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Metal and Nonmetal Mine Safety and Health

Report of Investigation

Surface Nonmetal Mine
(Nonmetallic Mineral N.E.C.)

Fatal Powered Haulage Accident

January 12, 2002

Daly Pit
Jim's Water Service, Inc.
Gillette, Campbell County, Wyoming
ID No. 48-01610

Accident Investigators

David A. Huston
Mine Safety and Health Inspector

Martin B. Kovick
Mine Safety and Health Inspector

Ronald Medina
Mechanical Engineer


On January 12, 2002, Douglas L. Rockafellow, equipment operator, age 62, was fatally injured when he was pinned between a front-end loader and a parked pickup truck.

The accident occurred because the loader's service brake system had not been properly maintained.

Rockafellow had a total of 30 years mining experience, one year as an equipment operator at this mine. He had not received training in accordance with 30 CFR, Part 46.


Daly Pit, a scoria operation, owned and operated by Jim's Water Service, Inc., was located 13 miles northwest of Gillette, Campbell County, Wyoming. The principal operating official was Leon L. Brady, pipeline manager. The mine was normally operated one, 12-hour shift a day, six days a week. Total employment was three persons.

Scoria was mined from the pit by a bulldozer and front-end loaders. Material was transported to the plant where it was crushed, sized and stockpiled. The finished product was sold primarily as road construction aggregate.

MSHA had not been notified of the commencement of mining at this operation prior to this accident. An inspection was conducted in conjunction with this investigation.


On the day of accident, Douglas L. Rockafellow (victim) reported for work at 6:00 a.m., his normal starting time. Rockafellow was assigned by Leon Brady, pipeline manager, to operate the primary jaw crushing plant at the Daly Pit. At about 7:00 a.m., Rockafellow started the crusher. Ronald Parks, loader operator, fed the crusher while Jerry Weaver, loader operator, transported the finished product from the plant to the stockpile.

Work proceeded normally until about 9:30 a.m. Weaver loaded a bucket of finished product and drove up the inclined stockpile ramp where he dumped the material. As Weaver proceeded to back the loader down the ramp, the engine stalled and Weaver was unable to steer the loader or to stop it with the service brakes. The loader traveled backward approximately 200 feet, striking Rockafellow and pinning him between the loader and his parked pickup truck. Weaver was not aware that he had struck Rockafellow until he exited the loader to check the damage and saw Rockafellow on the ground. He immediately summoned Parks and told him that Rockafellow was seriously injured.

Emergency assistance was summoned and arrived at the accident site a few minutes later. The victim was transported to the local hospital where he was pronounced dead. Death was attributed to severe blood loss due to severe chest, abdomen, and pelvic trauma.


MSHA was notified of the accident at 10:30 a.m., on January 13, 2002, by a telephone call from Donald Stauffenberg, Wyoming State mine inspector, to Danny Frey, 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, made a physical inspection of the accident site and equipment involved, interviewed persons, and reviewed documents relative to the job being performed by the victim. The investigation was conducted with the assistance of mine management, mine employees, and the Wyoming State mine inspectors. Miners did not request nor have representation during the investigation.


� The accident occurred 60 feet from the base of the finished product stockpile ramp. The ramp was 230 feet long and the grade varied between 10 to 13 percent.

� The wheel loader involved in the accident was a Caterpillar, Model 966C. The engine was a six-cylinder, 170 horsepower, Caterpillar, Model 3306, diesel. The operating weight of the loader was 37,000 pounds. The transmission had three forward and three reverse speeds.

� The Model 966C wheel loader was provided with a four wheel, full air-operated, S-cam actuated, internal expanding, drum type service brake system. Each wheel was equipped with a type 24 rotochamber.

� Two brake control valves were used in the braking system. One was mechanically connected to the brake treadle on the right side of the steering column, and the other was mechanically connected to the brake/neutralizer treadle on the left side of the steering column. When the brake/neutralizer treadle was depressed, air traveled to the brake rotochambers and transmission neutralizer control valve. When the brake treadle was depressed, air traveled to the brake rotochambers. Full actuation of the brake/neutralizer pedal shifted the transmission into neutral in addition to applying the service brake.

� When testing was conducted, the brake control valves rapidly leaked air on several occasions when the corresponding treadle valve was depressed. These intermittent air leaks were audible and quickly depleted the system air pressure. With the brake treadle depressed and the engine stopped, the air pressure fell from 130 psi to 90 psi in six seconds and continued to rapidly fall. In 45 seconds, the pressure fell to zero. The brake control valve connected to the brake/neutralizer treadle had a similar intermittent air leak with approximately the same leakage rate.

� The Caterpillar maintenance manual specified that the service brakes must be adjusted when the rotochamber push rod travel exceeded two inches. The push rod travel was out of adjustment at three of the four wheels. The push rod travel for the front-left rotochamber was 2-3/16 inches; the front-right, 2-1/4 inches; the rear-right 2-1/8 inches. At each of the three wheels, a 0.004-inch feeler gage could be inserted between the brake linings and the drum when the service brake was fully applied. The feeler gage could also be inserted between the drum and lining at these three wheels when the parking brake was fully applied. The lack of contact between the brake linings and the drum showed no significant braking force was generated at these three wheels.

� Service brake and parking brake tests were conducted on a 10 percent grade and on a 15 percent grade. Before placing the machine on a grade, it was operated on a level area to bring machine systems to operating temperature and to develop the normal rated operating air pressure. The bucket was empty and the machine was facing in the reverse direction (bucket end of the machine toward the top of the grade) during these tests. The service brake, when fully applied, failed to hold the machine on either a 10 percent grade or a 15 percent grade. The parking brake, when fully applied, also failed to hold the machine on either grade.

� When the gear selector was placed into reverse, the backup alarm functioned both when the engine was running and when it was shut down. If the engine was idling and an implement was moved to its end of travel position, so that the hydraulic pump pressure was forced to go over relief, the engine sometimes stalled. The throttle pedal and other operating controls were examined and no defects were found. The fuel tank was 35 percent full as measured on the fuel tank dipstick.

� The pickup truck slid approximately 31 feet after impact.


The root cause of the accident was the failure to establish procedures that required examination and prompt maintenance of the loader's service brake system.

The cause of the accident was failure to maintain the loader's service brake system in operable condition.


Order No. 7914062 was issued on January 14, 2002, under the provisions of Section 103(k) of the Mine Act:
A fatal accident occurred at this operation on January 12, 2002, when an equipment operator was crushed between a loader and a pickup truck. This order is issued to ensure 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 recover persons, equipment and/or return affected areas of the mine to normal operations.
This order was terminated on February 11, 2002, after it was determined that this area of the mine could resume normal operations.

Citation No. 6268669 was issued on January 23, 2002, under the provisions of Section 104(d)(1) of the Mine Act for violation of 30 CFR 56.14101(a)(1):
A fatal accident occurred at this operation on January 12, 2002, when an equipment operator was pinned between a loader and a pickup truck. The loader was not equipped with a service brake system capable of stopping and holding it on the elevated stockpile ramp. Failure to maintain a service brake system capable of stopping and holding the loader is a serious lack of reasonable care constituting more than ordinary negligence and is an unwarrantable failure to comply with a mandatory safety standard.
This citation was terminated on February 11, 2002, when the service brake system was repaired.

Related Fatal Alert Bulletin:
Fatal Alert Bulletin Icon FAB02M02


Persons Participating in the Investigation

Jim's Water Service, Inc.
Leon L. Brady .......... pipeline manager
Clifton J. Ritchie .......... safety director
Maxine M. Heigis .......... office secretary
Hio Orval Saathoff, Jr. .......... maintenance mechanic
Wyoming State Mine Inspectors
Donald G. Stauffenberg .......... state inspector of mines
Robert L. Solaas .......... deputy inspector of mines
N-Compliance Safety Services, Inc.
Kim Redding .......... safety consultant
Caterpillar Inc., Standards & Regulations Department
Mark A. Steffen .......... technician
Mine Safety and Health Administration
David A. Huston .......... mine safety and health inspector
Martin B. Kovick .......... mine safety and health inspector
Ronald Medina .......... mechanical engineer

Persons Interviewed

Jim's Water Service, Inc.
Leon L. Brady .......... pipeline manager
Clifton J. Ritchie .......... safety director
Hio Orval Saathoff, Jr. .......... maintenance mechanic
Jerry E. Weaver .......... loader operator
Ronald K. Parks .......... loader operator
Campbell County Fire Department
Cliff V. Dagsen .......... emergency medical technician
David L. Mansur .......... emergency medical technician, fire marshal
Campbell County Ambulance Service
Sterling L. Albers .......... emergency medical technician (intermediate paramedic)
Tim L. McDonald .......... emergency medical technician (paramedic)
Greg D. Mentzel .......... emergency medical service (department manager)