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UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
Metal and Nonmetal Mine Safety and Health

Report of Investigation

Underground Metal Mine
(Gold)

Fatal Powered Haulage Accident
November 6, 2000

Sixteen to One Mine
Original Sixteen to One Mine, Inc.
Alleghany, Sierra County, California
ID No. 04-01299

Accident Investigators

Stephen Cain
Supervisory Mine Safety and Health Inspector

Robert V. Montoya
Mine Safety and Health Inspector (Electrical)

Eugene D. Hennen
Mechanical Engineer

Dennis Tobin
Mine Safety and Health Specialist

Originating Office
Mine Safety and Health Administration
Western District
2060 Peabody Road, Suite 610
Vacaville, CA 95687
Lee D. Ratliff, District Manager





OVERVIEW


On November 6, 2000, Mark Raymond Fussell, miner, age 36, was fatally injured when his head struck the lip of a protruding ore chute while he was operating a locomotive.

The root cause of the accident was the failure of the mine operator to install warning devices ahead of and at the chute to conspicuously mark the restricted clearance. Failure to properly maintain the locomotive's speed controlling system was a contributing factor.

Fussell had 18 years of underground mining experience. He was rehired by this company in August 2000 and had worked at the mine a total of one year and eight months. He had received training in accordance with 30 CFR Part 48.

GENERAL INFORMATION


The Sixteen to One Mine, a multi-level underground gold mine, owned and operated by Original Sixteen to One Mine, Inc., was located one mile south of Alleghany, Sierra County, California. Principal operating officials were Michael Miller, President; Charles Brown, Secretary; Scott K. Robertson, Treasurer; and Jonathan Farrell, Mine Manager. The mine operated one, eight hour shift, five days a week. Total employment was twenty two persons; eleven of which worked underground.

Gold-bearing ore was drilled and blasted in stopes. Broken ore was mucked into ore chutes. The ore was loaded into rail cars, trammed by battery-operated locomotives to a rail-mounted skip at the level station, and hoisted to a storage pocket above the 800 level. It was transported out of the mine by trains through an adit to a surface dump site. The ore was separated by hand and a percentage was sold as specimen gold to various customers. The remainder was processed in the mill and poured into ingots.

The last regular inspection of this mine was conducted on August 15, 2000. Another inspection was conducted following the accident investigation.

DESCRIPTION OF THE ACCIDENT


On the day of the accident, Mark Fussell (victim) telephoned Jonathan Farrell, mine manager, and informed him that he would be late reporting to work. Fussell arrived at the mine between 7:30 a.m. and 8:00 a.m., and went to his assigned work area at the bottom of the 1777 Boll� raise located on the 1700 level. Farrell met Fussell at the raise a short time later and told him that Vincent Kautz, miner, would be his partner for the day. Farrell left the area and Fussell began securing a slusher at the top of the raise.

At approximately 12:00 p.m., Kautz arrived and met Fussell at the bottom of the raise. Fussell entered the raise and took measurements for timbers which were to be installed to secure the slusher. After he finished measuring, he came down the raise and boarded the locomotive parked approximately three to six feet in front of the ore chute. Fussell planned on tramming the locomotive in reverse to a wood stockpile area for a distance of approximately 50 yards to obtain the needed timbers. He asked Kautz if he wanted to ride to the timber stockpile on the rail car which was coupled to the rear of the locomotive. Kautz declined and began to walk towards the stockpile. Fussell then engaged the locomotive's controller and, as he backed the locomotive, his head struck the bottom corner of the chute. Kautz heard a noise, looked back, and saw Fussell pinned between the locomotive's battery compartment and the chute lip. Kautz ran to a nearby telephone, called for assistance, then returned to the accident site. He pushed the locomotive out from under the chute and freed the unconscious victim. Steve Sheppert, hoistman, arrived and began cardio-pulmonary resuscitation. The victim was transported to the shaft station, hoisted to the 800 level, and transported out of the mine where local emergency response personnel attended to him. Fussell was pronounced dead at the scene. Death was attributed to blunt trauma to the head.

INVESTIGATION OF THE ACCIDENT


MSHA was notified of the accident on November 6, 2000, at 3:15 p.m., by a telephone call from Michael Miller, company president, to Lee Ratliff, district manager. An investigation was started on the same day. An order was issued pursuant to Section 103(k) of the Mine Act to ensure the safety of the miners. An MSHA accident investigation team traveled to the mine, conducted an inspection of the accident site, interviewed miners, and reviewed appropriate training and work procedure documents. The miners did not request, nor have, representation during the investigation.

DISCUSSION


� The accident occurred on the 1700 level in the haulage drift below the 1777 Boll� raise. The drift measured approximately 6� feet wide and 8 feet high. One set of narrow gauge railroad tracks ran the length of the drift and they were in good condition. The accident site was dry and level. This area had been inactive for a period of time; however, work had commenced on this level the month preceding the accident when it was decided to mine the stope above the 1777 Boll� raise.

� The locomotive involved in this accident was a Mancha, Type B, Little Trammer. It weighed approximately 3000 pounds with the batteries installed. It was 48 inches high, 32 inches wide, and approximately five feet long. When facing the operator's controls, the seat was to the right side. A flatbed rail car was coupled to the locomotive at the time of the accident.

� The locomotive was positioned on the tracks so that the operator's seat was on the same side of the drift as the ore chutes. The locomotive could be turned around to face the opposite direction which would have reduced the risk of an operator striking his head on a chute.

� The locomotive was powered by a series wound, direct current (DC) drive with three tramming speed contacts in both forward and reverse. The contacts were initiated by a hand lever (drum controller) located to the right front of the operator when he was seated sideways on the machine. When the lever was in the middle position, none of the contacts were engaged. When the lever was rotated counter-clockwise, the three contacts for the reverse direction were engaged, one at a time, beginning with the lowest to the highest speed. Rotating the lever in the clockwise direction engaged the contacts for forward travel.

� Contacts for first speed in the drum controller engaged but would not move the machine in either forward or reverse when tested by MSHA. The contacts for second and third speed engaged properly. The machine could only be moved by engaging second or third speed, which resulted in quicker acceleration and a jerking motion. The locomotive accelerated faster in reverse than in forward. The locomotive was in reverse at the time of the accident. Dirt and carbon buildup was observed on the contacts, but did not play a role in the nonfunctional first speed. After further investigation, it was concluded that a resistor bank between the controller and motor was defective or "open" thus rendering first speed inoperable. It appeared to the investigators that this defective condition had existed for a period of time and that the locomotive's impact with the chute did not cause the resistor bank to fail. No other safety defects were found on the machine.

� The locomotive was equipped with a band brake attached to the end of the motor shaft. The brake was in good condition and was controlled by a hand-operated lever located to the right of the operator's seat. The lever was connected via linkage to the brake assembly. The brake was tested by MSHA during the investigation. When stationary, the locomotive would not move when the brake was set and engine power applied. The brake also stopped the machine when it was applied while the machine was moving. The brake had not been applied by the victim prior to the accident.

� The bottom of the wooden ore chute involved in the accident was 50 inches above the rail and extended eight inches inside the west rail, almost to the center of the track. This measurement meant that there was two inches of clearance between the top of the locomotive and the chute lip. To safely clear this chute, an operator would have to completely duck inside the operator's compartment of the locomotive when the locomotive passed under it. All other chutes on the 1700 level inspected by MSHA during the accident investigation had similar restricted clearances but did not extend as far out into the rails as the one involved in the accident. Heights of these chutes above the rail were the same as the one involved in the accident.

� None of the chutes on the 1700 level had markings on them to warn miners on mobile equipment of the restricted clearance hazard. Also, there were no warning signs in advance of any of these chutes to warn of upcoming restricted clearance hazards.

� It was evident to the investigators that the inoperative first speed and defective resistor bank had existed for a period of time.

CONCLUSION


The root cause of the accident was the failure of the mine operator to install warning devices in advance of and at the ore chute to conspicuously mark the restricted clearance. The operator's failure to promptly correct the defective speed controlling system contributed to the accident.

ENFORCEMENT ACTIONS


Original Sixteen to One Mine, Inc.

Order No. 7996015 was issued on November 6, 2000, under the provisions of Section 103(k) of the Mine Act:
A fatal accident occurred at this operation on November 6, 2000. A miner was operating a battery motor when his head struck an ore chute. This order is issued to assure the safety of persons at this operation until the affected area 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.
Order No. 7996015 was terminated on November 28, 2000. Conditions that contributed to the accident no longer exist and normal mining operations can resume.

Citation No. 7995404 was issued on January 12, 2001, under the provisions of Section 104(a) of the Mine Act for a violation of 30 CFR 57.9306:
A miner was fatally injured at this mine on November 6, 2000, while operating a Mancha locomotive on the 1700 level, when his head struck a protruding ore chute causing it to become wedged between the battery compartment of the locomotive and the chute. The chute extended into the drift to the midpoint of the train rails at approximately the same height as the locomotives operator's head. Warning devices had not been installed in advance of the ore chute to indicate restricted clearance nor had the chute been conspicuously marked, nor marked at all, to warn and remind miners of the restricted clearance.
The citation was terminated when colored tape was placed to warn equipment operators of chute locations. Additionally, the chute was modified so that locomotive operators can not contact it when operating a train.

Citation No. 7995405 was issued on January 12, 2001, under the provisions of Section 104(a) of the Mine Act for a violation of 30 CFR 57.14100:
A miner was fatally injured at this mine on November 6, 2000, when he struck his head on an ore chute protruding into the drift at approximately head level, after he engaged the speed controller of the Mancha locomotive he was operating. The locomotive had a clearly evident defect which had not been corrected in a timely manner to prevent a hazard to the miner. Alternatively, the locomotive was not taken out of service and placed in a designated area posted for that purpose, nor was the vehicle tagged or other effective method of marking the defective items used to prohibit further use of the vehicle until the noticeable defect was corrected.
This defect was easily detectable during a pre-operational or other similar inspection. It made continued operation hazardous to persons by causing the locomotive to be difficult to control at slow speeds or when starting from a stopped position. The machine's speed controller first point of power (slow speed) to the drive motor was not functioning as designed; thus, the locomotive would not move until the second point of power was contacted, when it would then jump or lurch forward.

Related Fatal Alert Bulletin:
Fatal Alert Bulletin Icon FAB2000M44



APPENDICES

A. Persons Participating in the Investigation
B. Persons Interviewed


APPENDIX A
Persons participating in the investigation:

Original Sixteen to One Mine, Inc.
Michael Miller ............... president
Jonathan Farrell ............... mine manager
State of California
Department of Industrial Relations
Divsion of Occupational Safety and Health
Timothy Hurley ............... associate engineer
Mine Safety and Health Administration
Stephen Cain ............... supervisory mine safety and health inspector
Robert Montoya ............... mine safety and health inspector (electrical)
Eugene Hennen ............... mechanical engineer
Dennis Tobin ............... mine safety and health specialist
APPENDIX B


Persons interviewed during the investigation:

Original Sixteen to One Mine, Inc.
Michael Miller ............... president
Jonathan Farrell ............... mine manager
Vincent Kautz ............... miner
Brit McDaniel ............... miner
John Barquilla ............... miner
Randy Meadows ............... miner
Joseph Barquilla ............... miner
Steven Sheppert ............... hoistman