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 Powered Haulage Accident
October 4, 2001
Harrison-Escalante Plant
B & R Materials Corp.
Tucson, Pima County, Arizona
ID No. 02-00704
Accident Investigators
Steve I. Pilling
Mine Safety and Health Inspector
Dean A. Horning
Mine Safety and Health Inspector
Dennis Tobin
Mine Safety and Health Specialist
Ronald Medina
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
OVERVIEW
On October 4, 2001, Bernardino R. Shepherd, service truck operator, age 39, was fatally injured when the service truck he was driving overturned. Shepherd was traveling into the pit to service the front-end loader when the brakes failed. The truck struck the side of the asphalt refuge pile and overturned. Shepherd was ejected from the truck as it rolled over. The accident occurred because the service truck was not maintained in a safe operating condition. The brake linkage came loose and the steering mechanism was defective.
Shepherd had a total of five weeks and three days mining experience all at this mine. Shepherd received eight hours of training on August 27, 2001, in accordance with CFR 30, Part 46.
GENERAL INFORMATION
The Harrison-Escalante Plant, a sand and gravel operation, owned and operated by B & R Materials Corp., was located in Tucson, Pima County, Arizona. The principal operating official was Roland C. Browne, president. The mine was normally operated one, 9-hour shift a day, five days a week. Total employment was 20 persons.
Sand and gravel was extracted from the pit with a front-end loader and conveyor belt. The material was transported to the plant where it was crushed/screened and stockpiled. The finished product was sold primarily for use as road construction aggregate and as a topsoil additive. The last regular inspection was completed on April 19, 2001.
DESCRIPTION OF ACCIDENT
On the day of the accident, Bernardino R. Shepherd (victim) reported to work at 8:30 a.m., his normal starting time. Shepherd drove the service truck to the shop, filled the service tank with 290 gallons of diesel fuel in preparation for servicing equipment in the pit and other areas of the mine. Shepherd was instructed to first service the track-hoe and then to proceed to the pit and service the front-end loader. At about 10:45 a.m., after servicing the track-hoe, Shepherd met James Weller, production superintendent, on the service road entering the pit. After a brief conversation, Shepherd continued down the inclined (11-14%) roadway. As the truck descended into the pit, Shepherd lost control. The truck struck an asphalt refuge pile at the bottom of the roadway before overturning on its top.
Dave Barton, front-end loader operator, was working in the pit and noticed the overturned truck as he approached the plant feeder. Barton drove to the service truck but did not see Shepherd. He got out of the loader and found Shepherd laying face down and motionless between the refuge pile and the truck cab.
Barton then notified Weller and they returned to the accident site where they checked Shepherd's pulse and could not detect signs of life. Emergency medical personnel were summoned as Weller and Manny Garcia, leadman, began first-aid on Shepherd. The emergency response team arrived within minutes and Shepherd was pronounced dead at the scene. Death was attributed to crushing injuries.
INVESTIGATION OF THE ACCIDENT
MSHA was notified at 12:40 p.m., on the day of the accident by a telephone call from Kim Schroeder, vice-president, to Benny Lara, supervisory mine safety and health inspector. An investigation was started the next 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 and conducted a physical inspection of the accident site, interviewed a number of persons and reviewed information relating to the job being performed by the victim. The investigation was conducted with the assistance of mine management, mine employees and the State of Arizona mine inspectors. The miners did not request nor have representation during the investigation.
DISCUSSION
The accident occurred at the bottom of the decline entering the pit. The roadway was approximately 19 feet wide and was on an 11 percent grade. The distance the truck traveled down the roadway was approximately 379 feet. After making contact with the refuge pile, which was approximately 26 feet high and had an angle of repose of 57 percent, the truck traveled about 50 more feet climbing the side of the refuge pile until it overturned and landed on its top.
The service vehicle involved in the accident was a 1962 Chevrolet, Series 60, 2-wheel drive truck. The truck was powered by a 350 cubic inch gasoline engine with a manual transmission. It had a single rear axle with dual tires. The flatbed of the truck was equipped with a 500 gallon diesel fuel tank, a 20 gallon drum of grease, an air compressor, and a hydraulic tank full of hydraulic oil. It was reported that the diesel fuel tank was full at the time of the accident.
The truck's service brakes were activated by a hydraulic master cylinder. The brake pedal arm was fastened to the brake push rod with a bolt, lock washer, and nut. The bolt, nut and lock washer was missing. This resulted in no braking capability.
The truck was not equipped with a parking brake. A Mico-lever lock was present in the truck and was a manually operated one-way check valve that could lock fluid under pressure in the service brake system. The lever lock system also became nonfunctional when the service brake push rod fastener failed.
The truck was equipped with a manual steering system. The steering shaft assembly consisted of two individual steering shafts that were coupled together lengthwise. The steering system was found nonfunctional due to the total disengagement of the lower steering shaft coupling assembly from the lower steering shaft. The lower steering shaft and coupling assembly had been modified from the original design by: 1) replacing a cross shaft assembly on the bottom end of the lower steering shaft with a 5/8-inch nut and bolt fastener that was 1-13/16 inches long; and 2) eliminating a U-shaped retainer designed to snap into two circumferential slots with a snap ring. The snap ring did not snap into the slots and therefore, did not hold the coupling assembly together. The upper steering shaft assembly had also been modified in that the lower bearing, a corresponding seat, and the bearing seal were missing. This allowed the steering shaft to move around radially and to have 3/4 inch of axial (up and down) movement. The mounting bolts that held the steering gear to the frame were loose. The passenger side tie rod had been repaired by placing a pipe over it and welding the assembly together. The pitman arm was cracked and there was a large amount of play in the ball joints and steering linkage.
Suspension system defects were found. Both lower control arm bushings were missing on the passenger side and the rear control arm bushing was missing on the driver's side.
The original inside door handle on the driver's side had been removed and replaced with a manually operated lever assembly fastened to the door. When latched, a rod extended out catching against the doorframe at the base of the window. The driver's side door was found in the open position.
The truck was not equipped with a complete seatbelt. Only one seatbelt strap was present on the driver's side (latch plate side). The mating side with the buckle was missing.
CONCLUSION
The root cause of the accident was the failure to establish a proper maintenance program at this mine. The accident occurred because basic operational components equipped on the truck failed due to their poor condition.
Contributing factors included the failure to provide adequate seatbelts and a proper latch on the driver's side door.
ENFORCEMENT ACTIONS
Order No. 7947397 was issued on October 4, 2001, under the provisions of Section 103(k) of the Mine Act:
A fatal accident occurred at this operation on October 4, 2001, when a service truck operator overturned his vehicle while driving down into the pit. This order is issued to ensure 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 October 6, 2001. The operator has permanently taken the 1962 C60 Chevrolet service truck out of service. Normal mining operations can resume.
Citation No. 7914225 was issued on October 4, 2001, under the provisions of Section 104(a) of the Mine Act for violation of 30 CFR 56.14100(d):
A fatal accident occurred at this mine on October 4, 2001, when the operator of a 2-1/2 ton service truck traveling the roadway into the pit lost control and overturned, resulting in fatal injures to the operator. Defects affecting safety (brakes and steering) had not been reported to and recorded by the mine operator.This citation was terminated on October 6, 2001. The service truck was considered a total loss by the operator and removed from service and will not be used again.
Citation No. 7914228 was issued on October 4, 2001, under the provisions of Section 104(a) of the Mine Act for violation of 30 CFR 56.14101(a)(3):
A fatal accident occurred at this mine on October 4, 2001, when the operator of a 2-1/2 ton service truck traveling the roadway into the pit lost control and overturned, resulting in fatal injures to the operator. The truck's braking system failed as the truck descended into the pit because it had not been maintained in functional condition.This citation was terminated on October 6, 2001. The service truck was considered a total loss by the operator and removed from service and will not be used again. The retraining of miners on reporting equipment defects and the service and maintenance of equipment was conducted. Stronger emphasis on maintenance by management has also been implemented.
Related Fatal Alert Bulletin:
FAB00M23
APPENDIX A
Persons Participating in the Investigation B & R Materials Corp.
Roland C. Browne .............. presidentArizona State Mine Inspectors
Kim S. Schroeder .............. vice-president
James C. Weller .............. mine superintendent
David Hamm .............. chief deputy mine inspectorMine Safety and Health Administration
Greg Becken .............. senior deputy mine inspector
Wes Cruea .............. deputy mine inspector
Steve I. Pilling .............. mine safety and health inspector
Dean A. Horning .............. mine safety and health inspector
Dennis Tobin .............. mine safety and health specialist
Ronald Medina .............. mechanical engineer
APPENDIX B
Persons Interviewed
B & R Materials Corp.
Roland C. Browne .............. president
James C. Weller .............. mine superintendent
Douglas A. McKee .............. shop foreman
Dave Barton .............. front-end loader operator