DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
Metal & Nonmetal Mine Safety and Health
Report of Investigation
Surface Nonmetal Mine
(Cement Plant)
Fatal Fall of Person Accident
June 23, 2000
Schueck Steel Co. (Contractor) ID# DF4
Little Rock, Arkansas
at
TXI
Midlothian Quarry and Plant
Midlothian, Ellis County, Texas
ID No. 41-00071
Accident Investigators
James M. Thomas
Supervisory Mine Safety and Health Inspector
Fred L. Gatewood
Mine Safety and Health Inspector
George H. Gardner Jr., P.E.
Civil Engineer
Hilario S. Palacios
Mine Safety and Health Specialist
Originating Office
Mine Safety and Health Administration
South Central District
1100 Commerce St., Room 4C50
Dallas, TX 75242-0499
Doyle D. Fink, District Manager
Mario Lopez Albarran, ironworker, age 39, was fatally injured on June 23, 2000, when he fell through the floor grating of a work platform under construction. Albarran was walking across the platform to borrow a cutting torch.
The accident occurred because sections of floor grating were not adequately supported and none of the floor grating had been secured. Contractor management failed to barricade the hazard or post warning signs to warn employees of the hazard.
Albarran had a total of 5 years mining experience as an ironworker. He had received training in accordance with 30 CFR, Part 48.
The Midlothian Quarry and Plant, a limestone quarry and cement plant, owned and operated by TXI, was located about 30 miles south of Dallas in Ellis County, Texas. The principal operating official was Mark Hill, plant manager. The quarry operated two, 10-hour shifts, seven days per week and the plant operated two, 12-hour shifts, seven days per week. Total employment was 239 persons.
Limestone was ripped by dozer and transported to a crusher by a front end loader. The crushed material was transported by conveyor to the plant where it was processed into cement. The finished product was stored in silos for bulk shipment to customers. TXI was expanding the Midlothian plant from a nominal 6000 tons per day (tpd) to a nominal 10,000 tpd of cement production. Part of that expansion was the construction of a new finish mill.
TIC - The Industrial Company was hired by TXI as the general contractor for the plant expansion. TIC was an independent contractor located in Steamboat Springs, Colorado. The principal operating official was Clint Delwisch, construction manager.
Schueck Steel was an independent contractor located in Little Rock, Arkansas. Schueck was contracted to perform the structural erection of the new finish mill. The principal operating official was Kelley McGill, project coordinator. The victim was employed by Schueck. Schueck was performing structural erection on one 12-hour shift per day.
The last regular inspection at this operation was completed on May 4, 2000. A regular inspection was conducted following this investigation.
DESCRIPTION OF THE ACCIDENT
On the day of the accident, Mario Lopez Albarran (victim) reported for work at 6:30 A.M., his regular starting time. The grating crew was assigned housekeeping chores at the new finish mill. Later, ironworkers Darwinn Reid and Albarran's brother, Pablo Lopez, were assigned to cut and fit grating at the mill on level 719. Shortly before the accident, Albarran was sent to work with his other brother, Alejandro Lopez, ironworker, to cut and weld angle iron underneath the floor grating of level 719. They used a manlift to access the upper deck of level 719 to deliver a work list and borrow a cutting torch from Reid and Pablo Lopez. They proceeded out onto level 719 toward the two employees that were working in the northeast corner.
As they were crossing the deck, Reid warned Alejandro he was approaching an area of inadequately supported floor grating. Alejandro walked around the hazard and looked back to see Albarran step onto the unsupported end of a section of grating. The 2-foot by 9-foot section of grating gave way, allowing him to fall through the opening. The victim fell about 50 feet to the concrete floor below. He was pronounced dead at the scene.
INVESTIGATION OF THE ACCIDENT
MSHA was notified at 1:30 P.M. on the day of the accident by a telephone call from Dale Hanks, new construction safety director for TXI, to Michael A. Davis, assistant district manager. An investigation was started the same day. MSHA's accident investigation team traveled to the mine and made a physical inspection of the accident site, interviewed a number of persons, reviewed information relative to the job being performed, and reviewed the victim's training records. An order was issued pursuant to section 103 (k) of the Mine Act to ensure the safety of miners. The miners did not request, nor have, representation during the investigation.
DISCUSSION
� The accident occurred in section E of the new finish mill on floor elevation 719'-11" (level 719).
� Finish Mill #6 at the clinker production plant was under construction on June 23, 2000. It was a clear, warm day and there was a gentle breeze. The work area was outdoors and uncovered.
� Structural steel and steel bar grating were fabricated by Markle Manufacturing Co. The galvanized steel grating was made from 1" X 3/16" steel bearing bars spaced at 1.5-inch centers by transverse cross bars on 4-inch centers. The grating had a maximum recommended span of 57 inches based upon 1/4 inches of deflection under a uniform load of 100 pounds per square foot.
� The design of level 719 included welding the grating to the underlying structural members. Most of the 1800 square foot platform had grating on it but none of the grating on level 719 had been secured in any way at the time of the accident. Schueck employees reported that it was a common practice to lay all grating before securing it in place.
� The victim fell with a section of grating that was 24 inches wide by 8 feet 11.5 inches long. There was no indication that the section of grating had any structural damage or flaws that could have contributed to the accident. It had been supported at the southern end by a W16X31 steel beam, at the center by a W21X62 steel beam, and was unsupported at the northern end. Additionally, it was not provided with any longitudinal support.
� A review of the structural design drawings disclosed that two members were missing, immediately beneath the subject grating. The missing steel arrived June 22 but had to be painted before installation and it was still in the yard at the time of the accident. One of the two missing members was a 6-foot W8X18 steel beam that was designed to support the northern end of the subject grating and the ends of several other sections of grating. The other member was a WT4X9 angle iron brace that was not designed to support grating directly but which would have caught the grating as it rotated about the center beam. Without the beam and angle in place, this grating was unstable when loaded on the northern end. The area around subject grating had not been barricaded or posted to warn employees of the hazard there.
� The construction sequence for the new finish mill was reversed prior to the award of the contract. The parties disagreed regarding the effect that this had on fabrication and delivery of the steel. The daily reports by Schueck foremen contained several entries regarding missing steel.
� Level 719 had a horizontal static lifeline around the perimeter and within four feet of the subject grating The victim was wearing a full-body harness and two lanyards but was not tied off to the lifeline.
� Figure 1, Appendix C, depicts the general conditions on level 719 where the victim fell through the grating. The subject grating is depicted near the northeast corner. A hammer, a cutting torch, and a welding lead were found by MSHA inspectors in the locations shown.
� Figure 2, Appendix C, shows the structural support for level 719 and includes a cross-sectional view of the subject grating (section A-A) and the approximate location where the victim stepped on it. The missing structural members are indicated by dashed lines.
� Schueck had experienced significant turnover in their workforce. Schueck was hiring only those that could document 12 months previous mining experience therefore only MSHA newly employed experienced miner training was required.
CONCLUSION
The root cause of the accident was management's failure to establish safe work procedures for installing floor grating. Management officials for Schueck knew there was a section of support beam missing and that sections of grating had been installed with no support at one end. Their failure to barricade or post signs to warn persons of the safety hazard and their lack of enforcement of their tie-off policy were contributing factors.
ENFORCEMENT ACTIONS
Citation/Order Issued to TXI
Order No. 7889351 was issued on June 23, 2000 under provisions of Section 103 (k) of the Mine Act:
A fatal accident occurred at the Finish Mill #6 area of the plant when a contractor's employee fell 50 feet to the floor below. This order is issued to assure the safety of all persons working in the construction area, including both the upper level deck and the concrete floor beneath it. The operator shall obtain approval from Mine Safety and Health Administration before returning the affected areas to normal operation.
This order was terminated on July 10, 2000 after it was determined the conditions that contributed to the accident no longer existed.
Citation No. 7899403 was issued on September 6, 2000 under the provisions of Section 104 (a) of the Mine Act for violation of 30 CFR 56.15005:
A fatal accident occurred at this operation on June 23, 2000, when a contractor's employee fell 50 feet after stepping on an unsecured floor grating at 719 level of the new finish mill. The victim was not tied off with a safety belt and line.
This citation was terminated on September 6, 2000, after it was determined that the company had held safety meetings on tie-off policy with all finish mill employees.
Citation No. 7899404 was issued on September 6, 2000, under the provisions of Section 104 (a) of the Mine Act for violation of 30 CFR 56.20011:
A fatal accident occurred at this operation on June 23, 2000, when a contractor's employee fell 50 feet after stepping on an unsecured floor grating at 719 level of the new finish mill. The unstable floor grating had not been barricaded and posted with warning signs.
This citation was terminated on September 6, 2000, after it was determined that all missing steel had been installed, the floor grating was secured and finish mill employees had been instructed in barricading or posting of warning signs.
Citations issued to TIC
Citation No. 7899405 was issued on September 6, 2000, under the provisions of Section 104 (a) of the Mine Act for violation of 30 CFR 56.15005:
A fatal accident occurred at this operation on June 23, 2000, when a contractor's employee fell 50 feet after stepping on an unsecured floor grating at 719 level of the new finish mill. The victim was not tied off with a safety belt and line.
This citation was terminated on September 6, 2000, after it was determined that the company had held safety meetings on tie-off policy with all finish mill employees.
Citation No. 7899406 was issued on September 6, 2000, under the provisions of Section 104 (a) of the Mine Act for violation of 30 CFR 56.20011:
A fatal accident occurred at this operation on June 23, 2000, when a contractor's employee fell 50 feet after stepping on an unsecured floor grating at 719 level of the new finish mill. The unstable floor grating had not been barricaded and posted with warning signs.
This citation was terminated on September 6, 2000, after it was determined that all missing steel had been installed, the floor grating was secured and finish mill employees had been instructed in barricading or posting of warning signs.
Citations issued to Schueck Steel
Citation No. 7899407 was issued on September 6, 2000, under the provisions of Section 104 (a) of the Mine Act for violation of 30 CFR 56.15005:
A fatal accident occurred at this operation on June 23, 2000, when a contractor's employee fell 50 feet after stepping on an unsecured floor grating at 719 level of the new finish mill. The victim was not tied off with a safety belt and line.
This citation was terminated on September 6, 2000, after it was determined that the company had held safety meetings on tie-off policy with all finish mill employees.
Citation No. 7899408 was issued on September 6, 2000, under the provisions of Section 104 (d)(1) of the Mine Act for violation of 30 CFR 56.20011:
A fatal accident occurred at this operation on June 23, 2000, when a contractor's employee fell 50 feet after stepping on an unsecured floor grating at 719 level of the new finish mill. The unstable floor grating had not been barricaded and posted with warning signs. Management engaged in aggravated conduct constituting more than ordinary negligence. They knew that the floor grating was not secured and that support steel was missing but they did not barricade the hazard or post warning signs. This was an unwarrantable failure to comply with a mandatory safety standard.
This citation was terminated on September 6, 2000, after it was determined that all missing steel had been installed, the floor grating was secured and finish mill employees had been instructed in barricading or posting of warning signs.
Related Fatal Alert Bulletin:
FAB2000M25
APPENDICES
A. Persons participating in the investigation
B. Persons interviewed
C. Sketches of the accident site
D. Accident Investigation Data Forms 7000-50a through 7000-50e
TXI
Dale Hanks....................new construction safety directorTIC - The Industrial Co.
John Strong .................... safety managerSchueck Steel Co.
Scotty Burgess....................site safety supervisorCity of Midlothian
Steven Dineen.....................corporate safety director
Dean Crenshaw....................construction inspectorMine Safety and Health Administration
Bryan McGee.......................police detective
Kyle E. Neal........................deputy police chief
George H. Gardner Jr.....................P.E., civil engineer
Fred L. Gatewood..........................mine safety and health inspector
Hilario S. Palacios..........................mine safety and health specialist
James M. Thomas..........................supervisory mine safety and health inspector
TXI
William (Bill) Brown ................... project manager cementTIC - The Industrial Co.
Clint Delwisch .................... construction managerSchueck Steel Co.
Scotty Burgess .................... site safety supervisor
Charles Emiro ...................... millwright
Ronaldo Graymountain ......... ironworker
Abraham Grisham ................ ironworker
Bobby Hightower ................ steel superintendent
Kelley McGill ...................... project coordinator
Alejandro Lopez .................. ironworker
Pablo Lopez ........................ ironworker
Darwinn Reid ....................... ironworker
Joe Rodriguez ...................... grating foreman