DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
COAL MINE SAFETY AND HEALTH
REPORT OF INVESTIGATION
Surface Warehouse
Fatal Powered Haulage
September 17, 2000
P & S Salvage, Inc. (9IG)
Evansville, Indiana
at
Chinook Mine
Midwest Coal Company
Brazil, Clay County, Indiana
I. D. No. 12-00322
Accident Investigators
Michael D. Rennie
Coal Mine Safety and Health Inspector
Steven M. Miller
Coal Mine Safety and Health Inspector
Jimmy M. Conley
Coal Mine Safety and Health Inspector
Wayne E. Colley
Approval & Certification Center - Technical Support
Originating Office - Mine Safety and Health Administration
District 8
2300 Old Decker Road, Vincennes, Indiana 47591
James K. Oakes, District Manager
Release Date 01-24-2001
OVERVIEW
On Sunday, September 17, 2000, at approximately 3:20 P.M., a fatal powered haulage accident occurred in the Annex Warehouse building at the Midwest Coal Company, Chinook Mine. Terry Pagett, victim, owner and operator of P&S Salvage, Inc., was loading truck parts with a battery powered stand-up forklift truck, when his forklift truck came in contact with a pallet on the overhead storage rack. The resultant contact caused the pallet and its contents to fall, striking Pagett in the head and upper body.
Pagett had loaded four pallets of BD 180 truck parts onto a two ton flatbed truck, and was in the process of retrieving a fifth pallet from the east aisle of the warehouse, when the accident occurred.
Pagett, who owned and operated P&S Salvage, Inc., had purchased salvage rights to several pieces of equipment, cables, and several BD 180 trucks and the associated parts for the trucks. Pagett had worked at this mine site since April 1999.
GENERAL INFORMATION
The Chinook Mine, Midwest Coal Company, is located five miles southeast of Seelyville, Indiana, along the Clay and Vigo County lines. The mine has been in operation under various ownerships since 1928, and had the distinction of being the oldest continuously operated surface mine in the state of Indiana before ceasing production in November 1998. The last train load of coal was shipped in January of 1999, and the mine was placed in non-producing status on February 2, 1999. The mine employed 158 miners in November 1998 and now has six miners performing reclamation work and rebuilding county roads. The employees at the mine are represented by United Mine Workers of America, Local 1216. The principal officers for the Chinook Mine at the time of the accident were:
President....................................................................... Kentland D. HolcombAn MSHA Safety and Health Inspection (AAA) was conducted on July 13, 2000. The previous Safety and Health Inspection (AAA) was conducted on March 1, 2000.
Secretary Treasurer....................................................... Ron Mills
Assistant Secretary........................................................ Earnest M. Reynolds
Assistant Secretary........................................................ George J. Sparks
Engineering Manager..................................................... Lonnie G. Nelson
Safety Director.............................................................. Lonnie G. Nelson
DESCRIPTION OF ACCIDENT
On Sunday, September 17, 2000, at approximately 3:20 p.m., a fatal powered haulage accident occurred in the Annex Warehouse at the Midwest Coal Company, Chinook Mine. Terry Pagett, victim, owner and operator of P&S Salvage, Inc., was operating an Allis-Chalmers battery powered stand-up forklift truck and was loading truck parts, when he backed the forklift under the east pallet racks, causing the Falling Object Protection (FOPS) to contact a pallet on the next overhead storage rack. The resultant contact caused the pallet and its contents to fall between the cross members of the storage rack, striking Pagett in the head and upper body.
At the start of the shift, Kenneth Randolph, a P&S Salvage employee, stated that Terry Pagett and he were working together, and Charles Pagett, victim's son, and Scott Barton were working together salvaging trucks at the silos. Randolph stated that he was assigned the task of draining the fuel tanks of the haul trucks, and stripping the wiring in preparation for the salvaging of the trucks. Randolph worked at this task until around mid day, at which time Pagett told Randolph to get the two-ton truck and meet him at the Annex Warehouse.
Upon Randolph's arrival at the warehouse, Pagett explained to him that they would use the forklift to remove some previously marked pallets of truck parts. Randolph stated that Pagett asked him if he would like to operate the forklift. Randolph responded that he did not know how to operate the forklift and did not feel comfortable operating this forklift. Pagett then told Randolph to position the two-ton truck in the south door and that he would operate the forklift.
Randolph stated that Pagett had loaded two pallets of parts onto the rear of the truck from the center aisle, and two pallets of parts on the front of the truck from the east aisle. At this point, Randolph repositioned the truck to allow Pagett to load another pallet of parts from the east aisle. When the truck was repositioned, Randolph started to climb onto the truck when he heard a crash. He then called for Pagett and did not hear a response. He then investigated and found Pagett lying on his back behind the forklift and beneath the pallet racks with blood coming from his head. Randolph went to the victim's side to see if Pagett would respond. When Pagett did not respond, Randolph called guard Lisa Rickert and asked her to call an ambulance, because Terry Pagett had been hurt. Randolph then called Charles Pagett and told him his father had been hurt. Randolph then went back in the warehouse and moved a large fire extinguisher to aid in recovery of Pagett. Charles Pagett arrived a short time later and went to his father. Charles Pagett turned his father on his side to aid in his breathing. He then went outside and phoned the Clay County Ambulance Service by cell phone.
The Clay County Ambulance Service arrived on the scene at 3:40 p.m., and finding Pagett in a supine position on the floor and unresponsive, they began assessing the condition of the patient. The Seelyville fire department arrived a short time later and assisted the Clay County Ambulance Service with the care of Pagett. The victim was moved out to a clear area, the EMT's then started CPR. When the Terre Haute Fire Department arrived, the Clay County EMT's then turned over the care of Pagett to the advanced life support unit paramedics, and assisted in the emergency treatment of Pagett along with the Seelyville Fire Department. The victim was then transported to Regional Hospital in Terre Haute, Indiana. Despite aggressive resuscitation efforts, Terry Pagett was pronounced dead at the Regional Hospital. The Vigo County Coroner performed an autopsy and determined that cause of death was due to blunt force trauma to the head.
INVESTIGATION OF THE ACCIDENT
The Mine Safety and Health Administration (MSHA) Vincennes, Indiana, Field Office, District 8, was notified by Billy Kent, Mine Supervisor, on Sunday, September 17, 2000, at approximately 5:50 p.m., Central Standard Time (CST), that a fatal accident involving a forklift truck operator had occurred earlier that day at the Midwest Coal Company, Chinook Mine. Emergency personnel from Clay County Ambulance Service, Terre Haute Fire Department Ambulance Paramedics, and Seelyville fire departments had been notified and quickly responded. After being informed of the accident, Lonnie E. Bryant, Coal Mine Inspector, was dispatched to the scene and secured the accident site and issued a 103(k) Order to ensure the safety of the miners.
MSHA dispatched an accident investigation team from the Benton, Illinois Field Office to the Vincennes, Indiana, Field Office, on Monday, September 18, 2000. Upon arriving at the office, the inspection team was briefed concerning the circumstances surrounding the accident. The accident team made contact with Joe Batson, Director of the State of Indiana Bureau of Mines and Minerals and United Mine Workers of America, District Representatives Butch Oldham and Joe Urban. The accident investigation team then traveled to the mine accident site and jointly began the investigation assisted by mine management, the Indiana Bureau of Mines, and United Mine Workers personnel. Interviews of individuals at the mine known to have actual knowledge of the facts surrounding the accident were conducted at the Chinook Mine office the afternoon of September 18, 2000. Wayne M. Colley, Electrical Engineer from the MSHA Triadelphia Approval and Certification Center, arrived on September 18, 2000 and assisted in the investigation.
DISCUSSION
1. The forklift truck is an Allis-Chalmers, Model SR 40 CR battery powered stand up forklift truck. The weight of the forklift truck was 4,321 pounds. The forklift has a twist type forward/reverse throttle handle. The forklift truck was equipped with a falling object protective structure ( FOPS).
2. The forklift truck is powered by a 24-volt rechargeable lead/acid battery.
3. The forklift truck is equipped with a spring applied, hydraulically released disk brake system which is located on the splined shaft of the DC electric motor. The brake system was inspected and no defects were found.
4. The forklift truck was equipped with a dead-man pedal that acts as a neutral start switch, and would not let the machine move until the pedal is depressed. The pedal was tested and found to be functioning properly.
5. The forklift truck controls and safety features were all tested during the investigation and found to be in proper working order.
6. The forklift truck hydraulic forks were loaded with material and placed approximately 24 inches above the floor. The hydraulic system leaked off during the night and allowed the forks to drop approximately six inches. This condition did not contribute to the cause of the accident.
7. The forklift truck was carrying a pallet of BD 180 truck parts, with a total weight of 973 pounds.
8. The forklift truck maintenance records were found to be inconsistent. The forklift was not being used on a regular basis.
9. Since there was adequate sunlight from the south doorway, the lights were not being used in the warehouse when the accident occurred.
10. The floor of the warehouse was smooth concrete.
11. There were only two people working in the warehouse at the time of the accident, however, there were no eye witnesses to the accident.
12. Terry Pagett had not received the required task training prior to operating the forklift truck, and had very little experience operating this forklift truck.
13. The forklift steering was a hydraulically assisted chain and gear driven system.
CONCLUSION
The accident occurred when the victim backed the forklift truck up against a pallet and dislodged stored material which fell and fatally injured the operator of the forklift truck. The following was considered to be contributing factors: (a) improper storage of material on the racks in the warehouse; (b) inadequate task and hazard training for the victim; (c) no examination for hazardous conditions was conducted in the area by a certified person.
ENFORCEMENT ACTIONS
The following citations/orders were issued to the mine operator due to conditions revealed during the investigation.
103(k) Order No. 7561921 was issued on September 17, 2000, and was terminated on October 23, 2000.
The mine has experienced a fatal powered haulage accident in the Annex Warehouse building. This order is issued to assure the safety of any person in the affected area or operating other equipment of this type until an investigation is completed to determine that the area or other equipment of this type is safe. Only those persons selected from company officials, state officials, miner's representative, and other persons who are deemed by MSHA to have information relevant to the investigation may enter or remain in the affected area.104(a) Citation No. 7572175 was issued for violation of CFR 77.208(a) on October 5, 2000, and was terminated on October 16, 2000.
The material in the Chinook Mine Annex Warehouse building was not stored and stacked in a manner which minimizes stumbling or fall of material hazards. A fatal accident has occurred in this warehouse as a result of material and spare parts falling on the victim. The pallet was not adequately supported to prevent the pallet and material from falling between the support beams. Material and spare parts have also been stored on broken pallets and damaged racks. Material stored on the floor was observed extending into the walkways.104(a) Citation No.7573487 was issued for a violation of 30 CFR 48.31(a)(1). On November 6,2000, and was terminated on November 13, 2000.
The mine operator did not provide the proper hazard training to a contractor who was fatally injured while operating a forklift truck in the Annex Warehouse building. The contractor was not trained in hazard recognition and avoidance of hazards in this building. The material stored in this building was not stored or stacked in a safe manner which minimized stumbling or falling of material.104(d)(1) Citation No.7574009 was issued for a violation of 30 CFR 48.27(a) on November 6, 2000, and was terminated on November 6, 2000.
The mine operator did not provide task training in the operation of a forklift truck to a contractor who was fatally injured while operating a forklift truck in the Annex Warehouse building. The operator gave permission for the contractor to operate the forklift truck.104(a) Citation No.7574010 was issued for a violation of 30 CFR 77.1713(a) on November 6, 2000, and was terminated on November 6, 2000.
An examination for hazardous conditions was not conducted in the Annex Warehouse building by a certified person designated by the operator. A fatal accident has occurred in this building as a result of material falling on a forklift truck operator.The following citations were issued to the contractor due to conditions revealed during the investigation:
104(a) Citation No.7574011 was issued for a violation of 48.31(a)(1) on November 6, 2000, and was terminated on November 15, 2000.
A contractor who was fatally injured while operating a forklift truck in the Annex Warehouse building was not trained in hazard recognition and avoidance of hazards in this building. The material stored in this building was not stored or stacked in a safe manner which minimized stumbling or falling of material.104(d)(1) Citation No.7573489 was issued for a violation of 30 CFR 48.27(a) on November 6, 2000, and was terminated on November 15, 2000.
A contractor who was fatally injured while operating the forklift truck in the Annex Warehouse building was not task trained in the operation of this forklift truck.
Related Fatal Alert Bulletin:
FAB00C26
Appendix C
APPENDIX A
Listed below are those persons who participated and/or were present during the investigation:
A.E.I. RESOURCES, INC.
Keith Smith ............... Safety DirectorMIDWEST COAL COMPANY
Chris Clark ............... Manager of Insurance and Employee Benefit Claims
Kentland D. Holcomb ............... President - OperationsP&S SALVAGE, INC.
Billy Kent ............... Supervisor
Lonnie G. Nelson ............... Engineering Manager
Phil Thomas ............... Safety Director ( retired )
Jeff Ayers ............... Safety Director ( Sycamore Mine )
Charles Pagett ............... Salvage EmployeeINDIANA BUREAU OF MINES
Kenneth Randolph ............... Salvage Employee
Scott Barton ............... Salvage Employee
Joe Batson ............... Director of Mines and MineralsUNITED MINE WORKERS OF AMERICA
Butch Oldham ............... Regional Safety RepresentativeHOLM CONSULTING
Robert Smith ............... Local No. 1216 President
Larry Youkum ............... Local No. 1216, Safety Committee
Charles Burgess ............... Local No. 1216, Chairman Safety Committee
Paul Holm ............... ConsultantNIEHAUS INDUSTRIAL SALES, INC.
Joe Hahn ............... PresidentMINE SAFETY AND HEALTH ADMINISTRATION
Donald R. Persinger ............... Supervisory Coal Mine Safety and Health InspectorAPPENDIX B
Steven M. Miller ............... Coal Mine Safety and Health Inspector
Michael D. Rennie ............... Coal Mine Safety and Health Inspector
Jimmy M. Conley ............... Coal Mine Safety and Health Inspector
Bruce A. Harris ............... Coal Mine Safety and Health Inspector
Lonnie E. Bryant ............... Coal Mine Safety and Health Inspector
Leland Payne ............... Mine Safety and Health Specialist (Training) Team Leader
Wayne E. Colley ............... Electrical Engineer Approval & Certification Center Technical Support
Listed below are those persons who were interviewed or provided information that was pertinent to the investigation:
VIGO COUNTY OFFICIALS
Susan Amos, M.D. ............... Vigo County CoronerCLAY COUNTY AMBULANCE SERVICE
Thomas Treadway, Jr. ............... EMTSEELYVILLE FIRE DEPARTMENT
Wesley Pruiett ............... EMT A
Tom Graham ............... CaptainTERRE HAUTE FIRE DEPARTMENT
Rick Long ............... EMT
Kenny Ladd ............... EMT
Harold Osborne ............... EMT
Terry Coker ............... Advanced EMTP&S SALVAGE EMPLOYEES
Jay Umbaugh ............... Paramedic
Mike Miller ............... Assistant Chief of EMS
Kenneth Alan Randolph ............... Salvage WorkerMIDWEST COAL COMPANY EMPLOYEES
Billy Kent ............... SupervisorALLIED EQUIPMENT COMPANY
Lonnie G. Nelson ............... Engineering Manager
Paul Raber ............... Service Representative