42-inch wide conveyor extended along the left side of the decline wall. On the opposite side, a 2-inch fresh water line, a 2-inch waste water line, and a 6-inch airline were mounted along the wall. The balance of the decline width was the roadway, which was approximately 19 feet wide. Ventilation was achieved utilizing a surface installed fan exhausting through 48 inch tubing.
3. The containers used to haul water out of the decline originally contained shot-crete accelerant used by the contractor. The weight of the empty container was 440 pounds, with a 265 gallon capacity. The total weight of the container filled with water was 2,600 pounds.
4. The forklift was 20.08 feet in overall length, including the forks, and 8.12 feet in width. It was 8.58 feet high. The forklift usually backed up the decline with its load since there was not enough room to turn it around. The operator's compartment was on the left side of the machine when backing up the tunnel. Normally the forks were raised to approximately 2-1/2 to 3 feet above the ground during travel with a water tote.
5. The forklift was examined for defects and none were found.
6. The forklift was a non-articulating, Ingersoll-Rand, variable reach rough terrain forklift, Model VR60B, manufactured in 1995, and weighed about 16,900 pounds. The forklift had a load capacity of 6,000 pounds with the boom fully retracted and 1,800 pounds with the boom fully extended. It was powered by a 4 cylinder, 243 cubic inch Perkins diesel engine. The unit was all-wheel drive. It was equipped with planetary steering and provided with a selection switch to select front-wheel steering, front and rear coordinated steering, or steering in a sideways "crabbing" method. The forklift was provided with a falling object protective structure (FOPS).
7. The boom on the forklift attached in the rear. The boom extended the full length of the machine and traveled past the right side of the operator's compartment. No partition separated the operator's compartment from the area where the boom was located. The floor of the operator's compartment was made of diamond tread steel plate which extended at the same level to the right into the area under the boom.
8. The approximate height of the access opening on the right side of the operator's compartment is 56 inches, measured from the operators' compartment floor to the underside of the FOPS structure. The forklift boom passes directly adjacent to this opening and moves up and down, changing the size of this opening when the boom control is actuated. It was revealed during the investigation that the forks were approximately 3 feet off the ground immediately prior to the accident. With the forks positioned approximately 3 feet above the ground, the forklift boom blocked approximately 15 inches of the 56-inch high access opening on the right side of the operators' compartment. With the boom in that position, the right side exit accessway height was reduced to 41 inches. The width of the access opening out of the right side of the operators' compartment was 10 inches for the first 19 inches above the operators' compartment floor. This portion of the access opening was narrow due to the cover over the engine and the plate which holds the right side of the dash. The remainder of this accessway opened to approximately 50 inches in width all the way to the underside of the FOPS.
9. The boom control lever for raising and lowering the boom was located on the engine compartment cover to the right of the operator's dash. The operator apparently was trying to exit the machine by putting his legs through the opening on the right side of the operator's compartment and hit the boom control lever, causing the boom to lower. From the location the boom was in just before the accident, it took approximately 2 seconds to lower it.
10. The transmission lever was in neutral at the time of the accident. The hand lever parking brake was pulled on. The lever was to the right of the operator's dash. The operator was against the parking brake lever after the accident occurred, but the brake was still applied.
The primary cause of the accident was the failure to block or secure the raised boom prior to the victim attempting to exit on the right side of the operator's compartment by attempting to go underneath the elevated boom of the forklift. The root cause was his inexperience in the operation of the rough-terrain forklift, which had restricted visibility, and he was not accustomed to operating equipment in an underground mine environment.
Order No. 7813827 was issued on September 29, 1999, under the provisions of Section 103(k) of the Mine Act:
A fatal accident occurred at this mine on September 29, 1999 when the operator of a high lift forklift was trapped under the boom, resulting in fatal injuries. This order is issued to assure the safety of persons at this mine until the affected areas and equipment can be returned to normal operations as determined by an authorized representative of the Secretary. The mine operator shall obtain approval from an authorized representative for all actions to recover equipment and/or return affected areas of the mine to normal use.The order was terminated on October 1, 1999. Conditions that contributed to the accident have been corrected and normal mining operations can resume.
Citation No. 7817889 was issued on October 29, 1999, under the provisions of Section 104(a) of the Mine Act for a violation of 30 CFR, Part 57.14211(c):
A laborer operating a rough terrain forklift was fatally injured at this operation on September 29, 1999. The victim parked the machine near the rib and was climbing out on the right side of the operator's compartment, necessitating him to go under the raised boom. His body contacted the boom control lever, causing the boom to drop on him. The boom was not secured to prevent accidental lowering to eliminate a hazard to persons.The citation was terminated on October 29, 1999. The contractor has installed a barrier to prevent employees from climbing on the boom side of the operator's compartment. The contractor has established a policy that no persons shall operate the rough terrain forklift until they have completed training. The contractor has provided documentation that training has been given to the employees that will operate this machine.
Related Fatal Alert Bulletin:
Persons Participating in the Investigation
Gunther-Nash Mining Construction Company
Thomas A. Braxmeier, vice president/operationsMine Safety and Health Administration
Albert J. Dudzik, project manager
Patrick Lowe, foreman (midnight shift)
Michael Morley, foreman (day shift)
Ralph D. Christensen, supervisory mine safety and health inspectorAPPENDIX B
William T. Owen, mine safety and health inspector
Eugene D. Hennen, mechanical engineer
Gunther-Nash Mining Construction Company
Oscar McLamb, continuous miner operator
Jon McCarty, mechanic
Gerald Parker, front-end loader operator
Harrison Bingham, electrician
Justin Pinegar, laborer
Randall Reed, shot-crete operator