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

Report of Investigation

Surface Nonmetal Mine
(Sand & Gravel)

Fatal Slip and Fall Accident

February 16, 2001

All-Lite Aggregate (B246)
Sparks, Washoe County, Nevada
at
Paiute Aggregates
Paiute Aggregates, Inc.
Wadsworth, Washoe County, Nevada
ID No. 26-00789

Accident Investigators

Richard R. Laufenberg
Supervisory Mine Safety and Health Inspector

Terry D. Power
Mine Safety and Health Inspector

Dennis L. Ferlich
Mechanical Engineer

Dennis Tobin
Mine Safety Specialist (Training)

Originating Office
Mine Safety and Health Administration
Rocky Mountain District



OVERVIEW


Wade W. Pearson, contract welder, age 43, was fatality injured on February 16, 2001, when he lost his balance and fell through a 3-foot by 8-foot opening in the floor decking of the booster pump level of the sand screening tower.

The accident was caused by the failure to provide railings or guards for the opening in the floor decking prior to work being performed.

Pearson had a total of 20 years mining experience and worked as a contract welder at the Paiute Aggregate mine about five months. He had not received training in accordance with 30 CFR Part 46.

GENERAL INFORMATION


Paiute Aggregates, a surface sand and gravel mine, owned and operated by Paiute Aggregates, Inc., was located near Wadsworth, Washoe County, Nevada. The mine normally operated one, 10-hour shift, six days a week. Total employment was 18 persons.

The victim was employed by All-Lite Aggregate, a mine operator, located in Sparks, Washoe County, Nevada. All-Lite Aggregate and Paiute Aggregates were owned by RMC Nevada, Inc. The principal operating official of RMC Nevada was Phillip K. Bonnell, president. All-Lite Aggregate assigned two persons on one, 10-hour shift, six days a week to work at the Paiute mine construction project.

Sand and gravel was extracted from the pit with an excavator. Material was hauled and conveyed to the plant where it was sized, washed, and stockpiled. The finished product was primarily used for construction aggregate. At the time of the accident a new crushing and screening plant was being erected at the site.

The last regular inspection of this operation was completed on July 22, 2000.

DESCRIPTION OF THE ACCIDENT


On the day of the accident, Wade Pearson (victim) reported to work at 6:30 a.m., at the All-Lite Aggregate mine site. A short time later he drove 45 miles to the Paiute Aggregates mine. Pearson completed various construction tasks during the morning.

At about 2:45 p.m., Ralph Williams and Kenneth Hrenko, contract welders, were attempting to install an 8-inch pipe on the booster pump level of the sand-screening tower. Williams asked Pearson, an experienced crane operator, to help with the installation of the pipe. Pearson operated the crane, positioning the pipe in place on the booster pump deck. Williams and Hrenko could not align the pipe properly to weld it in place. Pearson got out of the crane and went to booster pump deck to talk to Williams and Hrenko. They decided to reposition the sling on the pipe. Pearson went up to the next level and lowered a chain to Williams who wrapped the chain around the pipe to secure it in place. At about 3:30 p.m., Pearson returned to the booster pump level and walked up behind Williams and Hrenko. As Hrenko turned to his left, he notice Pearson falling through an opening in the floor deck.

Hrenko, Williams and other workers in the area rushed to the scene, administered first-aid and telephoned local emergency personnel. Pearson was transported by helicopter to a hospital in Reno, Nevada, and died at 9:05 p.m., that evening. The cause of death was multiple injuries due to blunt force trauma.

INVESTIGATION OF THE ACCIDENT


MSHA was notified at 6:25 p.m., on the day of the accident by a telephone call from Robert Totman, general manager, to Tyrone Goodspeed, supervisory mine safety and health inspector. An investigation was started the next day. 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. 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 at the booster pump level of the sand- screening tower. Standard steel decking material (grating) was used for flooring and the area measured approximately 11-feet by 11-feet. Handrails were installed around the perimeter of the deck. A 3-foot section of railing on the east side of the deck had been cut out with a torch and removed some time prior to the accident. The level was accessible by a series of stairs leading to the deck and was about 33 feet above the concrete pad at ground level.

� Near the center of the deck was an opening approximately 3-feet wide by 8-feet long (Appendix C). This opening was not protected by railings, barriers, or covers. The final design of the sand-screening tower called for a conveyor belt to be installed on the deck directly above the opening. Decking material for the 3-foot by 8-foot opening was engineered and designed to be installed after the conveyor was in place.

� The following items were found scattered on the deck in the area near the opening: four steel lifting eyes, two sections of grating about 6-inches by 6-inches, a chain block, a wire rope sling, and a 36-inch long 1-3/4 inch diameter pipe.

� A booster pump was located on the south side of the deck two feet from the opening in the deck floor and had been installed about one month prior to the accident by employees of Paiute Aggregates, Inc. A walkway approximately 30 inches wide on the west side of the deck was the only means to access the booster pump.

� At the time of the accident, two contract welders were working on deck next to the booster pump attempting to install an 8-inch horizontal fresh water pipe. The pipe was approximately 30 feet long and weighed about 860 pounds. The east end of the pipe being coupled to the booster pump piping was supported by both the crane and a chain attached to an overhead beam. The west end was resting on railing surrounding another deck on the screen plant.

� The crane boom and block were positioned against structural members of the tower restricting both vertical and horizontal movement of the pipe. The pipe could not be moved, the required distance, without first disconnecting the lifting sling and repositioning both the sling and the crane boom.

� The weather at the time of the accident was clear, calm, and with a temperature of 50 degrees F.

� The victim had not received site-specific hazard awareness training prior to performing work at the site. The company had a Part 46 training plan. Seven of ten contract miners on the site at the time of the accident had not received site-specific hazard awareness training.

� The construction of the new plant began in June of 2000, and production ended the first week of December 2000. Workplace examinations of production areas had been conducted; however, workplace examinations of the new construction were never conducted.

CONCLUSION


The accident was caused by the failure to ensure that the opening was guarded by railings, barriers or covers prior to work being performed on the deck. The failure to require a competent person to examine this work area for conditions that affected safety was a contributing factor. The victim's failure to receive site-specific hazard awareness training prior to work being performed at this mine was also a contributing factor.

ENFORCEMENT ACTIONS


Paiute Aggregates, Inc.

Order No. 7989993 was issued on February 17, 2001, under the provisions of Section 103(k) of the Mine Act:
A fatal accident occurred at this operation on February 16, 2001, when a contract welder fell 33 feet through a 3-foot by 8-foot deck opening. This order is issued to assure the safety of persons at this operation and prohibits any work in the affected area until MSHA determines that it is safe to resume normal operations as determined by an authorized representative of the Secretary of Labor. The mine operator shall obtain approval from an authorized representative for all actions to recover and/or restore operations in the affected area.
This order was terminated on February 21, 2001. Conditions that contributed to the accident have been corrected and normal operations may resume.

Citation No. 7923677 was issued on March 20, 2001, under the provisions of Section 104(d) of the Mine Act for violation of 30 CFR 56.11012:
A fatal accident occurred at this operation on February 16, 2001, when a contract welder fell 33 feet through a 3-foot by 8-foot deck opening. He was standing on the booster pump level next to the opening in the deck when the accident occurred. The opening was not protected by railings, barriers, or covers. Management engaged in aggravated conduct constituting more than ordinary negligence in that they failed to ensure that the opening was protected, prior to work being performed on the deck. This violation is an unwarrantable failure to comply with a mandatory standard.
This citation was terminated on March 20, 2001. The opening on the booster pump level was securely covered with decking material. The operator implemented a policy to ensure that floor openings be protected by either railings, barriers, or covers.

Order No. 7923678 was issued on March 20, 2001, under the provisions of Section 104(d)(1) of the Mine Act for violation of 30 CFR 56.18002(a):
A fatal accident occurred at this operation on February 16, 2001, when a contract welder fell 33 feet through a 3-foot by 8-foot deck opening. He was standing on the booster pump level next to the opening in the deck when the accident occurred. A competent person designated by the mine operator had not examined the booster pump level at least once each shift for conditions which may have adversely affected safety and health. Management engaged in aggravated conduct constituting more than ordinary negligence in that they failed to ensure work place examinations were conducted on shifts prior to the accident. This violation is an unwarrantable failure to comply with a mandatory standard.
This order was terminated on March 20, 2001. The operator implemented a policy requiring daily workplace examinations to be conducted for the entire plant and required that records be recorded.

Citation No. 7923679 was issued on March 20, 2001, under the provisions of Section 104(a) of the Mine Act for violation of 30 CFR 46.11(a):
A fatal accident occurred at this operation on February 16, 2001, when a contract welder fell 33 feet through a 3-foot by 8-foot deck opening. He was standing on the booster pump level next to the opening in the deck when the accident occurred. The contract welder had not received site-specific hazard awareness training prior to work being performed at this mine. The mine operator was aware of the Part 46 requirements. The Federal Mine Safety and Health Act of 1977 declares an untrained miner a hazard to himself and others.
This citation was terminated on March 20, 2001. Wade W. Pearson was fatally injured on February 16, 2001. The operator implemented a policy that ensured employees of all contractors received site-specific hazard awareness training prior to entering the mine site.

Related Fatal Alert Bulletin:
Fatal Alert Bulletin Icon FAB00M04


APPENDIX A


Persons Participating in the Investigation

Paiute Aggregates, Inc.
Robert Totman .......... general manager
All-Lite Aggregate
Thomas Herschbach .......... general manager
RMC Nevada, Inc.
Phillip K. Bonnell .......... president Spike Duque .......... vice-president/general manager
Marshall Bringle .......... safety director
Jackson and Kelly PLLC
Danielle M. Bonett .......... attorney
State of Nevada, Department of Business & Industry
William A. Hawkins .......... mine inspector
Mine Safety and Health Administration
Richard R. Laufenberg .......... supervisory mine safety and health inspector
Terry D. Power .......... mine safety and health inspector
Nathan Yost .......... mine safety and health inspector
Dennis L. Ferlich .......... mechanical engineer
Dennis Tobin .......... mine safety specialist (training)
APPENDIX B


Persons Interviewed

Paiute Aggregates, Inc.
Robert Totman .......... general manager
Leonard Wadsworth .......... front-end loader operator
Douglas P. Weigman .......... front-end loader operator
All-Lite Aggregate
Thomas Herschbach .......... general manager
Stephen H. Juri .......... welder
RMC Nevada, Inc.
Spike Duque .......... vice-president/general manager
Marshall Bringle .......... safety director
Maverick Mechanical Contractor
Ralph Williams .......... welder
Ken Hrenko .......... welder
Kappes Cassidy
Gary Dobson .......... welder
Michael S. Gordon .......... welder