UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION



Accident Investigation Report
Surface Nonmetal Mine

Fatal Machinery Accident


Capital City Aggregates
Jaxon Enterprises
Mound House, Lyon County, Nevada
ID No. 26-02267

April 23, 1996


By

Willie J. Davis
Supervisory Mine Safety and Health Inspector

James W. Ashton
Mine Safety and Health Inspector


Mine Safety and Health Administration
Western District
3333 Vaca Valley Parkway, Suite 600
Vacaville, California 95688

Fred M. Hansen
District Manager

GENERAL INFORMATION

John C. Reno, equipment manager, age 33, was fatally injured at about 2:00 p.m. on April 23, 1996, when the mobile crane that he was operating overturned. Reno had a total of 15 years mining experience, all with this company; the past six years as equipment manager. Reno had not received training in accordance with 30 CFR Part 48.

MSHA was notified at 5:27 p.m. on the day of the accident by a telephone call from James Baker, plant foreman. An investigation was started the following day.

Capital City Aggregates, a crushed stone operation, owned and operated by Jaxon Enterprises, was located at Mound House, Lyon County, Nevada. Principal operating officials were W. Jaxon Baker, president; Robert Towne, plant manager; and James Baker, plant foreman. The mine was normally operated one 8-hour shift a day, five days a week. A total of eight persons was employed.

Rock was excavated by a bulldozer in the pit and pushed to a crusher. After crushing and sizing, the material was transported by belt conveyors to appropriate stockpiles. The finished product was sold primarily for construction aggregate.

The last regular inspection of this operation was completed on January 18, 1996. Following the accident, another inspection was completed on June 14, 1996.

PHYSICAL FACTORS

The crane involved in the accident was a rubber-tired, 1984, Pettibone, Model 40 SCP, designed for rough terrain. Maximum boom extension was 92 feet and lifting capacity was 20 tons. At the time of the accident, the boom was secured in the travel position. An enclosed operator's cab was located on the left side of the vehicle. ROPS was not a part of the crane's cab design. Seat belts were not provided.

An examination of the crane by the investigators and MSHA technical specialists disclosed that both brake fluid reservoirs were empty. There was no evidence that leakage had occurred following the accident. A support bracket for the rear brake reservoir had been broken some time prior to the accident. Brake shoes, brake drums, and planetaries showed very little wear. Mark Collier, hot plant operator, had used the crane about two hours prior to the accident. Collier stated that steering and parking brake components were working properly. He said that the service brakes were not as effective in stopping the vehicle as they should have been, and that second gear in the transmission could not be engaged. At the time of the investigation the transmission lever was noted to be in the forward position, between first and second gear.

Because the crane was used at non-mining as well as mining operations, there was little information available that would indicate its maintenance and repair history. Also, the person responsible for, and knowledgable of, the crane's upkeep was the victim.

The road where the crane overturned was recently constructed for access to a new crusher location. From the main access road, the new road curved to the left before extending up the hill on a 12 percent grade. The road was 300 feet long, 18 feet wide and was cut into the hillside. An axle high berm meeting MSHA requirements was provided along the outer edge. The surface was dry and well compacted.

At the time of the accident, the weather was clear, cool, and dry.

DESCRIPTION OF ACCIDENT

On the day of the accident, John Reno (victim) arrived at the work site at about 7:00 a.m. As equipment manager, Reno worked discretionally at various company-owned operations. At this site, he was responsible for overseeing the relocation of the primary crusher and was also involved in construction of the project. Part of his duties included operating equipment used for site preparation and moving and reassembling the crusher components.

At about 1:30 p.m., Reno went to the company-owned asphalt plant, a distance of about one-fourth mile, to get the crane. Thomas Gregory, a contract mechanic who was assisting Reno, stated that he observed Reno returning with the crane on the inclined roadway enroute to the new crusher location at about 2:00 p.m.. Gregory said that the crane traveled about 100 feet up the grade, stopped for a few seconds, and then began rolling back down the road. Since Reno was looking to the rear, with his head out the window, Gregory thought Reno was in control of the crane. Near the bottom of the grade the crane appeared to be gaining speed. At the curve, it continued in a straight line. The wheels on the right side ran onto a mound of compacted dirt off the roadway and the crane came to a stop. Gregory stated that Reno braced himself as the crane rocked from side to side and then overturned, crushing the operator's cab. Gregory ran to the crane and saw that Reno, who was still in the cab, was unresponsive and badly injured. After another employee arrived, Gregory ran to his service truck and called the local 911emergency number.

Emergency Medical Technicians arrived a short time later, but were unable to revive Reno. He was pronounced dead at the scene.

CONCLUSION

The accident occurred because the service brake system on the crane had not been properly maintained. Consequently, the brakes were not capable of stopping or holding the vehicle on a grade. An effective maintenance program, which would have including pre-operational equipment inspections and prompt correction of safety defects, could have prevented this accident.

CITATIONS/ORDERS

Order No. 3910443

Issued on April 24, 1996, under provisions of Section 103(k) of the Mine Act.

This order was issued to insure the safety of persons until affected areas of the mine could be returned to normal operation and was terminated on June 20, 1996.

Citation No. 4140759

Issued on May 23, 1996, under the provisions of Section 104(a) of the Mine Act for violation of 30 CFR 56.14101(a)(3):

The braking system on the Pettibone 40 SCP crane involved in a fatal accident was not being maintained in a fully functional condition. Both brake fluid reserviors were empty. The crane overturned after descending a 12 percent grade and running onto a compacted mound of dirt.

This citation was terminated on May 31, 1996, upon receipt of written notice from the mine operator that the crane would not be repaired or returned to service.

Citation No. 7953816

Issued on September 17, 1996, under provisions of Section 104(a) of the Mine Act for violation of 30 CFR 56.14100(d):

The Pettibone 40 SCP crane involved in a fatal accident was found to have defects that affected safety. The previous operator stated to the investigator that the service brakes were weak and the second gear was missing. The investigation disclosed that the brake fluid reservoir for the rear brakes was supported only by the brake lines as the support bracket was broken. The crane had been operated with these defects. There were no records that these defects had been reported and recorded.

This citation was terminated on September 17, 1996. The crane had been taken out of service.

[FAB96M14]