UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
Northeastern District
ACCIDENT INVESTIGATION REPORT
SURFACE NONMETAL MINE
FATAL POWERED HAULAGE ACCIDENT
Devault Quarry
Devault Crushed Stone Co.
A Division of Allan A. Myers Inc.
Devault, Chester County, Pennsylvania
MSHA ID No. 36-00060
February 6, 1996
By
Dale R. St. Laurent
Supervisory Mining Engineer
Ricky J. Horn
Mine Safety & Health Inspector
Northeastern District
Mine Safety & Health Administration
230 Executive Drive, Suite 2
Cranberry Township, Pennsylvania 16066-6415
James R. Petrie, District Manager
GENERAL INFORMATION
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:
- Keep seat belts fastened.
- Never leave the operator's seat without first lowering
the lift arm, or engaging the lift arm stops, and
shutting off the engine.
- Never attempt to work the controls unless properly
seated.
- WARNING: Keep your body inside the operator's cab while
operating the skid-steer loader. Never work with your
arms, feet or legs beyond the operator's compartment.
Stay alert. Should something break, come loose,
or fail to operate in your equipment, stop work, lower
lift arms, shut off engine and inspect the machine.
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.
CONCLUSION
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.
VIOLATIONS
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.
The citation was abated on 3/12/96, after it was found thta the
Case, Model 1835B, Uni-loader (SN 17191198), had been removed
from the property.
RECOMMENDATIONS
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
Approved by:
James R. Petrie
District Manager
Related Fatal Alert Bulletin: [FAB96M03]
|