DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
Metal and Nonmetal Mine Safety and Health
REPORT OF INVESTIGATION
Surface Nonmetal Mill
(Nonmetallic Mineral)
Fatal Powered Haulage Accident
April 28, 2000
Atlas Services (5IU)
DeQuincy, Calcasieu Parish, Louisiana
at
DeQuincy Plant
Asbury Louisiana Inc.
DeQuincy, Calcasieu Parish, Louisiana
16-01267
Accident Investigators
Willard J. Graham
Supervisory Mine Safety and Health Inspector
George Olivier, Jr.
Mine Health and Safety Inspector
Eugene D. Hennen
Mechanical Engineer
Originating Office
Mine Safety and Health Administration
South Central District
1100 Commerce Street, Room 4-C-50
Dallas, Texas 75242-0499
Doyle D. Fink, District Manager
OVERVIEW
Gayle L. Johnson, laborer, age 42, was fatally injured on April 28, 2000, when he fell from the agricultural tractor he was operating and was struck by the rotary cutter attachment. The victim was mowing grass in the field adjacent to the plant and was not wearing a seat belt. The accident occurred because management had not established procedures that required seat belts to be worn when operating the tractor and had not established the proper speed to operate when mowing on a grade.
Johnson had a total of two days experience, all at this mill site. He had approximately 27 years experience operating agriculture tractors. He had not received training in accordance with 30 CFR, Part 48.
GENERAL INFORMATION
DeQuincy Plant, a processed carbon surface mill operation, owned and operated by Asbury Louisiana, Inc., was located in DeQuincy, Calcasieu Parish, Louisiana. The principal operating official was Bruce Williams, plant superintendent. The mine was normally operated one, 10-hour shift a day, four days a week. The shipping and receiving department operated one, 8-hour shift a day, five days a week. Total employment was 16 persons.
Petroleum coke and graphite were transported to the mill site from various sources world wide. These materials were blended, crushed, ground and sized into a finished product of processed carbon used in the production of steel and other industrial applications.
The victim was employed by Atlas Services located at DeQuincy, Louisiana. James Gibson, owner, was the principal official. The contractor had been hired to mow grass at this plant. Total number of employees was two.
The last regular inspection of this operation was completed on December 15,1999. A regular inspection was conducted following this investigation.
DESCRIPTION OF THE ACCIDENT
On the day of the accident, Gayle Johnson (victim) arrived at the plant site around 8:30 a.m.. There was no established procedure for check in and Johnson spoke to no one before beginning work. The field to be mowed had been marked the day prior by James L. Gibson, owner of Atlas Services, who mowed one swath around the outer perimeter of the field. Robert Smart, quality control manager, saw Johnson on the tractor heading toward the front field between the highway and the railroad tracks around 8:45 a.m.. Johnson was last observed mowing at 9:20 a.m..
At 9:30 a.m., a passer-by in a pickup truck stopped at the plant office and informed Rachel Templet, office manager, a tractor was running circles in the east field without an operator.
Templet radioed Aaron Nash, shipping and receiving clerk, of the situation. When Nash arrived he found the tractor and rotary cutter turning tight circles but he could not see Johnson. Nash stopped the tractor then drove the field and located Johnson on the east side near the rail spur. Johnson was conscious and Nash attended to him while emergency personnel were summoned. Emergency personnel arrived a few minutes later, however, they were unable to detect any vital signs and the victim was pronounced dead at the scene. Cause of death was attributed to multiple internal and external injuries.
INVESTIGATION OF THE ACCIDENT
MSHA was notified of the accident at 12:00 p.m. by a telephone call from Gerald Crawford, plant manager, to Steven Montgomery, mine safety and health inspector. An investigation was started the same day. MSHA's accident investigation team traveled to the mine and conducted a physical inspection of the accident site, interviewed a number of persons, and reviewed the work procedures performed at the time of the accident. All relevant training records were reviewed. An order was issued pursuant to Section 103 (k) of the Mine Act to ensure the safety of miners. The contractor and mine company employees did not request, or have, representation during the investigation.
DISCUSSION
The equipment involved in the accident was a 1995 Long, Model 2610, agricultural tractor. The tractor was powered by a four cylinder diesel engine rated at 63 horsepower at the power take off. The rotary cutter, manufactured by Howse, measured six and one half feet by six and one-half feet.
� The accident occurred in the east field, south of the railroad main line and east of the mine entrance road about 100 yards from the plant. The field was approximately 6 acres and primarily flat with the exception of the drainage ditch that ran parallel to the rail spur on the east side of the field. At this location, the field sloped toward the ditch at an 11 percent grade. The slope was marked by a number of ruts caused by water runoff. The ruts varied 5 to 7 feet apart, ranging 4 to 9 inches deep.
� The grass height was approximately knee high. The area to be cut had been marked off the day prior by James Gibson, owner of Atlas Services, by cutting a 6 foot wide strip around the perimeter of the field.
� The physical inspection at the scene indicated the victim had cut across the field from west to east, effectively halving it. When he crossed the field he turned north as he neared the ditch cutting an additional two feet outside the perimeter established by Gibson. The tractor's direction of travel was perpendicular to the slope. The victim fell from the tractor midway through the ditch. The tractor then exited the ditch in a sweeping turn to the west.
� The tractor was traveling north when the victim fell from the right side of the tractor, landing in front of the right tire. It appears the victim turned the steering wheel to the left as he fell. This shifted the rotary cutter to the right side where it ran over the victim.
� The tractor was equipped with a power take off shaft which powered the rotary cutter. Maximum power take off RPM was 540 at engine RPM of 2160. The tractor transmission was a four speed forward in a standard H configuration with reverse. It had a high and low range setting which provided eight speeds forward and two reverse. The tractor was found operating in third gear high range (7th gear.) which according to the manufacturer's manual would have resulted in an operating speed of about 12.32 m.p.h. at 2400 RPM.
� A hand throttle was mounted under the steering wheel and found to be set at idle speed. It was also equipped with a foot activated throttle mounted on the right running board. The victim was apparently using this pedal to control the speed. � The brake system was a dry band independent or simultaneous foot applied. The brake pedals were located on the right side running board.
� The tractor was equipped with two rear fenders with running boards provided on both sides. The front axle length measured 67 inches outside to outside of the tires with the rear axle measuring 73 inches. It came equipped with Roll-Over-Protective-Structure and seat belt. The belt was frayed and deteriorated with the buckle end tied in a knot behind the seat.
� The rotary cutter was mounted to the tractor by a standard three point hydraulic hook-up and was powered by the tractor's PTO. It was equipped with two swing blades which were driven in a counter clock wise direction.
CONCLUSION
The root cause of the accident was managements failure to implement procedures that required seat belts to be worn when operating the tractor. Their failure to establish work procedures that required the tractor to be operated at the proper speed when mowing on a grade was a contributing factor.
ENFORCEMENT ACTIONS
Asbury Louisiana Inc.(operator)
Order No. 7887283 was issued on April 28, 2000, under the provisions of Section 103 (k) or the Mine Act:
On April 28, 2000, a contractor employee was thrown/fell from a moving tractor which was mowing the mine property with a rotary cutter/bush hog. The employee was struck by the operating rotary cutter/bush hog which resulted in a fatal injury. This order is issued to assure the safety of the persons at this operation until the mine or affected areas can be returned to normal operation 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.This order was terminated on May 5, 2000. Conditions that contributed to the accident no longer exists and normal operations may resume.
Citation No. 7894005 was issued on June 23, 2000, under the provisions of section 104 (a) of the Mine Act for violation of 30 CFR 56.14130g:
On April 28, 2000, a contractor employee was fatally injured when he was thrown from an agricultural tractor and was struck by the rotary cutter he was pulling. The victim was not wearing a seat belt while operating the tractor. The latch end of the seatbelt was tied in a knot behind the seat. It was apparent from the build-up of dust and grime on the seatbelt it had not been used for a considerable length of time. This condition was readily apparent.This citation was terminated on June 27, 2000. The mine operator has implemented procedures to insure all contractor employees comply with MSHA regulations concerning seat belt usage.
Citation No. 789011 was issued on June 23, 2000, under the provisions of section 104 (a) of the Mine Act for violation of 30 CFR 56.9101:
On April 28, 2000 a contractor employee was fatally injured when he was thrown from a moving agricultural tractor and was struck by the rotary cutter he was pulling. The operating speed was not consistent with the terrain the equipment was operating on. The tractor was operating in third gear high range while mowing on a slope lined with ruts.This citation was abated on 6/27/00. The company has implemented procedures requiring frequent monitoring of all contractors on the mine site.
Atlas Services (contractor)
Citation No.7894004 was issued on June 23, 2000, under the provisions of section 104 (a) of the Mine Act for violation of 30 CFR 56.14130g:
On April 28, 2000, an employee was fatally injured when he was thrown from an agricultural tractor and was struck by the rotary cutter he was pulling. The victim was not wearing a seat belt while operating the tractor. The latch end of the seatbelt was tied in a knot behind the seat. It was apparent from the build-up of dust and grime on the seatbelt it had not been used for a considerable length of time. This condition was readily apparent.This citation was abated on June 27, 2000. The contractor has implemented procedures requiring the wearing of seat belts.
Citation No. 7894012 was issued on June 23, 2000, under the provisions of section 104 (a) of the Mine Act for violation of 30 CFR 56.9101:
On April 28, 2000 an employee was fatally injured when he was thrown from a moving agricultural tractor and was struck by the rotary cutter he was pulling. The operating speed was not consistent with the conditions the equipment was operating on. The tractor was operating in third gear high range while mowing on a slope lined with ruts.This citation was abated on June 27, 2000. Employees has been retrained on the appropriate speed consistent with the equipment used and area conditions where the equipment is operated.
Related Fatal Alert Bulletin:
FAB2000M15
APPENDIX A
Persons participating in the investigation
Atlas Services
James L. Gibson, ownerAsbury Louisiana Inc.
Bruce F. Williams, plant superintendentCalcasieu Parish Sheriff
Gerald H. Crawford, plant manager
Robert A. Smart, quality control manager
Aaron L. Nash, shipping and receiving clerk
Rachael D. Templet, office manager
James H. Maddox, deputyMine Safety and Health Administration
Willard J. Graham, supervisory health and safety inspectorAPPENDIX B
George Olivier, Jr., health and safety inspector
Eugene D. Hennen, mechanical engineer
Persons Interviewed
Atlas Services
James L. Gibson, ownerAsbury Louisiana Inc.
Bruce Williams, plant superintendent
Gerald H. Crawford, plant manager
Robert Smart, quality control manager
Aaron Nash, shipping and receiving clerk
Rachael Templet, office manager