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
(Crushed Stone)


Fatal Handtool Accident


K. R. Wilson Contracting, Inc.
Sullivan Plant
Sullivan, Crawford County, Missouri
I.D. No. 23-00746

June 20, 1997
By

Donald L. Richards, Metal & Nonmetal Mine Inspector
and
Billy K. Terry, Metal & Nonmetal Mine Inspector


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

Doyle D. Fink
District Manager

GENERAL INFORMATION

Vernon R. Abney, truck driver, age 41, was fatally injured about 4:45 p.m., June 20, 1997, when a portable rachet type hoist failed, allowing the suspended fender of a front-end loader to fall and strike the victim. Abney had a total of 3 years mining experience, 40 weeks as a truck driver at this operation. He had not received training in accordance with 30 CFR Part 48.

Kenneth R. Wilson, owner notified MSHA at 4:55 p.m. on the day of the accident. An investigation was started the same day.

The Sullivan Plant, owned and operated by K. R. Wilson Contracting, Inc., was located on County Road FF, 3 1\2 miles West of Sullivan, Crawford County, Missouri. The principal operating official was Kenneth R. Wilson, president. The mine was normally operated one, eight-hour shift a day, five days a week. Six persons were employed.

Limestone was extracted by drilling and blasting a single bench. Broken material was hauled by front-end loader and truck to the plant where it was crushed, sized and stockpiled. The finished products were used in general industry and road construction.

The last regular inspection of this operation was completed on February 7, 1997. Another inspection was conducted in conjunction this investigation.

PHYSICAL FACTORS

The loader involved in the accident was a 1966, Caterpillar wheel loader Model 988A, serial number 87A1575. It had been idle for two or three weeks awaiting replacement of a brake expander tube on the left rear wheel.

The fender over the left rear wheel of the loader was hinged on the front, and supported by a bracket on the rear. Two cleated steps were installed on the fender, one near the rear and another near the top. The fender weighed 425 pounds. The wheel and hub assembly weighed 2700 pounds.

In order to provide clearance for the removal and installation of the wheel assembly, the loader fender was raised to a near vertical position with the boom hoist. A portable ratchet type hoist with 3/16 inch cable secured the fender in the raised position by connecting the hooks to the top fender step and the lifting eye on top of the roll-over protection structure (ROPS).

An RO model TC 120-4 boom hoist mounted on a Ford Model 9000 truck chassis was used to lift the fender and wheel assembly. The truck was positioned with the boom at an approximate 40 degree angle to the loader wheel. At this angle it was necessary to swing, lift and boom in/out to remove and install the wheel assembly. This procedure varied from the usual practice of positioning the truck with the boom perpendicular to the wheel, which then required only lifting and booming in/out to accomplish the task.

DESCRIPTION OF THE ACCIDENT

Vernon Abney, (victim) truck driver, reported for work at 8:00 a.m. on the day of the accident, his regular starting time. He performed his usual task of hauling material from the quarry to the crusher.

Larry Bouse, foreman began the brake repairs on the front-end loader at approximately 12:30 p.m.. Bouse, working by himself, raised the loader fender with the boom hoist and secured it to the ROPS with the portable ratchet hoist. He removed the wheel assembly with the boom hoist and proceeded with the brake repairs.

Abney finished his shift at 4:25 p.m. and went to assist Bouse with the brake repairs on the front-end loader. Bouse had nearly finished the repair, except for installation of the last oil seal in the hub and mounting the wheel assembly on the loader. Abney and Bouse were joined by Ronald Haanpaa, plant operator, who had also finished his shift. Abney helped Bouse install the oil seal before the wheel assembly installation began.

Haanpaa operated the boom hoist to swing the wheel assembly in place. The position of the boom hoist at an angle to the loader made the task of lining up the hub planetary gears with the loader spindle more difficult than normal. Abney went under the loader to guide the hub onto the spindle, Bouse was on top of the hood of the loader to relay instructions from Abney to Haanpaa. The effort continued until 4:45 p.m. without success. Abney suggested that they totally remove the fender to facilitate the movement of the boom hoist cable attached to the wheel. Bouse agreed and told Abney to come out from under the loader.

Abney was moving out of the wheel well past the rear of the suspended wheel assembly when the portable ratchet hoist failed allowing the hinged fender to fall. Inspection of the cable hoist during the investigation revealed the compression type clamp, that secured the cable in a loop where it was attached to the hoist, had failed. The failed clamp allowed the cable to detach from the hoist and slip through the sheave block. Additionally, the following defects in the cable hoist observed during the investigation included: the drum guard which contained rating and manufacturer information was missing; bolts on the cable hoist were loose; a damaged sheave pulley bearing would not roll; a hook was deformed; some cable wires were broken; and a bolt marked "CAT" had been installed, as a replacement for an original bolt, to hold the loop end of the cable to the main frame.

Abney's head was caught between the falling fender and the fender support bracket. Haanpaa saw Abney fall and got down from the boom truck and rushed to his aid. Bouse came down and saw the massive injury and immediately went to the office to summon help. Abney was pronounced dead at the scene by the county coroner.

CONCLUSION

The failure to remove or properly block the front-end loader fender, prior to installing the wheel assembly, was the direct cause of the accident. The use of a defective portable ratchet hoist, which allowed the loader fender to fall contributed to the cause of the accident. Failure to wear a hard hat was a contributing factor to the severity of the injury.

VIOLATIONS

Order Number 4444897

Issued on June 20, 1997 under the provision of Section 103(k) of the Mine Act:

A fatal accident has occurred involving a 988-A serial number 87A1575, during a brake repair job. This order is to protect the safety of all persons, until the procedures used to replace the tire can be re-evaluated.

The order was terminated on June 24, 1997.

Citation Number 7856213

Issued on July 18, 1997, under the provision of Section 104(a), for violation of 30 CFR 56.14211(b):

On June 20, 1997 an employee was fatally injured when a raised fender of a 988A caterpillar front-end loader fell striking him. The portable hoist, which was used to secure the hinged 425 pound fender, failed.

The citation was terminated on July 18, 1997 when the fender was removed from the loader.

Citation Number 7856215

Issued on July 18, 1997, under the provision of Section 104(d)(1), for violation of 30 CFR 56.14100(b):

On June 20, 1997 an employee was fatally injured when a raised fender of a 988A caterpillar front-end loader fell striking him. The portable hoist, which was used to secure the hinged 425 pound fender, failed when the cable compression clamp broke. Additionally, it had loose bolts, the pulley bearing would not roll and the 3/16 inch cable was attached with a bolt marked "CAT". The cable had broken wires and the rating information was missing. The handle did contain a warning against unauthorized alteration. The foreman was directing a wheel assembly installation on the loader and allowed the defective equipment, which had been altered and not maintained, to be used. This constitutes more than ordinary negligence and is an unwarrantable failure to comply with the standard.

The citation was terminated on July 18, 1997 when the cable hoist had been removed from service.

Citation Number 7856214

Issued on July 18, 1997, under the provision of Section 104(a), for violation of 30 CFR 56.15002:

On June 20, 1997 an employee was fatally injured when a raised fender of a 988A caterpillar front-end-loader fell striking his head. When he left his truck to assist with the loader repairs, he did not put on a hard hat where there was a danger of falling objects.

The citation was terminated on July 18, 1997 when the operator had hard hats furnished for all employees.

[FAB97M35]