DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
Metal and Nonmetal Mine Safety and Health
REPORT OF INVESTIGATION
Surface Nonmetal Mine
(Sand and Gravel)
Fatal Exploding Vessels Under Pressure Accident
July 21, 2000
DOD: September 9, 2000
Rockland Materials Pit 1
GTI Capital Holdings, L.L.C. d/b/a Rockland Materials
Phoenix, Maricopa County, Arizona
ID No. 02-02867
Accident Investigators
Ronald S. Goldade
Supervisory Mine Safety and Health Inspector
Dean Horning
Mine Safety and Health Inspector
Hilario Palacios
Mine Safety and Health Specialist
Stephen B. Cole
Mechanical Engineer
Originating Office
Mine Safety and Health Administration
Rocky Mountain District
P.O. Box 25367 DFC
Denver, CO 80225-0367
Irvin T. Hooker, District Manager
On July 21, 2000, Jack D. Clark, loader operator, age 23, was severely injured at 1:55 p.m., and died of the injuries on September 9, 2000. He was removing material for a leach pad when the bucket of the front-end loader ruptured a high pressure transmission natural gas line. The accident occurred because management had not identified and posted the pipeline's location on the mine property.
Clark had a total of two years mining experience, 28 weeks as a loader operator at this mine. He had received training in accordance with 30 CFR Part 48.
The Rockland Materials Pit 1, a surface sand and gravel operation, owned and operated by GTI Capital Holdings, L.L.C. d/b/a Rockland Materials, was located in Phoenix, Maricopa County, Arizona. The principle operating officials were Grant Goodman, member (board of directors); George Jones, mining manager; Joe Schumacher, transportation/safety director; and Wesley May, chief operations officer. The mine normally operated two, 10-hour shifts, 5-1/2 days per week. Total employment was 30 persons.
Material was extracted from the single-bench mining area, transported by front-end loader to the primary crushing facility and processed into crushed sand and gravel aggregate. The aggregate was processed through a wash plant and classified as graded sand and gravel for resale and usage in the company's concrete plant.
The last regular inspection of this operation was completed on May 19, 2000.
On the day of the accident, Jack Clark (victim) reported for work at 6:00 a.m., his normal starting time. Todd Zealley, lead loader operator, instructed Clark to load over-the-road haul trucks with material as necessary. This work progressed without incident. Around 8:00 a.m., Zealley and Clark discussed continuing excavation at the leach pad site. Both employees excavated at the site intermittently between loading of customer and company trucks.
At approximately 1:55 p.m., Zealley was loading a customer truck, and saw Clark enter the excavation site from the west side. He then observed an eruption of dust followed by a flash and flames engulfing the loader operated by Clark. Zealley dismounted his loader and attempted to aid Clark but was forced to retreat due to the intense noise and heat. Clark was observed exiting the loader and running/crawling towards the roadway north of the site. The 911 emergency system was activated by personnel at the site. Clark was able to crawl to a water ditch on the north perimeter of the mine site which enabled him to escape the heat. Upon arrival at the site, the emergency team attended to Clark and he was transported a short distance by ambulance to a loading area and air evacuated to a Phoenix, Arizona hospital and burn center. Clark died on September 9, 2000. His death was attributed to complications from severe burns to 80% of his body.
MSHA was notified at 3:10 p.m., on the day of the accident by a telephone call from Clarence Ellis, consultant, for the mining company, to Dean Horning, mine safety and health inspector. An investigation was started the same day. An order was issued pursuant to Section 103(k) of the Mine Act to ensure the safety of miners. MSHA's accident investigation team traveled to the mine site, made a physical inspection of the accident site, interviewed personnel, reviewed records related to the job task and assignment performed by the victim and reviewed and evaluated the training records. The miners did not request, nor have, representation during the investigation.
� The accident occurred at the sand stockpile area on the northern section of the mine between the crusher and the wet plant. The area was being excavated to construct a leach pad for drying of processed finish sand material. The construction was approved by George Jones, mining manager, and the work had commenced on the day prior to the accident. The excavation was to remove sand material left from a depleted stockpile. This excavation was to extend down to the dirt level and the area was to be backfilled with coarse rock to allow the new sand pile placed on the pad to drain off water and result in a dry sand.
� The excavated accident area was declined to the center location of the buried gas line. The decline ramps were dug from the east to west direction and the west to east direction with the deepest area in the middle of the two declined ramps. The west ramp was 110 feet in length and 64 feet wide. It declined at 2 degrees to the east. The east ramp was 120 feet in length and 64 feet wide and declined at 7 degrees to the west. The deepest point of the excavation was in the middle and was also the location of the buried gas line. The depth was measured at approximately 60 inches of material removal from grade on the north side and 72 inches from grade on the south.
� The pipeline was straight as it traversed the mine site in a north-south direction. A surface control valve (No. 5) was located approximately 900 feet south of the accident site. A natural gas identification stake/sign was located northeast of the accident site; however, the stake was not visible due to stockpile locations. The stake was located at the north edge of the mine property. Warning signs were located at the valve area to the south; however, the signs were blocked from view by stockpiled material.
� The No. 2039 natural gas transmission pipe was a 16-inch diameter with a .250-inch wall thickness. The pipeline was installed around the year 1950 and had been active since. The pipe was approved for 650 pounds per square inch (psi) and was in operation at 560 psi at the time of the accident.
� The equipment involved in the accident was a 1999, Komatsu WA 500 front-end loader, S/N A70359, equipped with a IMAC 7-foot cubic yard rock bucket. The loader was destroyed in the accident.
The root cause of the accident was management's failure to barricade or identify the location and the depth of the natural gas pipeline traversing the mine property. Management had knowledge of the pipeline location and knew that the excavation was in progress at the area. Management's failure to designate a competent person to examine the work area for conditions that affect safety was a contributing factor.
Order No. 7945723 was issued on July 22, 2000, under the provisions of Section 103(k) of the Mine Act:
A serious accident occurred at this operation on July 21, 2000, when a loader operator was removing overburden at a leach pad being constructed on the north side of the mine property. The loader struck a gas line, which erupted into flames causing serious injuries. This order is issued to assure the safety of persons at this operation until the mine or affected areas 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 return affected areas of the mine to normal operations.This order was terminated on September 18, 2000. Conditions that contributed to the accident have been corrected and normal mining operations can resume.
Citation No. 7945882 was issued on July 26, 2000, under the provisions of Section 104(d)(1) of the Mine Act for violation of 30 CFR 56.20011:
On July 21, 2000, a serious accident resulting in fatal injuries occurred at this mine when the loader operator ruptured a high pressure natural gas line while excavating in the stockpile leach area. The rupture caused an explosion and fire. The employee suffered severe burns at the time of the accident and later died. The natural gas pipeline location was not barricaded or identified with warning signs to identify the hazard. The mine operator has engaged in aggravated conduct constituting more than ordinary negligence in that he knew that the pipeline was buried in the location of the excavation. This violation is an unwarrantable failure to comply with a mandatory standard.This citation was terminated on September 18, 2000. A cyclone fence was erected on the path of the natural gas pipeline through the mine property. Signs of identification were installed. All personnel are instructed of the pipeline location.
Order No. 7945883 was issued on July 26, 2000, under the provisions of Section 104(d)(1) of the Mine Act for violation of 30 CFR 56.18002:
On July 21, 2000, a serious accident resulting in fatal injuries occurred at this mine when the loader operator ruptured a high pressure natural gas line while excavating in the stockpile leach area. The rupture caused an explosion and fire. The employee suffered severe burns at the time of the accident and later died. On July 20 and 21 an examination of the work area to inspect for conditions that could affect the safety and health of persons was not conducted and recorded. The mine operator has engaged in aggravated conduct constituting more that ordinary negligence. This violation is an unwarrantable failure to comply with a mandatory safety standard.This order was terminated on September 18, 2000. The examination requirements were reviewed with mine management. The company has committed to compliance with a written compliance plan.
Related Fatal Alert Bulletin:
FAB2000M38
A. Persons Participating in the Investigation
B. List of Persons Interviewed During the Investigation
Persons Participating in the Investigation:
GTI Capital Holdings L.L.C. d/b/a Rockland Materials
Grant H. Goodman . . . . . . . . . . . . . . . . . . . . . . member (board of directors)Jackson and Kelly PLLC
>Wesley F. May . . . . . . . . . . . . . . . . . . . . . . . . . chief operating officer
Joe Schumacher . . . . . . . . . . . . . . . . . . . . . . . . .transportation/safety director
George Jones . . . . . . . . . . . . . . . . . . . . . . . . . . .mining manager
Wendy Wyman . . . . . . . . . . . . . . . . . . . . . . . . . assistant to mining manager
David M. Arnold . . . . . . . . . . . . . . . . . . . . . . . . attorneyEl Paso Natural Gas
Larry J. Meyer . . . . . . . . . . . . . . . . . . . . . . . . . consultant engineerState of Arizona Mine Inspector
David Hamm . . . . . . . . . . . . . . . . . . . . . . . . . . .chief deputy state mine inspectorMine Safety and Health Administration
Ronald S. Goldade . . . . . . . . . . . . . . . . . . . . . . supervisory mine safety and health inspector
Dean Horning . . . . . . . . . . . . . . . . . . . . . . . . . . mine safety and health inspector
Hilario Palacios . . . . . . . . . . . . . . . . . . . . . . . . .mine safety and health specialist
Stephen B. Cole . . . . . . . . . . . . . . . . . . . . . . . . mechanical engineer
GTI Capitol Holdings L.L.C. d/b/a Rockland Materials
Grant H. Goodman . . . . . . . . . . . . . . . . . . . . . member (board of directors)Scorpion Transportation
Wesley F. May . . . . . . . . . . . . . . . . . . . . . . . . chief operating officer
Joe Schumacher . . . . . . . . . . . . . . . . . . . . . . . .transportation/safety director
Dyrel Maggard . . . . . . . . . . . . . . . . . . . . . . . . crusher/loader operator
Vince Alger . . . . . . . . . . . . . . . . . . . . . . . . . . .crusher operator
Wendy Wyman . . . . . . . . . . . . . . . . . . . . . . . .mining manager assistant
Todd Zealley . . . . . . . . . . . . . . . . . . . . . . . . . .loader operator
Sharon Holman . . . . . . . . . . . . . . . . . . . . . . . .aggregate dispatcher
Tom Claybar . . . . . . . . . . . . . . . . . . . . . . . . . .plant manager, concrete
>George Jones . . . . . . . . . . . . . . . . . . . . . . . . . mining manager
John Sellers . . . . . . . . . . . . . . . . . . . . . . . . . . shipping manager, dispatcher
Dave Goss . . . . . . . . . . . . . . . . . . . . . . . . . . .shop manager
Edel Ladd . . . . . . . . . . . . . . . . . . . . . . . . . . . dispatcher
Robert Smith . . . . . . . . . . . . . . . . . . . . . . . . . owner operator