January 20, 2014
The Mine Safety and Health Administration (MSHA) has released the investigation report on a September 19, 2013, fatality at a dimension slate operation operation involving a 31-year-old laborer who was killed after the flatbed cargo truck he was operating overturned.
MSHA notes that the victim “transporting four full 250-gallon water totes, which were not secured, while traveling uphill on a steep mine access road. One of the totes shifted and fell off the bed of the truck onto the roadway. The truck began drifting backwards on the 25 percent grade and the remaining water totes shifted. The service brake failed and Farr could not control the truck. The truck turned sharply to an embankment and rolled over onto its roof. The victim was ejected from his seat and entrapped in the operator’s cab.”
According to the investigation report, MSHA identified three root causes of the accident
The first root cause was that “[m]anagement failed to ensure that routine maintenance was performed on the braking system on the truck. The service braking system for the truck had not been maintained in a functional condition. The main brake line on the truck rusted through, resulting in the brake fluid leaking out of the braking system..”
Following the fatality, operation management implemented the following corrective action: “Management established policies and procedures to ensure that maintenance is performed on haul trucks to keep the equipment in functional condition..”
MSHA noted the second root cause to be that “[m]anagement failed to develop policies and procedures to ensure that loads are properly secured before being transported on trucks.”
The following corrective action was implemented for the second root cause: “Management developed procedures to be followed to properly secure loads before materials, including totes, are transported on trucks. Mobile equipment will also be kept in functional condition. All persons have been trained regarding these procedures.”
MSHA reported that the third root cause was “[m]anagement policies, procedures, and controls did not ensure the victim wore his seat belt when operating the haul truck.”
The following corrective action was implemented for the third root cause: “All truck drivers received additional training regarding the required use of seat belts when operating haul trucks. Management will monitor truck drivers to ensure seat belts are worn.”
MSHA issued and two orders and four citations on September 19, 2013, to the operation.
The first order was issued under the provisions Section 103(j) of the Mine Act and was later modified to Section 103(k) of the Mine Act. The order was issued “to prevent the destruction of any evidence which would assist in investigating the cause or causes of the accident. It prohibits all activity at the Northrup Quarry until MSHA has determined that it is safe to resume normal mining operations.”
The second order was issued under the provisions of 104(d)(1) of the Mine Act for violation of 30 CFR 56.14100(c). MSHA notes: “…the victim was transporting four, full 250-gallon water totes on the bed of a M35A2 military truck. The rear left wheel (driver’s side) was missing on the truck compromising the stability of the truck. The rear left wheel was taken off in August 2013 with the truck being operated to transport water totes, pallets, and processed stone during the month of September without the wheel being replaced. The mine foreman engaged in aggravated conduct constituting more than ordinary negligence in that he was aware of the rear left wheel was taken off, not replaced and operated the truck in this condition to transport materials. This violation is an unwarrantable failure to comply with a mandatory safety standard.”
The first citation was issued under the provisions of 104(a) of the Mine Act for a violation of 30 CFR 56.9101. MSHA notes: “While traveling uphill on the mine road the truck began to drift backwards, turned sharply towards the South embankment, rolled over onto its roof and crushed the operator’s cab. The victim failed to maintain control of the truck while it was in motion resulting in the fatal accident.”
The second citation was issued under the provisions of 104(a) of the Mine Act for a violation of 30 CFR 56.14131(a). MSHA notes: “While traveling uphill on the mine road, one water tote shifted and fell off the bed of the truck onto the roadway between the second and third switchback. The remaining water totes shifted while the truck was drifting backwards above the third switchback. The shifting water totes compromised the stability of the truck resulting in the truck rolling over onto its roof and crushing the operator’s cab.”
The third citation was issued under the provisions of 104(a) of the Mine Act for a violation of 30 CFR 56.14131(a). MSHA notes: “The victim was not wearing a seat belt creating an ejection hazard. The mine road consists of steep grades, difficult sharp turns or switchbacks, and drop offs of up to 50-feet. The victim was ejected from his seat and entrapped in the operator’s cab. The truck was used to haul pallets, water totes, and processed rock up and down the mine road on an as needed basis.”
The fourth citation was issued under the provisions of 104(a) of the Mine Act for a violation of 30 CFR 56.14101(a)(3). MSHA notes: “While traveling uphill on the mine road, the truck drifted backwards on a 25 percent grade when the service brake failed. The service braking system for the truck had not been maintained in a functional condition. The main brake line on the truck rusted through, resulting in the brake fluid leaking out of the brake system. The rusted brake line was mounted to the frame of the truck behind the air tanks.”
To read the full investigation report, click here.