UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
Western District
Metal and Nonmetal Mine Safety and Health
ACCIDENT INVESTIGATION REPORT
SURFACE METAL MINE
FATAL MACHINERY ACCIDENT
Robinson Mine, I.D. No. 26-01916
Magma Nevada Mining Company
Morbark Sales Corp., Contractor ID - UTU
Ruth, White Pine County, Nevada
March 10, 1995
By
Ronald G. Ainge
Mine safety and Health Inspector
and
David A. Kerber
Mine Safety and Health Inspector
Western District Office
3333 Vaca Valley Parkway, Suite 600
Vacaville, California
Fred M. Hansen, District Manager
GENERAL INFORMATION
Robert Crawford MacDonald, a 31 year old equipment operator, was
fatally injured at about 9:50 a.m., March 10, 1995, when the top
in-feed yoke of a wood chipper fell and struck him. MacDonald,
employed by Morbark Sales Corporation at the time of the
accident, had one day of mining experience at this property.
Garry Day, MSHA Western District Assistant Manager, was notified
of the accident by Robert Philips, Contracts Manager for Robinson
Mine, at 10:50 a.m., March 10, 1995. An investigation was begun
the same day.
The Robinson Mine was a surface copper and gold operation owned
and operated by Magma Nevada Mining Company, Robinson Mining,
Ltd. Partnership, located in Ruth, White Pine County, Nevada.
The mine and mill had about 550 employees and operated three
shifts, seven days a week.
Primary activities at the mine site were directed toward the
construction of a mill and settling pond. Some workers were
involved in recovering gold, from previously mined ore, through a
heap leaching process.
Magma had contracted with Ames Construction Inc. to build a large
waste water impoundment area. Ames had then contracted with
Morbark Sales Corp. to chip the trees and brush that were to be
removed from the impoundment area.
Company Officials were:
Magma Nevada Mining Company, Robinson Mining, Ltd. Partnership
Harry C. Smith, President
Mian S. Khalil, Project Manager
Susan Stoddard, Safety Coordinator
Ames Construction Inc.
Richard J. Ames, President
Roger L. McBride, Director, Safety & Health
Michael Johnson, Division Manager
Richard Katsma, Project Engineer
Steve Park, Division Safety Manager
Guy Walkos, Project Safety Officer
Pete Smyle, Project Superintendent
Morbark Sales Corp.
Noval Morey, CEO
Milan W. Robinson, Plant Manager
The operator required that all contractors conduct Part 48
training. Ames Construction, Inc. trained their employees as
well as Morbark Sales Corp. employees according to a MSHA
training plan approved December 9, 1994.
The last regular inspection at this property was conducted
on November 25-26, 1994.
PHYSICAL FACTORS
The accident involved an E-Z Mountain Goat Chipper, model
number 50/36, serial number 1010, manufactured by Morbark
Sales Corporation, Winn, Michigan. The chipper was being used
to reduce trees and brush into chips in an area being converted
to a waste water impoundment.
The E-Z Mountain Goat was powered by a 750 horsepower diesel
engine. The chipper unit was mounted on a Caterpillar 325L
undercarriage. It was equipped with a knuckle boom with a
grappler on the end that picked up trees and brush and fed them
into the chipper.
The in-feed area consisted of; a caterpillar chain feed conveyer
on the lower portion of the chute, two in-feed wheels on each
side of the opening, and a floating roller at the top. These
components were used to guide the material into the chipper. The
top roller was raised and lowered by hydraulic cylinders which
put pressure on the trees and brush to control the feed rate.
Hydraulic drive motors provided forward and reverse motion to the
conveyer and the feed wheels.
There was an area between the operator's cab and the outer edge
of the in-feed chute that periodically clogged with wood chips
and other material. This buildup of material had to be cleared
because it would prevent the in-feed roller from being completely
lowered. It was necessary for the roller to be in the lowered
position to allow for the changing of the chipper knives. For
the machine to work efficiently, the knives had to be changed or
rotated at least once a day.
When the buildup occurred, the operator had to crawl into the
in-feed area and remove the material by hand. Prior to
entering this area, he/she was to place the in-feed roller and
yoke assembly in the fully raised position and install locking
pins. Wood chips or other debris on top of the chipper cover
could prevent the yoke assembly from being completely raised and
result in improper, or incomplete, insertion of the locking pins.
The locking assembly consisted of two pieces of one inch, inside
diameter, metal tubing welded onto each side of the in-feed
roller yoke. This tubing aligned with two more pieces of tubing
that were welded to the chipper cover. To hold the in-feed
roller in the upright locked position, two 1-inch metal pins
were to be inserted into the tubing of the yoke and then into the
tubing on the cover. The investigation determined that only one
pin had been utilized.
The in-feed roller and yoke assembly that struck the victim was
about 36 inches wide, 18 inches in diameter, and weighed
approximately 2500 pounds.
The weather was rainy and cold with a high temperature of about
55 degrees.
DESCRIPTION OF ACCIDENT
Robert MacDonald reported for work at 6:00 a.m., his scheduled
starting time. He operated the E-Z Mountain Goat Chipper without
incident until about 9:30 a.m. At that time he radioed Pete
Smyle, Project Superintendent for Ames Construction Inc., and
asked him to have the service truck and compressor brought to his
location so that he could change the knives on the chipper.
Smyles directed David DeMartin, Ames Construction Inc.
maintenance foreman, and Dane Bjerky, Ames Construction Inc.
oiler, to take the requested equipment to MacDonald. This was
accomplished at about 9:40 a.m. DeMartin spoke with MacDonald
for about five minutes and then he and Bjerky left the area.
At about 9:55 a.m., Gary Goodrich, Magma Nevada Environmental
Manager, and five visitors went to the chipper area to observe
the machine in operation. When they arrived, the engine was
idling and MacDonald appeared to be working on the inside of the
in-feed area. He was on his knees with his legs crossed at the
ankles. After watching MacDonald for a couple of minutes and
detecting no movement, Goodrich became concerned and climbed onto
the machine.
He saw that MacDonald's head was pinned between the yoke of the
in-feed roller and the frame of the feed chute. Goodrich shook
and spoke to MacDonald but there was no response. He then went
to the operator's cab, shut down the engine, and radioed for
help.
Richard Katsma, Ames Construction Project Engineer/Manager,
arrived at the accident scene at 10:00 a.m. He checked MacDonald
for vital signs. Finding none, he radioed Magma's office and
instructed them to call 911 for assistance.
The rescue unit from Ruth, Nevada arrived at the scene at
10:32 a.m., but were unable to resuscitate the victim. The White
Pine County coroner arrived at 10:40 a.m. and pronounced
MacDonald dead.
CONCLUSION
The primary cause of the accident was the failure to properly
lock the in-feed yoke in the upright position prior to entering
the chipper. A buildup of chips, and the lower pin holes being
filled with material, may have prevented the yoke assembly from
being locked in the fully upright position. Contributing factors
may have been engine vibrations or the performance of work that
dislodged a partially inserted pin.
VIOLATIONS
Citation No. 3933668, 104(a), 56.14211(c). Issued to Morbark
Sales Corp. 03/10/95
The operator of the Morbark 50136 E-Z Mountain Goat chipping
machine, serial no. 1010, failed to properly secure the in-feed
roller in the upright locked position while he was cleaning
debris from between the feed chute and the operator's cab. The
yoke assembly fell and struck the man in the left temple area
causing a skull fracture resulting in a fatal injury.
Citation No. 3933669, 104(a), 56.14100(a). Issued to Morbark
Sales Corp. 03/10/95.
The operator of the Morbark 50136 E-Z Mountain Goat chipping
machine, serial no. 1010, was not doing a pre-shift examination
of his equipment. During the accident investigation interview of
the other operator it was determined that a pre-shift examination
was not being conducted on the mobile equipment.
There was only one pin available on the machinery that could be
used to lock the yoke assembly in the upright position. There
were provisions for two pins. During a pre-shift inspection it
should have been noted that one pin was missing.
Respectively submitted by:
/s/ Ronald G. Ainge
Mine Safety and Health Inspector
/s/ David A. Kerber
Mine Safety and Health Inspector
Approved by:
Fred M. Hansen,
Manager, Western District
Related Fatal Alert Bulletin: [FAB95M10]
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