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DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
Metal and Nonmetal Mine Safety and Health
REPORT OF INVESTIGATION
Surface Nonmetal Mine
(Dimension Sandstone)
Fatal Falling Material Accident
April 5, 2007
Holland & Sons Tire
Contractor ID No. R239
at
1845 Texas Stone Products, Inc.
Texas Stone Products, Inc.
Lometa, Lampasas, Texas
Mine ID No. 41-03518
Investigators
Willard J. Graham
Supervisory Mine Safety and Health Inspector
Terry L. Worley
Mine Safety and Health Inspector
Originating Office
Mine Safety and Health Administration
South Central District
1100 Commerce Street, Room 462
Dallas, TX 75242-0499
Edward E. Lopez, District Manager
OVERVIEW
On April 5, 2007, Curtis Holland, contractor tire repairman, age 45, was fatally injured while replacing tires on a wheel loader. He was pinned under the loader when it fell off two supporting hydraulic jacks.
The accident occurred because policies and procedures failed to ensure that persons could safely perform the task of changing tires on a wheel loader. The loader was not adequately blocked against hazardous motion.
GENERAL INFORMATION
Texas Stone Products, Inc., a surface dimension sandstone operation, owned and operated by 1845 Texas Stone Products, Inc., was located 9 miles south of Lometa, Lampasas County, Texas. The principal operating official was William B. Davis, president. The mine operated one 10-hour shift, 5-6 days per week. Total employment was 19 persons.
Sandstone was mined from the quarry using wheel loaders and an excavator. The mined material was sized by hand and various mechanical methods then palletized. The final products were sold commercially.
Holland & Sons Tire, a tire service from Lampasas, Texas, was owned by Curtis Holland. One employee helped Holland repair and replace tires, usually on over-the-road trucks. Mine management called Holland to repair a tire on a wheel loader.
The last regular inspection at this operation was completed on May 17, 2006.
DESCRIPTION OF THE ACCIDENT
Curtis Holland, victim, and Christopher Sims, helper, went to the mine the afternoon of April 4, 2007, to replace a tire on the wheel loader. Matthew Simmons, service supervisor, directed them to the waste disposal area of the mine where the wheel loader was parked with a flat left front tire.
Holland started the loader and dumped some waste material from the bucket. He used the bucket to lift the front of the loader and a jack was placed under the front axle. After removing the rim locking ring and breaking the tire loose from the rim, Holland determined that the tire was not repairable. Management decided to replace all four tires on the loader so Holland and Sims left to order them.
On the day of the accident, April 5th, Holland and Sims arrived about 2:30 p.m. to replace the tires. They went directly to the loader and replaced the left front tire without incident. They placed a hydraulic jack under the left rear axle, removed the valve stem from the left rear tire, and then went to work on the right rear tire while the left rear tire deflated. A hydraulic jack was placed under the right rear axle to lift the right side and the valve stem was removed from the right rear tire.
The left rear tire was deflated so Holland and Sims removed the locking ring from the left rear tire rim and snapped a large set of locking pliers onto the outer tire ring at both the three o'clock and nine o'clock positions. A 1/8-inch link chain was wrapped around the nose of each set of locking pliers. The other end of each chain was attached to a 1500-pound capacity cable come-a-long that was also attached to the rear bumper of Holland's service truck.
The come-a-long was tightened to exert pressure in an attempt to break the tire from the rim. This method would not break the bead so Holland crawled under the left rear of the loader and positioned a portable hydraulic tire bead breaker where the tire contacted the rim. Sims stood behind the left rear tire and operated the foot pedal of the bead breaker. Holland repositioned the bead breaker twice before the tire separated from the inner rim.
The rear of the loader immediately shifted toward the right side, fell from the jacks supporting it, and pinned Holland. Sims used his cell phone to call for emergency medical assistance then checked Holland for a pulse but he was non-responsive. Sims got another hydraulic jack from the service truck and tried unsuccessfully to lift the rear of the loader off Holland.
Mine employees heard the loader fall and Sims yelling. Martin Jasso, production supervisor, used his CB radio to call the mine office for help. Another loader, equipped with forks, was used to lift the wheel loader off Holland. He was pronounced dead at the scene by the Justice of the Peace. Death was attributed to blunt force trauma.
INVESTIGATION OF THE ACCIDENT
On the day of the accident, MSHA was notified at 4:31 p.m., by a telephone call from William B. Davis, president, to MSHA's emergency hotline. Edward Lopez, district manager, was called and 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 scene, interviewed employees, and reviewed documents and work procedures relevant to the accident. MSHA conducted the investigation with the assistance of mine management and employees.
DISCUSSION
Location of the Accident
The accident occurred at a waste disposal area of the mine. The ground in the area was dry, hard-packed, and sloped about one and one half percent downhill from south to north. The sky was clear and visibility was good.
Wheel Loader
The wheel loader involved in the accident was a Case Model 721C. It weighed 30,000 pounds and had a rated bucket capacity (heaped) of 2.6 cubic yards. The left rear tire being removed was a 20.5R25 type 2A V-steel traction radial. The tire was 59 inches in diameter, fit on a 28-inch rim, and weighed about 900 pounds.
Service Truck
Holland's service truck was a Ford F-250 pickup equipped with a utility bed. Panels on each side of the bed provided lockable storage. A small compressor mounted behind the truck cab was used to provide air pressure for lifting jacks, the tire bead breaker, and tire inflation. Tires could be placed in the middle of the open truck bed.
The service truck was parked about 10 feet from the loader in a parallel position facing east on the south side of the loader. The truck was positioned so the come-a-long could be attached to the rear bumper.
Tire Bead Breaker
The tire bead breaker was a model 10101 ESCO air over hydraulic device designed for use on one, two, and three-piece truck rims without first removing them from the truck. When properly positioned, it would break a truck tire from the rim in seconds using 10,000 pounds of force. Compressed air was provided to the bead breaker through a foot pedal and an 8-foot section of high pressure hose.
Hydraulic Jacks
Twenty-ton air-over-hydraulic bottle jacks were placed under the left and right rear axles of the loader. Each jack's base was 5.2 inches by 8.8 inches and the round head was 1.8 inches in diameter. The jack under the left rear axle had been placed on a wooden block 5.5 inches high by 5.5 inches wide by 37.4 inches long. The jack under the right rear axle had been placed on a wooden block 5.5 inches high by 3.8 inches wide by 31.8 inches long.
After the accident, the height (base to the head of the extended cylinder) of each jack was 18 inches. Each of them was equipped with dual springs positioned to retract the cylinder into the jack housing when the hydraulic pressure was released. When tested, each jack remained in the extended position until the pressure was released. No defects were found with either jack.
Training and Experience
Curtis Holland had eight years experience repairing and replacing tires. Christopher Sims had worked with Holland for two weeks but had not changed a loader tire prior to the accident. Holland and Sims had not been given site-specific hazard awareness training as required by 30 CFR, Part 46. It was determined this violation did not contribute to the cause of this accident and the operator was issued a non-contributory citation.
ROOT CAUSE ANALYSIS
A root cause analysis was conducted and the following root cause was identified:
Root cause: Policies and procedures were inadequate. Potential hazards were not addressed before performing the task of changing tires on a wheel loader. Procedures were not established to ensure the wheel loader was blocked against hazardous motion.
Corrective Action: Contractors should establish policies and procedures to ensure that tasks are safely completed. Any potential hazards associated with their tasks should be thoroughly addressed. Repairs to mobile equipment should not be made until it is blocked against hazardous motion.
CONCLUSION
The accident occurred because policies and procedures failed to ensure that persons could safely perform the task of changing tires on a wheel loader. The loader was not adequately blocked against hazardous motion.
ENFORCEMENT ACTIONS
1845 Texas Stone Products, Inc.
Order No. 6224107 was issued on April 5, 2007, under provisions of Section 103(k) of the Mine Act:
A fatal accident occurred at this operation on April 5, 2007, when two tire company personnel were replacing tires on the Case 721C wheel loader. This order is issued to assure the safety of all persons at this operation. It prohibits all activity at the accident site 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 to the affected area.This order was terminated on April 11, 2007, when conditions that contributed to the accident no longer existed.
Holland & Sons Tire
Curtis Holland was a sole proprietor acting as a contractor. Upon Holland's death, the sole proprietorship ceased to exist. Therefore, a citation for failure to block the loader against hazardous motion was not issued.
Related Fatal Alert Bulletin:
FAB07M07
Fatality Overview: PowerPoint / PDF
APPENDIX A
Persons Participating in the Investigation
845 Texas Stone Products, Inc
William B. Davis .......... presidentMine Safety and Health Administration
Martin Jasso .......... production supervisor
Matthew W. Simmons .......... service supervisor
Christopher S. Webb .......... general manager
Willard J. Graham .......... supervisory mine safety and heath inspector
Terry L. Worley .......... mine safety and health inspector