UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION


South Central District
Metal and Nonmetal Mine Safety and Health

Accident Investigation Report
Surface Nonmetal Mine
(Limestone)

Fatal Powered Haulage Accident


Garves W. Yates & Sons, Inc.
Y-200 Portable (Noelke Pit)
Sheffield, Pecos County, Texas
I.D. No. 41-03206


February 14, 1997

By

Ronald M. Mesa, Special Investigator
and
Daniel J. Haupt, Supervisory Special Investigator


Originating Office
South Central District Office
1100 Commerce Street, Room 4C50
Dallas, Texas 75242-0499


Doyle D. Fink
District Manager

GENERAL INFORMATION

Juan L. Ortiz, front-end loader operator, age 31, was fatally injured about 1:15 p.m. on February 14, 1997, when the loader he was operating traveled over a 30-foot quarry face. Ortiz had a total of three years mining experience, all as a loader operator at this operation. He had not received training in accordance with 30 CFR Part 48.

Wayne Yates, vice president notified MSHA at 3:05 p.m. on the day of the accident. An investigation was started the following day.

The Y-200 Portable is a portable crushing unit and was moved to various pits within the state of Texas. The Noelke Pit is leased and operated by Garves W. Yates & Sons, Inc., and was located on Highway 349 in Sheffield, Pecos County, Texas. The principal operating officials were Wayne Yates, president; Garves W. Yates, vice president; and Jo Yates, board chairman. The mine was normally operated one 10-hour shift per day, five days a week. A total of five persons were employed. Limestone mining started at the pit on January 6, 1997.

Limestone was drilled and blasted from a single bench with heights that varied from 26 to 31 feet. It was then transported by front-end loader to the crushing plant where it was crushed, screened, and stockpiled. The finished product was used in the road building and general construction industry.

The last regular inspection was completed on January 24, 1996, and another regular inspection was conducted after the fatal accident investigation.

PHYSICAL FACTORS INVOLVED

The front-end loader involved in the accident was a 1991 Caterpillar, Model 980-F, serial number 08CJ0029. It was purchased new in November 1991. The maximum speed was 34.6 miles per hour (mph) and the operating weight was 61,046 pounds. The loader was powered by a six cylinder Caterpillar turbo charged 3406C diesel engine.

The loader was 29 feet 6 inches long and 11 feet wide. The ROPS (Roll-over Protective Structure) for this loader met ROPS criteria SAE J394a, SAE J1040c and ISO 3471-1980. The loader was equipped with seat belts that met the requirements of SAE J386.

The service brake system was four-wheel, air-over-oil, fully enclosed, oil-immersed, multiple-disc brakes. They were self-adjusting with modulated engagement. Two brake pedals allow standard braking with the right brake pedal and transmission neutralization with the left pedal. The parking brake system was spring-applied, air-released and the dry-drum parking brake acts on the main drive line. The secondary brake system uses the parking brake on the main drive line. If the air pressure dropped below 276 kPa (40 psi) when the transmission was engaged, the Computerized Monitoring System would activate a flashing action lamp and sound an audible alarm to warn the operator. The brakes would automatically apply to bring the loader to a controlled stop. The operator could apply the secondary brake system manually.

Post accident tests on the braking system indicated that all the braking systems were functional. There were no apparent safety or mechanical problems with the loader.

The vertical high wall measured 29 feet 6 inches in height. On the day of the accident an Ingersoll Rand ECM 370 rock drill was parked on top of the high wall. The drill was equipped with an air compressor that was used routinely to blow out air filters on loaders. This occurred about once a week and the practice was for the loader operators to drive to the drill location.

At the top of the quarry wall where the accident occurred, the overburden had been stripped back about 70 feet from the quarry face. The slope in this area declined toward the face at about 21 percent at the overburden to about 16 percent at the quarry face.

DESCRIPTION OF THE ACCIDENT

Juan Ortiz, front-end loader operator, reported to work at 7:30 a.m. on February 14, 1997. Ortiz was instructed by Juan Ochoa, plant supervisor, to operate the loader in the quarry. Ortiz began his usual task of hauling stone with the loader from the bottom bench of the quarry to the crushing plant. Ortiz ran the loader without any problems until around 12:15 p.m.

Because it was Friday, Juan Ochoa, plant supervisor decided to shut down early to perform crusher maintenance, cleanup and let the crew go home early. Ortiz drove the loader from the crusher to the top of the quarry in order to blow out the air filters, stopping the equipment with it facing the edge of the highwall at a location 49 feet from the drill and 20 feet from the highwall's edge. He set the bucket of the loader on the ground and got out of the loader with the engine still running and with out setting the parking brake.

Apparently, Ortiz was standing on the deck outside the cab when the loader began to roll forward towards the high wall. Reacting to the loader movement, he reached inside the cab and shifted the loader into reverse. Ortiz did not get inside the loader.

Lendro Hernandez, laborer was shoveling at the crusher. He turned and observed Ortiz jumping from the deck of the loader as it was going over the edge of the high wall. He stated that the engine was running and the back up alarm was sounding as it went over the high wall. Ortiz landed on the quarry floor near the overturned loader.

Ochoa immediately went to the bottom bench and checked the victim's pulse, and after finding none, called 911 for medical assistance. The Pecos County Sheriff's department arrived at the scene within fifteen minutes and found no signs of life in the victim. Don Pitts, justice of the peace pronounced Ortiz dead at the scene. Ortiz was transported to Crane, Texas.

When examined after the accident, the parking brake was engaged. No skid marks or other physical evidence indicates that the braking systems were engaged for the 16-20 feet that the loader traveled between where it originally stopped and where it over traveled the highwall. The following factors indicate that the parking brake was not engaged when the loader left the highwall. The victim attempted to reverse the direction of the loader, as heard by the sole witness. The grade on which the equipment was stopped declined to the edge of the highwall, and the equipment operator had "dropped the bucket" of the loader, a common industry practice for stopping and holding mobile equipment.

CONCLUSIONS

The primary cause of the accident was the failure to set the parking brake on the loader before leaving the equipment unattended.

VIOLATIONS

Order Number 4447577

Issued on February 14, 1997, under the provision of Section 103(k):

On 2/14/97, a fatal accident occurred when the 980 F Caterpillar front-end loader ran off the top of a 29-foot 6-inch high face in the northeast section of the quarry. This order is issued to secure the area and the loader until MSHA deems they are safe for the other miners. The loader will be moved to the main shop in Abilene, Texas for further testing of the brake system.

The order was terminated when the loader was taken out of service and removed from the mine site on 2/16/97.

Citation Number 4447579

Issued under the provision of Section 104(a), for violations of 30 CFR 56.14207:

A fatal accident occurred at this mine on 2/14/97, when a Caterpillar 980-F (Serial 308CJ00295) front-end loader traveled over a 30-foot high wall. The service brakes and the parking brakes were functional. Tire tracks showed no signs of any skiding or sliding action. Evidence indicated that the operator stopped the loader, lowered the bucket to the ground and then exited the operator's cab without setting the park brake and without chocking or turning the wheels into a bank. The bucket did not hold the loader and it started to roll towards the edge of the high wall. The operator had shifted the loader into reverse gear and jumped from the loader as it went over the edge. He and the loader landed on the bench below.

The citation was terminated on 2/16/97 when the loader was destroyed and removed from the mine site. All employees were instructed in the proper procedures for setting parking brakes on mobile equipment.

[FAB97M09]