DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
ACCIDENT INVESTIGATION REPORT
SURFACE NONMETAL MINE
FATAL POWERED HAULAGE ACCIDENT
Devault Crushed Stone Co.
A Division of Allan A. Myers Inc.
Devault, Chester County, Pennsylvania
MSHA ID No. 36-00060
February 6, 1996
Dale R. St. Laurent
Supervisory Mining Engineer
Ricky J. Horn
Mine Safety & Health Inspector
Mine Safety & Health Administration
230 Executive Drive, Suite 2
Cranberry Township, Pennsylvania 16066-6415
James R. Petrie, District Manager
Jamie H. Boyer, laborer, age 20, was fatally injured at about 12:15 p.m. on February 6, when he was crushed between the lift arm and the roll-over protective structure (ROPS) of a small utility loader. He had approximately 9 months total mining experience, all at this mine, and had operated the loader for about 6 months.
The Devault Quarry, a crushed limestone operation owned and operated by Devault Crushed Stone Company, a Division of Allan A. Myers, Inc., was located near Devault, Chester County, Pennsylvania. The principal operating official was Daniel J. Johnson, general manager. The plant was normally operated one 8-hour shift, 5 days a week. An average of 13 persons was employed; 9 were at the mine on the day of the accident. Limestone was extraced by drilling and blasting multiple benches in the quarry. Front-end loaders were then used to load the broken material into a hopper which fed the primary crusher. The material was then crushed, screened, sized and stockpiled. The entire plant, including the stockpiles, was located in the quarry. Most of the finished product was used by Myers, Inc. at their nearby asphalt and concrete mix operations.
Boyer had not received training in accordance with 30 CFR Part 48. He did, however, receive new hire safety orientation training and task training in the operation of the utility loader, along with about 10 hours of supervised practice. he last regular inspection of this operation was completed October 11, 1995.
PHYSICAL FACTORS INVOLVED
The accident occurred on a level concrete pad surrounding the tertiary crushing plant. A 3-foot high concrete block barrier bounded the outside edge of the pad. Parts of the pad were covered by several inches of snow from a recent storm.
The equipment involved was a Case, Model 1835B, skid-steer, Uni-loader, S/N 17191198, manufactured in 1986. It was equipped with rubber tires and a small loader bucket attached to lifting arms at the front. Access to the machine was gained by lowering the bucket to the ground and stepping on or over it to get into the open-faced operator cab. The machine was powered by a 4-cylinder diesel engine. Engine speed was controlled by a small lever located near the operator's left calf, below his seat. This lever was found in the up position (high idle) at the time of the accident.
The unit was steered and propelled by long control levers located on each side of the operator's seat. At the end of the right side control lever was a handle that tipped the bucket for dumping when moved inward toward the operator's legs. When the handle was moved outward, it retracted the bucket against the lifting arms for carrying a load or tramming. The Bucket was found in the retracted position at the time of the accident. The bucket was empty except for a small piece of ice frozen to the bottom of the bucket.
At the end of the left side control lever was a handle that lowered the lift arms when moved inward toward the operator's legs. When the handle was moved outward, it raised the lift arms. A test was conducted during the investigation which showed, at high idle, the lift arms would rise from the ground to the height of the ROPS in about 3 seconds. Boyer's left knee was in close proximity the left control handle when he was found by coworkers immediately after the accident.
The Uni-loader was equipped with a ROPS and had steel mesh on the sides and back of the support members. Access to the operator's seat could only be gained from the front of the unit. The front of the ROPS extended over the operator's seat. The distance from the floor of the loader to the ROPS was approximately 4 feet 10 inches. When the lift arms were raised, there was about 7 inches clearance between the left arm and the front left side of the ROPS where Boyer was pinched.
An inspection of the loader revealed no mechanical defects. The seat belt was in good condition and sized for use by this operator. The cab and access area were clean with no mud or ice present. This particular model Uni-loader was not manufactured with a safety interlock or cut-out device that prevented movement of the arms or bucket when the operator was not seated. While later models were so equipped, there was no retro-fit kit available from the equipment manufacturer.
The weather was good and visibility was clear on the day of the accident. Evidence indicated that Boyer had made about two passes with the Uni-loader to remove snow from the concrete pad near the block barrier. There was dirty, icy snow dumped on top of the barrier and at least one bucket load of snow had been dumped over the barrier. There were fresh scrapes visible along a nearby section of the barrier which may have been caused during a previous pass.
The operator's manual was found in the vehicle. The following safety warnings were specified:
DESCRIPTION OF THE ACCIDENT
On the day of the accident, Jamie Boyer (victim) reported for work shortly before his 9:00 a.m. starting time. Boyer fueled the Uni-loader at the facility across the road and then drove it to the office about 15 minutes later. Michael Menkins, superintendent, instructed Boyer to clean up snow and spilled material from around the tertiary crushing plant. Menkins would be working with the crew at the nearby primary crusher.
Various employees saw Boyer working around the tertiary crushing plant that morning. At about noon, the crew was finished at the primary crusher. Menkins radioed Michael Glinski, maintenance man, who was working on the other side of the tertiary plant. He requested that Glinski go to the motor control center (MCC) and remove his lock so the primary crusher could be started. Glinski said he would do so in about 5 to10 minutes. At about 12:15 p.m., Glinski was walking toward the MCC when he noticed Boyer, who appeared to be standing up in the Uni-loader. Thomas Hullihan, laborer, also saw Boyer apparently standing in his loader and decided to check on him because Boyer was not moving.
Upon reaching the Uni-loader, Hullihan saw that Boyer was trapped and shouted Boyer's name. Glinski, hearing Hullihan's shout, ran over to assist him. They found that Boyer was pinned between the left lift arm and the ROPS. Glinski called on the radio for assistance and then got into the loader and lowered the lift arms to free Boyer. He then raised the arms all the way so they could carry Boyer out. Glinski shut off the machine and was assisted by other employees in giving Boyer first aid and CPR. Menkins heard Glinski's radio call and drove to the site. Upon seeing Boyer's condition, he went the office and called 911.
The local fire department and EMTs arrived minutes later and continued CPR and first-aid treatment. Boyer was unconscious and had no pulse. He was transported to a local hospital where he was pronounced dead.
The primary cause of the accident was the failure to maintain control of the loader while it was running. Boyer had apparently gotten out of the seat, while the loader was running and accidentally bumped the handle on the control lever that raises the lift arms. A contributing factor was the lack of an automatic safety device to prevent movement of the bucket and arms when the operator gets out of the seat. Newer units are provided with bars that swing down over the operator's lap or have a sensor in the seat.
Order No. 4440110 was issued under the provisions of Section 103(k) of the Mine Act on 2/6/96, to secure the safety of persons in the area.
This order was abated on 2/23/96, after MSHA had concluded the investigation.
Citation No. 4430167 was issued under the provisions of Section 104(a) on 2/23/96, for violation of 30 CFR 56.9101:
A fatal accident occurred at this operation on 2/6/96, when the operator of a Case Uni-loader, Model 1835B (SN 17191198), was crushed between the bucket lift arm and the roll-over protective structure (ROPS). The victim had stood up and raised out of his seat while the Uni-loader was running and activated the control mechanism which raised the bucket arms.
Case, Model 1835B, Uni-loaders should be retro-fitted with a safety device to prevent movement of the bucket and lift-arms when the operator is not seated, or they should be replaced with a loader that is equipped with this device.
Respectfully submitted by:
/s/ Dale St. Laurent
Supervisory Mining Engineer
/s/ Ricky J. Horn
Mine Safety and Health Inspector
James R. Petrie
Related Fatal Alert Bulletin: