DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
Metal and Nonmetal Mine Safety and Health
Report of Investigation
Surface Nonmetal Mine
Fatal Machinery Accident
April 22, 2002
Dakota Mahogany Quarry
Dakota Granite Co.
Milbank, Grant County, South Dakota
ID No. 39-00009
Rodney D. Gust
Mine Safety and Health Inspector
Jeran C. Sprague
Mine Safety and Health Inspector
Walter C. Slomski
Steven J. Miller
Mine Safety and Health Specialist
Mine Safety and Health Administration
Rocky Mountain District
P.O. Box 25367, DFC
Denver, CO 80225-0367
Irvin T. Hooker, District Manager
Matthew H. Veen, driller, age 22, was fatally injured on April 22, 2002, when his clothing became entangled in the drill steel of the drill he was operating.
The accident occurred because the victim positioned himself too close to the rotating drill stem and his loose clothing became entangled in the drill stem.
Veen had one year mining experience, all at this mine as a driller. He had received training in accordance with 30 CFR, Part 46.
Dakota Mahogany Quarry, a dimension granite operation, owned and operated by Dakota Granite Co., was located six miles east of Milbank, Grant County, South Dakota. The principal operating official was John J. Stengel, president. The mine was normally operated one 10-hour shift a day, four days a week, and one 5-hour shift on Fridays. Total employment was 30 persons.
Granite was drilled and explosives were used to free the blocks. The stone blocks were transported to the saw shop with a front-end loader. The waste stone was transported by haul truck to a stockpile. The finished product was sold for use as building construction materials.
The last regular inspection of this operation was completed on December 19, 2001.
On the day of the accident, Matthew H. Veen (victim) reported for work at 6:00 a.m., his normal starting time. Veen performed his normal duties as a slot driller which consisted of drilling a series of holes to make a continuous slot in the granite. The drill had been setup at this location on the previous shift. The quarry floor had a build up of water due to rain and snowfall from the day before.
Veen had finished drilling about 13, four-inch deep, spotter holes and had begun to remove water using compressed air and a blowpipe. Daryl Hopkins, driller/bit sharpener, stopped to retrieve worn bits from Veen at about 7:00 a.m.
At approximately 9:30 a.m., the morning break whistle sounded and the crew went to two different lunchrooms. Lowell Christensen, quarry foreman, was at the bottom of the east-end of the quarry and heard Veen's drill operating. Christensen knew something was wrong because the drill sounded like it was running or operating, but not drilling holes. Upon arrival, Christensen saw Veen entangled in the rotating drill steel. Christensen immediately shut off the controls and radioed for help. Christensen checked for vital signs but found none. Blain Gatz, quarry laborer, arrived and also checked for vital signs and found none. Gatz helped Christensen cut Veen's coat away from the drill steel to free him. Steve Moguard, saw operator, and Mick Redman, quarry superintendent, arrived at that time and started CPR. Emergency medical personnel arrived and transported Veen to a local hospital where he was pronounced dead at 10:30 a.m. Death was attributed to severe blunt chest trauma.
MSHA was notified of the accident at 10:34 a.m. on April 22, 2002, by a telephone call from Dave Buri, personnel manager of Dakota Granite Co., to Darrell Boyer, acting supervisory mine safety and health inspector. An investigation was started 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, 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 and mine employees.
The accident occurred in the northeast corner of the quarry along the east highwall.
The drill involved in the accident was a Tamrock SD-600, rock drill, Serial No. A514506, manufactured on August 6, 1990. The drill rig was equipped with a Tamrock L-600 pneumatic hammer drill, operating at a recommended air pressure of 87 to 101.5 pounds per square inch, gage (psig) and drilling with left-hand rotation. Feed pressure rating was 29 psig. Pressure in the main air supply line to the drill was reported to be 100 psig and at the machine about 90 psig.
An air-driven hydraulic system was used to drive the drill feed extension cylinder/chain feed system (mast slide), hydraulic jacklegs for machine height adjustment, and carriage movement.
Both the temporary/portable noise shield and the machine fixed noise shield were located against the highwall not far from the drill. The company reported that the shield was removed because of the close proximity to the highwall.
The quarry highwall where the drill was positioned was approximately 72 feet in height and near vertical. The drill steel was 17 inches from the highwall.
The drill was not equipped with a pull cord, tethers or panic bar to stop the stem rotation in the event of an emergency. The company did not have maintenance records for the drill. Reportedly, the only modifications to the drill were noise shields, platforms and separation of the dust collector from the drill frame.
The dust collection unit was positioned in front of the drill attached to a suction head at the drill steel dust boot location by a flexible 4-inch hose approximately 25 feet long. The 18-inch long inlet pipe to the suction head was fixed and angled 25 degrees toward the highwall, along ground level on the opposite side from the drill steel controls. Positioning of the inlet pipe at this angle caused the hose to bind against the highwall and possibly kink as the drill carriage traveled away from the operator. Drill operators stated they had to occasionally pull the hose or reach in front of the drill steel and kick the hose to keep it free and away from the drill as it moved.
The drill used 1-1/2-inch diameter drill steel that varied from 4 to 18 feet in length. At the time of the accident, the victim was using a 4-foot drill steel and a 2-1/2-inch diameter bit to drill pilot holes.
A very small burr was found about 13 inches from the bottom of the 4-foot drill steel used during the accident.
A bungee cord was used to hold the suction head open so the operator could view the drilling area while collaring the hole.
The main control panel for operation of the drill had a double pivoting arm with lock pins to move the control valve bank to the desired position.
The machine's main control lever lengths varied and controlled the following functions: drill rotation; percussion; rotation; drill feed; guide flush; drill steel flush; retaining centralizer; feed flow control valve (adjustable); dust collector; indexer (carriage); indexer (carriage) brake; air motor control valve; chain feed movement; carriage directional valve; hydraulic jack (leg) valve.
The controls were located 2-1/2 to 3 feet from the east highwall at the time of the accident. The drill rotation control lever was 4 feet 7-1/2 inches from the rotating drill stem. Tests of the control functions determined that no operational control defects existed that would have contributed to the cause of the accident.
Radios for communication were assigned to the supervisor, truck drivers and front-end loader operators. Drill operators did not have radios.
The following personal protective equipment was being used: hardhat, steel-toed boots, double hearing protection, safety glasses, and gloves.
Evidence from the investigation indicated the victim was wearing loose, multi-layered clothing consisting of two shirts and two flannel jackets lined with insulation.
Based on the information gathered during the investigation, it is likely that Veen may have moved near the rotating drill stem and tried to kick his leg or reach his arm between the drill steel and the highwall to free the dust suction hose. This allowed Veen's jacket to be caught in the rotating drill stem.
Root causes of the accident included: the failure to modify the angle of the dust inlet pipe on the dust boot to prevent the suction hose from becoming caught against the highwall; the failure to implement procedures that directed drillers to stay clear of moving drill stems; the failure to prohibit drillers from wearing loose clothing.
Order No. 7919987 was issued on April 22, 2002, under the provisions of Section 103(k) of the Mine Act:
A fatal accident occurred at this operation on April 22, 2002, when a slot drill operator drilling in the quarry was caught in the drill steel. This order is issued to ensure the safety of all persons at this operation. It prohibits all activity in the quarry area until MSHA has determined that it is safe to resume normal mining operations in this area. The mine operator shall obtain prior approval from an authorized representative for all actions to recover and/or restore operations to the affected area.This order was terminated on April 28, 2002, after it was determined that this area of the mine could resume normal operations.
Citation No. 6269139 was issued on May 7, 2002, under the provisions of Section 104(a) of the Mine Act for violation of 30 CFR 56.7005:
A fatal accident occurred at this operation on April 22, 2002, when a slot driller was entangled in drill steel of his drill. The victim was operating the drill in the quarry and did not stay clear of the rotating drill stem.
This citation was terminated on May, 7, 2002, after safety meetings were held to discuss the cause of the accident and accident prevention policies were implemented that required employees to stay clear of rotating drill stems and prohibited loose clothing. Safe operating procedures of slot drills has been developed and implemented. A modification was also made to the dust collector suction head.
Related Fatal Alert Bulletin:
Dakota Granite Co.
David H. Buri ......... personnel managerMine Safety and Health Administration
Lowell A. Christensen ......... quarry foreman
Michael H. Redman ......... quarry superintendent
Rodney D. Gust ......... mine safety and health inspector
Jeran C. Sprague ......... mine safety and health inspector
Walter C. Slomski ......... mine safety and health specialist, mining engineer
Steven J. Miller ......... mine safety and health specialist
Lowell A. Christensen ......... quarry foreman
Daryl I. Hopkins ......... slot-drill operator
Clifford H. Joslin ......... yardman