DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
Metal and Nonmetal Mine Safety and Health
REPORT OF INVESTIGATION
Surface Nonmetal Mine
(Dimension Stone)
Fatal Powered Haulage Accident
January 09, 2002
River Stone Company
River Stone Company
Jarrell, Williamson County, Texas
ID No. 41-04333
Accident Investigators
Ralph Rodriguez
Supervisory Mine Safety and Health Inspector
Emilio Perales
Mine Safety and Health Inspector
F. Terry Marshall
Mechanical Engineer
Originating Office
Mine Safety and Health Administration
South Central District
1100 Commerce Street, Room 462
Dallas, Texas 75242
Michael A. Davis, Acting District Manager
OVERVIEW
On January 9, 2002, Omar R. Martinez, laborer, age 21, was fatally injured when he was ejected from the cab of the front-end loader he was operating and was run over by the rear wheel.
The accident occurred because the loader's service brakes had not been properly maintained and the victim had not been instructed relative to the manufacturer's operating procedures for this wheel loader. Contributing factors included the failure to maintain the haul road and the failure to provide seat belts.
Martinez had a total of four months experience at this mine. He had a total of one year mining experience and had not received training in accordance with 30CFR, Part 46.
River Stone Company, a dimension stone operation, owned and operated by River Stone Company, was located in Jarrell, Williamson County, Texas. The principal operating official was David Olalde, owner. The mine operated one, 8-hour shift, six days a week. Total employment was six persons.
A track loader was used to remove overburden. The limestone was cut into blocks using a track mounted saw. A wheel-loader was used to move the blocks from the quarry to the saw where they were cut into different sizes and sold for use in construction.
MSHA had not been notified that this mine had been operating prior to this accident. The first regular inspection of this mine was conducted immediately following this investigation.
On the day of the accident, Omar R. Martinez (victim) reported for work at 7:00 a.m., his normal starting time. He operated a skid steer loader, loading blocks of stone onto the rock chopper table. At about 4:00 p.m., the rock chopper was shut down. Martinez then operated the wheel-loader to begin moving stones from the quarry. Gregorio Ramos, track loader operator, was on the second level facing the quarry when he observed Martinez going down the ramp and saw the loader strike a large rock. Martinez was bounced from the seat, falling onto the left side of the cab floor, with his feet inside the cab and his body hanging from the cab. When the loader struck another rock, Martinez was ejected from the cab and run over by the rear wheel.
David Olalde, owner, was operating a skid steer loader in the pit area when he observed the accident. He ran to the scene and after checking Martinez he went to the top of the pit and instructed Phil Dobransky, mechanic, to call 911. Emergency personnel arrived in a few minutes and the County coroner pronounced the victim dead at the scene.
Death was attributed to massive injuries to the head and torso.
INVESTIGATION OF THE ACCIDENT
MSHA was notified at 8:30 a.m. on January 10, 2001, by a telephone call from David Olalde, owner of River Stone Company, to Keiko Brown, San Antonio field office secretary. An investigation began 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; conducted a physical inspection of the accident site, interviewed persons, and reviewed training records and work procedures relating to the job being preformed by the victim. Management officials and employees assisted in the investigation. The miners did not request nor have representation during the investigation.
DISCUSSION
� The accident occurred on the decline road into the quarry. The road connected the upper pit bench with the lower bench. The road was constructed on a 10 percent grade and was about 178 feet in length. The road had been constructed from pit material that had not been compacted. The road surface was littered with large rocks and ruts.
� The front-end loader involved in the accident was a 1986 Fiat Allis, model FR-10. It was provided with four-wheel drive, powered by a Fiat six-cylinder turbo-charged diesel engine rated at 110 horsepower. The wheelbase was 110 inches. The transmission had four speeds in the forward direction and three speeds in the reverse direction. It had articulated steering and was provided with ROPS cab. Estimated weight of the machine was 25,000 pounds.
� The loader sustained little damage during the accident. After striking the rocks, the loader rolled to a stop at the bottom of the ramp. The engine covers and the muffler system were vibrated off as a result of traveling over the uneven terrain on the ramp.
� The transmission controls were found with the speed selector in first gear and the directional control in neutral.
� The service brake system consisted of a dual circuit air over hydraulic system with a caliper disc brake on each side of both the front and rear axle. One brake converter supplied the two caliper disc brakes on the front axle and a second brake converter supplied the two caliper disc brakes on the rear axle. The loader was designed with two separate foot pedals that could be used to apply the service brakes. The right side pedal, next to the accelerator foot pedal, was intended to apply only the service brakes. The left side pedal was intended to apply the service brakes and neutralize the transmission.
� The parking brake was an internal expanding shoe drum brake on the front output shaft of the transfer case. A control lever mounted on the floor to the left side of the operator's seat provided mechanical application of the parking brake. The adjuster knob on the parking brake control lever was found at its maximum adjustment (end of adjustment). The parking brake shoes were visibly fluid soaked due to hydraulic hose leaks and/or transmission fluid leaks.
� Drawbar tests using a tension link that measured the braking force capacities were performed on both the service brakes and the parking brake. This was done to estimate the available braking force of the wheel loader in the condition it was found after the accident. Test results indicated neither the service brake nor the parking brake was capable of producing any measurable braking force.
� The right side foot pedal was found disconnected from the service brake system. The left side foot pedal activated the brake converters for both axles and neutralized the transmission.
� The air system had air leaks that were intermittent and varied in loss rates. The left side service brake valve was leaking air through the exhaust port and the supply line from the compressor to the air reservoirs had a leak at a fitting connection. This resulted in intermittent conditions where the air compressor could not maintain main air system pressure within the operating range with the engine at idle. The system's response was slow in that it was difficult to raise main air system pressure even with engine rpm above idle.
� Brake fluid for each of the two brake converters was supplied by the same fluid reservoir. This reservoir was found to be empty. After filling this brake fluid reservoir, two hydraulic leaks were found within the service brake system. The right front caliper was leaking brake fluid from a caliper piston seal and the brake converter for the rear axle service brakes was leaking brake fluid from the exhaust port of the air chamber. Brake fluid leaking out of the exhaust port of the air chamber was indicative that brake fluid was leaking past the seals of the hydraulic master cylinder of the brake converter.
� The operator's compartment did not have a seat belt. Nothing within the seating area was visually recognized as mounting hardware for a seat belt assembly or a component of a seat belt assembly. Manufacturer's product literature lists a seat belt as "standard equipment".
� The steering system was functional and no problems were visually detected that may have affected the operator's ability to steer the machine.
� Neither the low air pressure warning buzzer or the red "Low Air Pressure" warning indicator light on the dash panel functioned when the needle in the dash panel's air pressure gage fell below the green area, operating range. The red "Park Brake On" warning indicator light on the dash panel did not function when the parking brake was applied.
� The victim had not been task trained on this equipment and had not received any prior training related to part 46.
� Evidence indicated Martinez had the transmission control in first gear forward as he descended the ramp. If he applied the left brake pedal, the transmission would have shifted into neutral allowing the loader to gain speed. The air leaks, coupled with the brake fluid leaks, resulted in the brake system being incapable of slowing the loader.
CONCLUSION
The root cause of the accident was the failure to establish procedures requiring examination and prompt maintenance of the loader's service brake system.
The accident occurred because the loader had defective service brakes. The following contributing factors were identified: failure to provide and maintain seat belts, the lack of adequate training, failure to maintain the ramp free of rocks and ruts.
ENFORCEMENT ACTIONS
Order No. 6213123 was issued on January 9,2002, under the provisions of section 103 (k) of the Mine Act:
A fatal accident occurred at this operation on January 9,2002, when a front-end loader operator was thrown from the loader and ran over by the rear wheel. 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.This order was terminated on January 22, 2002. Conditions that contributed to the accident have been corrected and it was determined that the mine could safely resume normal operations.
Citation No. 6201536 was issued on January 20, 2002, under the provisions of Section 104 (a) of the Mine Act for violation of 30 CFR 56.14130(a)(3):
A fatal accident occurred at this operation of January 9, 2002, when a miner was ejected from the Fiat Allis FR-10 wheel loader and run over. The manufacturer had equipped the loader with seat belts, but they had been removed.This citation was terminated on February 20, 2002, after the loader was equipped with seat belts that meet the requirements of SAE J386.
Citation No. 6201537 was issued on January 9, 2002 under the provisions of Section 104 (a) of the Mine Act for violation of 30 CFR 56.14101(a)(1):
A fatal accident occurred at this operation on January 9, 2002, when a miner was ejected from a Fiat Allis FR-10 wheel loader and run over. The service braking system on this loader would not stop or hold the loader on the roadway where the accident occurred. The mine operator was aware the brakes had been inoperable since 01/07/02 and had not removed the wheel loader from service.This citation was terminated on March 6, 2002, after the mine operator repaired the brakes. The machine was tested and the service and parking brakes were able to hold the loader on the steepest grade on which it travels.
Citation No. 6201538 was issued on January 9, 2002 under the provisions of Section 104 (a) of the Mine Act for violation of 30 CFR 56.9313:
A fatal accident occurred at this operation on January 9, 2002, when a miner was ejected from a Fiat Allis FR-10 wheel loader and run over. The road (ramp) where the accident occurred had an approximate 10 percent decline and contained spilled material, large loose rocks, and ruts.This citation was terminated on February 27, 2002, when the mine operator removed the ramp from service. He has agreed to maintain future ramps free of large rocks with well compacted materials and maintain berms on all roadways.
Citation No. 6201539 was issued on January 9, 2002 under the provisions of Section 104 (a) of the Mine Act for violation of 30 CFR 46.7a:
A fatal accident occurred at this operation on January 9, 2002, when a miner was ejected from a Fiat Allis FR-10 wheel loader and run over. The miner normally operated a skid steer type loader. The miner had not received task training for the Fiat Allis FR-10 wheel loader prior to operating this machine.This citation was abated on 02/20/2002, after all miners received training and are now in compliance with part 46.
Related Fatal Alert Bulletin:
FAB02M01
APPENDIX A
Persons Participating in the Investigation River Stone Company
Jose D. Olalde .......... ownerWilliamson County Sheriff's Department
Gregorio S. Ramos .......... track loader operator
Phil Dobransky .......... mechanic consultant
Charles T. Kelly .......... deputy sheriffMine Safety and Health Administration
Chad C. Marek .......... deputy sheriff
John M. Burks .......... officer
Marcos A. Vivas .......... officer
Ralph Rodriguez .......... supervisor mine safety and health inspector
F. Terry Marshall .......... mechanical engineer
James R. Fitch .......... mine safety and health inspector
Emilio Perales .......... mine safety and health inspector
Jerry Y. Anguiano .......... mine safety and health inspector
APPENDIX B
Persons Interviewed
River Stone Company
Jose D. Olalde .......... owner
Gregorio S. Ramos .......... track loader operator
Phil Dobransky .......... mechanic consultant