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

REPORT OF INVESTIGATION

Underground Nonmetal Mine
(Potash)

Fatal Powered Haulage Accident

December 9, 2002

IMC Potash Carlsbad, Inc.
IMC Potash Carlsbad, Inc.
Carlsbad, Eddy County, New Mexico
Mine I.D. No. 29-00802

Investigators

James M. Thomas
Supervisory Mine Safety and Health Inspector

Kevin L. Busby
Mine Safety and Health Inspector

Joe D. Nicholas
Mine Safety and Health Inspector

Originating Office
Mine Safety and Health Administration
South Central District
1100 Commerce St., Room 462
Dallas, TX 75242-0499

Edward E. Lopez, District Manager


OVERVIEW

On December 9, 2002, Jeffrey S. Bain, delivery truck driver, age 48, was fatally injured when he was struck by a roll of conveyor belting that fell from the side of a flatbed trailer.

The accident occurred when a roll of 30-inch belting was unloaded from a flatbed trailer. The victim was standing on one side of the trailer. A Forklift operator, on the other side of the trailer, thought he was unloading a roll of 60-inch belting. Consequently, when he placed the forks under the 30-inch belting, they extended 16 inches under a second roll of 30-inch belting. When he raised the forks, the second roll of belting overturned and fell from the trailer striking the victim.

A task analysis had not been conducted to identify possible hazards and establish safe procedures to follow when unloading delivery trucks. Hazard training provided to delivery truck drivers did not address unloading the trucks. No guidance was given to the drivers regarding a safe location to position themselves when material or equipment was being unloaded from their trucks.

Bain had 22 weeks of experience as an over the road truck driver with Muskoka Transport Limited.

GENERAL INFORMATION



IMC Potash Carlsbad, Inc., an underground potash mine and mill owned and operated by IMC Potash Carlsbad, Inc. (IMC), was located about 25 miles east of Carlsbad, Eddy County, New Mexico. The principal operating official was Donald J. Purvis, general manager. The mine operated two 12-hour shifts, 7 days a week while the mill operated three 8-hour shifts, 7 days a week. Total employment was 534.

Sylvite and langbeinite potash ores were mined utilizing continuous miners in a room and pillar system. Mined material was conveyed to one of two production shafts by a series of mobile bridge and belt conveyors, hoisted to the surface, and conveyed to the mill to produce several potash products. There were seven shafts penetrating the multi level mine with active mining on four levels ranging in depth from 700 feet to 1,100 feet. The finished products were sold to the agricultural industry.

Philco Services of Carlsbad, New Mexico was contracted to perform general maintenance and repair in the mill. The principal operating official of Philco was owner Thomas R. Phillipi. The miner who was unloading the roll of belting with the forklift was an employee of this contractor.

Muskoka Transport Limited of Bracebridge Barrie, Ontario, Canada was the trucking company delivering the belting. The principal operating official of Muskoka Transport Limited was Paul Hammond, president. Bain was a truck driver for this company.

The last regular inspection at this operation was completed on September 23, 2002.

DESCRIPTION OF THE ACCIDENT


On the day of the accident, Jeffrey S. Bain (victim) checked in at the IMC security gate at 8:23 a.m. to deliver two rolls of belting. Security personnel directed him to the warehouse storage area where he parked his truck. Bain went into the warehouse and notified Amos Uriquidez, warehouse clerk, that he was there to deliver two rolls of belting. Both men went to the truck and confirmed the order. Uriquidez went to the warehouse to get a Hyster forklift, which he then parked in front of Bain's truck. In the meantime, Bain removed the nylon straps and chains securing the rolls of belting onto the trailer.

James K. Frintz, forklift operator, employed by Philco Services, had just driven a Manitou forklift into the warehouse yard to pick up a load of conveyor rollers for the plant. Uriquidez asked Frintz if he would unload the two rolls of belting because the Manitou forklift had a telescopic boom and long forks. Frintz agreed and moved his forklift into position to lift a roll of belting. Bain was standing at the rear of the trailer and Uriqui4dez was located near the front of the trailer. Believing that he was lifting a roll of 60 inch belting, Frintz positioned his forks fully under a roll of 30 inch belting on his side of the trailer. He did not realize that the forks had extended about 16 inches under a second roll of 30 inch belting on the opposite side of the trailer. At the same time, Bain walked around to the side of the trailer opposite Frintz and began rolling up the nylon tie down straps.

As Frintz lifted the roll of belting about a foot, he saw something move on the opposite side of the trailer and stopped. The roll of belting on the opposite side of the trailer had overturned, knocked Bain to the ground, and rolled over him. Frintz saw Bain on the ground, lowered the forks, exited the cab, and ran to the victim where Uriquidez met him. Other employees responded and CPR was administered until the company ambulance arrived. The victim was taken to the hospital where he was pronounced dead due to multiple blunt force injuries.

INVESTIGATION OF THE ACCIDENT


MSHA was notified at 9:25 a.m. on the day of the accident by a telephone call from Mike Stanley, warehouse supervisor, to James M. Thomas, supervisory mine safety and health inspector. An investigation was started the same day and an order was issued pursuant to section 103(k) of the Mine Act to ensure the safety of miners. An MSHA accident investigation team traveled to the mine, made a physical inspection of the accident scene, interviewed employees, and reviewed training records, and work procedures relevant to the accident. The MSHA team conducted the investigation with the assistance of mine management, a representative of miners, and the miners.

DISCUSSION


Accident Location
The accident occurred outside the parts warehouse. The ground was generally flat and level with dry conditions. Visibility was good with clear skies.

Delivery Truck
The delivery truck was a Western Star connected by a fifth wheel to a Dorsey aluminum-framed flatbed trailer. The trailer bed was 8 feet wide, 48 feet 6 inches long and measured 4 feet 9 inches above the ground. A visual inspection of the truck and trailer was conducted with no defects noted.

The trailer bed was loaded from front to back in the following manner. The front 5 feet of the trailer held rolled up tarpaulins. Next, a roll of 60-inch belting was secured to the bed, followed by a small gap then two rolls of 30-inch belting were secured side by side. This was followed by unidentified material covered with a tarpaulin and another roll of 60-inch belting that was secured to the bed. The last 4 to 5 feet of the trailer was free of cargo.

Rolls of Belting
The two 30-inch rolls of belting involved in the accident were to have been unloaded. Each roll was 4 feet 6 inches in diameter, and weighed 3105 pounds.

Forklift
The forklift involved in the accident was owned by Philco Services. It was a Manitou model MVT 1130L powered by a 93-hp diesel engine and equipped with a telescopic boom and standard 48-inch long forks. The forklift was inspected and found to be in good operational condition with no defects.

Training
IMC did not have written task training procedures in place for unloading materials from delivery trucks or rail transports. Past practice was for the driver to remove load securing chains and straps and then company personnel would perform the actual unloading of materials.

Bain had received hazard training in accordance with 30 CFR Part 48. The review of training records showed hazard training had been given to Bain at the IMC security gate. This training did include instructions to drivers to observe traffic signs and to be aware of limited visibility while backing up in areas of the plant. This training did not limit the driver's activities or address the hazards specific to unloading supplies and equipment delivered to the mine.

Frintz was employed by Philco as an experienced miner and had been working at the IMC site for about 3 1/2 years. Frintz had received annual refresher training on March 1, 2002, in accordance with the approved Part 48 training plan. The forklift was in the area to drop off material from the mill and to pick up other material to be transported back to the mill. Unloading delivery trucks was not an assigned duty for Philco Services employees but they had done this in the past because the telescopic boom of the Manitou forklift made unloading easier.

ROOT CAUSE ANALYSIS


A root cause analysis was conducted and the following causal factors were identified:

Causal Factor: A task analysis had not been completed for unloading supplies and equipment delivered to the mine.

Mine management did not supervise the task of unloading the truck. A warehouse clerk was left to supervise this work. The forklift operator thought he was unloading one roll of belting. While attempting to place the forks under one roll of belting, the forklift operator overturned a second roll of belting, causing it to fall on the victim.

The delivery truck driver walked to the opposite side of the trailer being unloaded and could not be seen by the forklift operator.

Corrective Action: Task analysis should be conducted for safe unloading procedures when supplies and equipment are unloaded from trucks and rail cars. Procedures should be established to identify hazards and establish the proper steps to safely complete the job.

Causal Factor: Hazard training for delivery truck drivers did not instruct them to position themselves, in a safe location, while material was unloaded off their truck.

The company provided hazard training to all delivery truck drivers who entered the mine. This training was general in nature and addressed traffic rules, hazards when backing up, and restricted visibility. This training did not limit the drivers' activities outside their trucks during loading or unloading. It did not discuss possible hazards to persons standing near trucks and rail cars during loading or unloading.

Corrective Action: Implement training that will ensure all persons are in the clear prior to and during loading or unloading activities. Hazard training for vendors and delivery drivers should include instructions for all persons to remain in their vehicle unless they are directed to a safe location during loading or unloading.

CONCLUSION


The accident occurred when a roll of 30-inch belting was unloaded from a flatbed trailer. The victim was standing on one side of the trailer. A Forklift operator, on the other side of the trailer, thought he was unloading a roll of 60-inch belting. Consequently, when he placed the forks under the 30-inch belting, they extended 16 inches under a second roll of 30-inch belting. When he raised the forks, the second roll of belting overturned and fell from the trailer striking the victim.

A task analysis had not been conducted to identify possible hazards and establish safe procedures to follow when unloading delivery trucks. Hazard training provided to delivery truck drivers did not address unloading the trucks. No guidance was given to the drivers regarding a safe location to position themselves when material or equipment was being unloaded from their trucks.

ENFORCEMENT ACTIONS


Order No. 6220171 was issued on December 9, 2002 under provisions of Section 103(k) of the Mine Act:
A fatal accident occurred at this operation on December 9, 2002 when a delivery truck was in the process of being unloaded. This order is issued to assure the safety of all persons at this operation. It prohibits all activity in the area where the delivery truck is located and equipment involved until MSHA has determined that it is safe to resume normal mining operations in the area. The mine operator shall obtain prior approval from an authorized representative for all actions to recover and/or restore operations in the affected area.
This order was terminated on December 11, 2002, after it was determined that conditions that contributed to the accident had been corrected and normal operations could resume.

Citation No. 6228417 was issued on March 3, 2003 under the provisions of Section 104(a) of the Mine Act for violation of 30 CFR 57.9201.
A fatal accident occurred at this operation on December 9, 2002 when a delivery truck driver was struck by a roll of conveyor belting that fell from the side of a flat bed trailer. Provisions had not been made for unloading to prevent a hazard to persons from falling or shifting supplies.


Related Fatal Alert Bulletin:
Fatal Alert Bulletin Icon FAB02M39




APPENDIX A


Persons Participating in the Investigation

IMC Potash Carlsbad, Inc.
Donald J. Purvis .......... general manager
William N. Holder .......... manager safety & training
Steven R. Smith .......... director EHS
Steven H. Rennie .......... surface safety supervisor
David G. Tackett .......... underground safety supervisor
William H. Boyer .......... surface production manager
Michael G. Stanley .......... warehouse supervisor
Philco Services
Thomas R. Phillipi .......... owner Joe B. Gordon .......... superintendent
United Steel Workers of America
William Pierce .......... representative of miners
Mine Safety and Health Administration
Kevin L. Busby .......... mine safety and health inspector
Joe D. Nicholas .......... mine safety and health inspector
James M. Thomas .......... supervisory mine safety and health inspector
APPENDIX B

Persons Interviewed

IMC Potash Carlsbad, Inc.
Amos Uriquidez .......... warehouse clerk
Merced A. Duran .......... warehouse clerk
Bobby R. Franco .......... maintenance mechanic
Philco Services
James M. Frintz .......... forklift operator