UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION

District 4

REPORT OF INVESTIGATION
SURFACE FACILITY

FATAL OTHER (HAND TOOLS) ACCIDENT

Herndon Processing Company
Keystone No. 2 Plant (I.D. No. 46-03158
Karco Inc. (I.D. No. EUV)
Herndon, Wyoming County, West Virginia

February 6, 1997

by

Ernie Ross, Jr.
Coal Mine Safety and Health Inspector


Originating Office - Mine Safety and Health Administration
100 Bluestone Road, Mount Hope, West Virginia 25880
Earnest C. Teaster, Jr., District Manager

OVERVIEW

Abstract

On Thursday, February 6, 1997, about 2:17 p.m., a hand tools accident occurred at the Herndon Processing Company, Keystone No. 2 Plant. Eddie Dean Shrewsberry, truck driver, received fatal crushing injuries while working under the first section of the Bantam T-350 crane boom. Benny Hodges, crane operator, and Shrewsberry were in the process of removing the boom from the crane prior to transporting the crane to the Karco Inc. shop for repairs. The victim was pronounced dead on arrival at Raleigh General Hospital at 3:40 p.m., February 6, 1997, by Dr. Daniel McVey.

The accident occurred while the victim was positioned under the boom using a metal punch and ball peen hammer to remove the two bottom box boom hinge pins which retained the first and second boom sections together. The total length of the five-sectioned, latticed crane boom was 56 feet. Hodges stated that he discussed with the victim how the boom would be removed as they were traveling to the area where the crane was located. The plan was to separate the boom between the first and second sections. This would allow sections two through five to be removed in one piece. Upon arrival at the crane, Hodges lowered the crane boom to an approximate level position. The distance between the bottom of the first crane boom section and the ground was approximately 28 inches. The victim placed one 30-inch crib block in an upright, vertical position under the boom between the first and second sections. He then positioned himself under the first boom section and proceeded to remove the bottom box boom hinge pins. After the right side pin was removed, the victim began to punch the left side pin through the connector holes. The boom hinged downward as the pin cleared the connector holes, and the first and second boom sections separated. The upright crib block was dislodged by the movement of the boom, allowing the first section of the boom to fall, crushing the victim between the boom and the ground.

The accident occurred because the crane boom was not securely blocked in position prior to persons working under the boom. The boom control cables were not disconnected from the end of the boom, which allowed the boom to remain in tension. Another contributing factor to the accident was that the victim had no previous experience working on or around the crane and had never participated in the removal of the crane boom. The victim had not received the required task training prior to performing work duties on the crane.

Eddie Dean Shrewsberry, age 34, had approximately 12 years experience as a truck driver, including about 11 days experience for Karco Inc.

Background

The Herndon Processing Company, Keystone No. 2 Plant, is located at Herndon, Wyoming County, West Virginia. The Keystone No. 2 Plant began operation in August 1990. The plant operates 2 shifts a day, 6 days a week, processing coal trucked in from several area contract mines. Employment is provided for 14 persons on the day and evening shifts.

Herndon Processing Company is a subsidiary of Barkers Ridge Development Company of Herndon, West Virginia. The principal officers of Herndon Processing Company are Harold C. Collins, President/Treasurer; Steven R. Stroupe, Secretary; and Donald Cook, Safety Consultant.

Karco Inc. (I.D. No. EUV) has worked on Herndon Processing Company property for approximately 3 years. Karco was contracted to provide coal haulage, cleaning of settling ponds, and other various property maintenance duties as needed. A crane, backhoe, small dump truck, and four coal trucks are utilized to perform these duties. According to officials of both companies, Herndon Processing Company does not direct the work force nor participate in the work conducted by Karco Inc. Herndon Processing Company monitors the progress and adequacy of the work requested. Karco Inc. employs 10 persons on 2 shifts, 6 days per week.

The principal officers of Karco Inc. are Karla Rowe, President, and Jason Rowe, Foreman.

The last Mine Safety and Health Administration (MSHA) regular inspection (AAA) at this preparation plant was completed on December 2, 1996.

STORY OF EVENT

On Thursday, February 6, 1997, Eddie Dean Shrewsberry, truck driver, reported to work at the Karco shop at about 12:00 noon. Shrewsberry's regular starting time was 3:00 p.m. On February 5, 1997, Jason Rowe, foreman, requested that Shrewsberry report to work a couple of hours early to assist Benny Hodges, mechanic/crane operator, in whatever jobs that had to be done. Rowe usually assisted Hodges in performing maintenance work. Rowe, however, had not performed work for several days due to a knee injury and subsequent surgery.

At about 11:00 a.m. on February 6, 1997, Rowe telephoned Hodges and informed him that the settling ponds behind the Keystone No. 2 Plant needed to be cleaned soon. The Bantam T-350 crane, which is used to clean the settling ponds, had not been operated in 7 months. The transmission on the crane was damaged when it was last operated. Hodges was instructed to remove the boom from the crane in order to transport the machine to the shop for repairs. Shrewsberry was to assist Hodges in preparing the crane for transport.

Hodges and Shrewsberry cleaned and performed various duties around the shop from 12:00 noon until about 2:00 p.m. Hodges informed Shrewsberry that they had to travel to the plant to remove the boom from the crane. At about 2:00 p.m., Hodges and Shrewsberry traveled 1.5 miles from the shop to the settling pond area behind the Keystone No. 2 Plant superintendent's office. Hodges stated the decision was made to separate the boom between the first and second sections and remove sections two through five in one piece. The entire boom could then be slid to the side, allowing the crane to be removed from the area. This crane boom had been removed approximately four times in the last 3 years, while on Herndon Processing Company property, by Hodges and Rowe. Hodges stated that the boom had never been removed in one piece.

Hodges entered the operator's compartment of the crane after arrival at the site. The boom was swung to the side and the 1/2-yard muck bucket was removed. The boom was then returned to the front of the crane and lowered to an approximate level position. The distance from the bottom of the first section of the boom to the ground was approximately 28 inches. The sheave wheel rope guides were not attached at the top of the first boom section in the frame-mounted holes provided. The boom control ropes remained attached to the end of the boom. This would allow the boom to remain in tension. Shrewsberry obtained one crib block, 30 inches in length, from the outrigger frame and placed it in an upright vertical position underneath the boom. The crib block was placed near the connection point of the first and second boom sections. The ground area underneath the boom contained mud from 4 to 6 inches in depth.

Hodges stated he was standing on the platform outside the operator's compartment as Shrewsberry removed the bottom right side box boom hinge pin between the first and second boom sections. The crane's engine was operating at this time. Hodges stated he heard Shrewsberry hammering on the left side pin. The boom fell as the sections suddenly separated. Hodges observed the boom hinging downward, pinning Shrewsberry under the first section of the boom. Hodges entered the operator's compartment and actuated the boom lift lever in an attempt to raise the boom. The upward movement of the end of the boom had no lifting effect on the first boom section. A hinging effect was created between the first and second boom sections, with the bottom box boom hinge pins removed. Hodges pulled the stop switch on the crane and exited the operator's compartment. He then physically tried to lift the first boom section off Shrewsberry, to no avail. Hodges stated he traveled to his pickup truck, about 50 feet away, and obtained a hydraulic jack. The jack was ineffective due to the muddy conditions under the boom. He then traveled toward the plant superintendent's office about 50 feet away from the crane.

At about 2:20 p.m., Don Cook, safety consultant, and Garnie Kennedy, plant manager, were talking in the plant manager's office. Cook observed Hodges through the office window. Hodges was bending over, clutching his chest. Cook and Kennedy rushed to Hodges and offered assistance. Cook stated that Hodges kept pointing toward the crane and was trying to talk. Cook then looked toward the crane and observed the boom in a hinged position. He then traveled to the crane and observed Shrewsberry pinned under the first section of the boom. Cook, an emergency medical technician, checked Shrewsberry for vital signs and found none. Kennedy requested that Shelby Akers, plant superintendent, have the front-end loader brought to the site to lift the boom. Cook called 911 for an ambulance. Akers called the scale house and instructed Dennis Large, scale-house man, to bring the Cat 966C front-end loader to the site. The front-end loader arrived at the site within minutes. A chain was connected between the front-end loader bucket and the end of the first section of the boom. The boom was raised, and the victim was removed from underneath the boom.

An ambulance from the Upper Laurel Ambulance Service arrived on the scene at 2:32 p.m. The victim was placed on a backboard and transported to Raleigh General Hospital, Beckley, West Virginia. The victim was pronounced dead on arrival at 3:40 p.m. by Dr. Daniel McVey.

Hodges was transported by Jan-Care Ambulance Service at 3:10 p.m. to the Princeton Community Hospital, Princeton, West Virginia, and treated for chest pains.

INVESTIGATION OF THE ACCIDENT

The Mine Safety and Health Administration was notified at 2:35 p.m., February 6, 1997, that a possible fatal accident had occurred. MSHA personnel began to arrive at the site about 3:30 p.m. A 103(k) Order was issued to ensure the health and safety of the miners until the accident investigation was completed.

MSHA and the West Virginia Office of Miners' Health, Safety and Training jointly conducted the investigation with the assistance of the plant and contractor management personnel, the miners, and representatives of the miners.

All parties were briefed by plant personnel as to the circumstances surrounding the accident. A discussion was held with everyone available who had knowledge of the accident. Representatives of all parties traveled to the accident scene, where a thorough examination was conducted. Photographs and relevant measurements were taken and sketches were made at the accident site.

Interviews of individuals known to have knowledge of the facts surrounding the accident were conducted at the MSHA Pineville Field Office conference room at 9:00 a.m., February 7, 1997. Benny Hodges, the only eyewitness to the accident, was interviewed at the Herndon Processing Company main office at 1:00 p.m. on February 11, 1997.

The physical portion of the investigation was completed on February 13, 1997, and the 103(k) Order was terminated.

DISCUSSION

Training

There were no records presented to indicate that newly employed experienced miner training had been given to Eddie Dean Shrewsberry, truck driver, prior to his assignment of work duties on January 27, 1997. There were no records presented to indicate that Eddie Dean Shrewsberry had ever received instruction in the safety and health aspects and safe work procedures of the task of dismantling the Bantam T-350 crane boom, as required by Part 48.

Physical Factors

1. The victim had been working for Karco Inc. only 11 days prior to the accident.
   
   
2. The victim, a truck driver, had not received newly employed experienced miner training before assignment of work duties on January 27, 1997.
   
   
3. The victim had not received instruction in the safety and health aspects and safe work procedures of the task of dismantling the Bantam T-350 crane boom prior to performing this task on February 6, 1997.
   
   
4. The 56-foot boom on the Bantam T-350 crane, Serial No. 12591, was not securely blocked in position prior to the performance of work duties underneath the crane boom. Only one crib block, 30 inches in length, was placed in an upright, vertical position under the boom for support.
   
   
5. The accident occurred while Shrewsberry was positioned under the boom, using a metal punch and ball peen hammer to remove the two bottom box boom hinge pins which retained the first and second boom sections together.
   
   
6. Hodges stated the plan was to separate the boom between the first and second sections and remove sections two through five in one piece. Hodges had participated in the removal of the boom several times. He stated he had never removed the boom in this manner previously.
   
   
7. The boom was swung to the side and the 1/2-yard muck bucket was removed. The boom was then returned to the front of the crane and lowered to an approximate level position. The distance from the bottom of the first section of the crane boom to the ground was approximately 28 inches.
   
   
8. The boom control ropes remained attached to the end of the boom. This would cause the boom to remain in tension.
   
   
9. Jason Rowe, foreman, had requested that Shrewsberry report to work a couple of hours early to assist Benny Hodges, mechanic/crane operator, with whatever jobs that had to be done.
   
   
10. Hodges stated he was standing on the platform outside the operator's compartment as Shrewsberry removed the bottom right side box boom hinge pin between the first and second boom sections. The crane's engine was operating at this time.
    
    
11. The boom hinged downward as the second box boom hinge pin cleared the connector holes between the first and second boom sections.
    
    
12. Jason Rowe, foreman, usually assisted Hodges in performing maintenance work. Rowe had not worked for several days due to a knee injury and subsequent surgery.

CONCLUSION

The accident and resultant fatality occurred as the victim was positioned underneath the inadequately supported Bantam T-350 crane box boom. The victim removed the two bottom box boom hinge pins between the first and second boom sections. The removal of the bottom pins caused the boom to separate and hinge downward, which resulted in the victim being crushed between the first boom section and the ground. The victim had not received instruction in the safety aspects and safe work procedures of the task of dismantling the Bantam T-350 crane box boom prior to performing this task.

CONTRIBUTING VIOLATIONS

A 104(d) (1) Citation, No. 3749110, was issued to Karco Inc., stating in part that the victim was not instructed in the safety and health aspects and safe work procedures of the task of dismantling the Bantam T-350 crane boom prior to performing this task. This was a violation of Section 48.27(c), 30 CFR.

A 104(a) Citation, No. 3749106, was issued to Herndon Processing Company, stating in part that the operator failed in his overall responsibility for the health and safety of all persons working on his property by not ensuring that the victim had received newly employed experienced miner training prior to assignment of work duties on his property. This was a violation of Section 48.26(a), 30 CFR.

A 104(a) Citation, No. 3749107, was issued to Herndon Processing Company, stating in part that the operator failed in his overall responsibility for the health and safety of all persons working on his property by not ensuring that the victim had received the required task training prior to performing the task of dismantling the crane boom. This was a violation of Section 48.27(c), 30 CFR.

A 104(a) Citation, No. 3749108, was issued to Karco Inc., stating in part that the 56-foot boom on the Bantam T-350 crane, Serial No. 12591, was not securely blocked in position prior to persons working underneath the boom. This was a violation of Section 77.405(b), 30 CFR.

A 104(a) Citation, No. 3749109, was issued to Karco Inc., stating in part that the victim did not receive newly employed experienced miner training before being assigned work duties on January 27, 1997. This was a violation of Section 48.26(a), 30 CFR.

Respectfully submitted by:

Ernie Ross, Jr.
Coal Mine Safety and Health Inspector

Approved by:

Richard J. Kline
Assistant District Manager

Earnest C. Teaster, Jr.
District Manager

Related Fatal Alert Bulletin:
FAB97C03