DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
Report of Investigation
(Sand and Gravel)
Exploding Vessel Under Pressure
October 30, 1999
West Bloomfield Mine
Elam Sand & Gravel Corporation
West Bloomfield, Ontario County, New York
ID No. 30-02863
Dennis A. Yesko
Supervisory Mine Safety and Health Inspector
Mark A. Barlow
Mine Safety and Health Inspector
F. Terry Marshall
Mine Safety and Health Administration
230 Executive Drive, Suite 2
Cranberry Township, PA 16066-6415
James R. Petrie, District Manager
Anthony R. Salerno, mechanic, age 50, was fatally injured at about 7:45 a.m., on October 30, 1999, when he was struck by the lock ring and flange from a multi-piece rim wheel he was mounting on a truck. The accident occurred because the lock ring had been improperly installed on the wheel rim.
Salerno had 29 years of maintenance experience of which 6 months were at this mine. He had not received training in accordance with 30 CFR, Part 48.
The West Bloomfield Mine, a sand and gravel operation, owned and operated by Elam Sand & Gravel Corporation, was located at West Bloomfield, Ontario County, New York. The principal operating official was David Spallina, president. The mine normally operated one, 10-hour shift a day, four days a week, and one, 8-hour shift on Fridays, with maintenance work conducted on Saturday. Total employment was 5 persons.
Sand and gravel was extracted from a 15-foot bench by a front-end loader and transported by truck to the plant where it was crushed, washed, sized and conveyed to stockpiles. The finished product was sold as construction aggregate.
Independent Material Haulers, an independent contractor who provided commercial trucking for the mine operator, was co-located at the West Bloomfield Mine. The principal operating official was Franic Alloco, president.
The last regular inspection of this operation was completed on October 10, 1999. Another inspection was conducted following this investigation.
DESCRIPTION OF ACCIDENT
On the day of the accident, Anthony Salerno, (victim) reported for work at 5:13 a.m. His normal starting time was 6:00 a.m. He proceeded to the plant shop where he began changing the front tires on a 1988 Mack slinger truck. Victor Alloco, dispatcher for Independent Material Haulers, spoke to Salerno at about 7:20 a.m., and stated that nothing seemed out of the ordinary at that time. At about 7:45 a.m., Alloco heard a loud explosion from the shop area. Alloco and his brother Franic ran to the shop where they observed a large cloud of dust. They yelled for Salerno, but received no response. Franic Alloco observed Salerno lying against an exit door at the Southeast corner of the shop, approximately 27 feet from the front of the slinger truck. He yelled for his brother to call 911. He then checked for vital signs and could find none. Emergency medical personnel arrived and transported Salerno to a nearby hospital where he was pronounced dead. Death was attributed to blunt force trauma to the chest.
INVESTIGATION OF THE ACCIDENT
MSHA was notified at about 9:45 a.m., on the day of the accident by a telephone call from Rita Dreimiller, office manager for the mine operator to MSHA's headquarter's office. An investigation was started the same day. MSHA's investigative team traveled to the mine and made a physical inspection of the accident site with the assistance of mine management and the miners. The miners did not request, nor have, representation during the investigation. An order was issued on the day of the accident pursuant to section 103(k) of the Mine Act to ensure the safety of the miners.
1. The accident occurred in the plant shop which serviced both mining equipment and over-the-road equipment.
2. The truck involved in the accident was a tandem axle Mack Econodyne truck, company number 45, manufactured in July, 1988. The chassis was provided by Mack Trucks and was equipped with Goodyear, Motor Wheel M tube-type (VM contour), three-piece flat base rims and 14/80R20 tube-type tires on the steering axle.
3. The steering axle of the truck was supported with two hydraulic jacks and supplemented by two adjustable safety jacks under each side of the frame.
4. The steering tires that had been removed from the two front multi-piece rims were both 365/80R20 Michelin XZA tube-type tires rated for a maximum load of 10,000 pounds at a pressure of 130 PSI. The 365/80R20 tire size is equivalent to a size 14/80R20 tube-type tire.
5. The victim had fitted both rim assemblies with new 365/80/R20 (14/80R20) Hankook F40 TBR tube-type tires rated at a maximum load of 9,920 pounds at 135 PSI, 13.00/14.00R-20 Black Eagle Inner Tubes (part number 44-7070), and 365/80R20 Hanta liners.
6. An inflation restraint device was found in the shop and was believed to be used by the victim during inflation. No inflation device was present in the immediate accident area.
7. The left front tire/wheel assembly put together by the victim was found outside the north bay door of the shop near a hot water pressure washer. The pressure washer was a model 3004, manufactured by Mi-T-M Corporation, and was apparently used by the victim to clean the tire/wheel assemblies after the new tires were installed. The tire pressure in the left front tire measured about 130 PSI.
8. The rim base of the right front wheel assembly involved in the accident was found mounted on the right spoke wheel of the Mack truck's steering axle. A single rim clamp had been positioned onto one of the six rim studs, but a nut had not yet been installed to secure this clamp onto the stud.
9. A red tire dolly had been used by the victim to place the tire/wheel assembly onto the right front spoke wheel prior to the accident. The tire dolly received structural damage to several of its steel members during the accident. The dolly's hydraulic jack, used to adjust the tire height, was found near the south wall of the shop. The tire involved in the accident, along with its tube and liner, were found on this tire dolly.
10. A visual inspection of the right front tire and the tire liner involved in the accident revealed no structural failure or damage.
11. A visual inspection of the inner tube involved in the accident revealed that the inner portion of the tube had split where it contacted the liner. The split was continuous and extended around the entire inner circumference of the tube except for approximately 3 inches. The tube's valve stem had also separated from the tube and was found, without a valve stem cap, against the south wall of the shop. Pieces of a plastic valve stem cap were found inside the rim base and in the right spoke wheel.
12. A Dodge 2500 pickup truck was parked in the bay to the right side of the Mack truck, facing the same direction. It sustained damage on its left side during the accident. The left front tire was scraped and the left side of the front bumper was damaged. Several fasteners were torn out and several scrape marks were visible. The scrape marks on the bumper and the tire were consistent with the structural members of the tire dolly.
13. An air impact gun and an air supply line were found near the right front of the Mack truck, but they were not connected together.
14. All six of the rim nuts for the right front wheel were piled together near the right front of the Mack truck. Five of the rim clamps for this side were found scattered across the shop floor on the right side of the Mack truck. All six of the rim nuts and rim clamps for the left side were piled together near the left front of the Mack truck. All of the twelve rim clamps were identified to have a part number of 150J251. No wear or deformation of these parts was detected.
15. A small sledge hammer was on the shop floor on the right side of the Mack truck near the rim base.
16. The components of the rim assemblies were stamped by the manufacturer in accordance with Federal Motor Vehicle Safety Standards 120 (FMVSS 120). The stamping designations indicated that all of the components were identified by Tire and Rim Association dimensions. Both rim assemblies consisted of Motor Wheel 20 x 10.0 M rim bases, Motor Wheel F 20 x 10.0 M flanges and Motor Wheel LR 20 x 7.5-8.5-10.0 M lock rings. These components were properly matched according to the Occupational Safety and Health Administration's (OSHA) "Multi-piece Rim Matching Chart," 1992 Edition.
17. Visual inspection of the right rim base gutter, lock ring, and flange revealed corrosion, grease, and rubber build-up on some of their critical seating areas. No structural failure or excessive wear was noted that could have caused the rim wheel separation.
18. Red paint and structural damage were observed on the tire side of the lock ring. This structural damage caused the lock ring's shape to be concave toward the tire side. Red paint and structural damage were also observed on the weather side of the flange. This structural damage caused the flange's shape to be concave toward the weather side. The structural damage on horizontal members of the tire dolly was determined to be geometrically consistent with the damage done to both the lock ring and the flange. Visual inspection of the corner of the lock ring safety tab, located on the weather side, showed that the corner of the safety tab was abraded and shiny. Visual inspection of the flange revealed that the lock ring seating area, located on the weather side, showed shiny scratches and indentations geometrically consistent with the corner of the lock ring safety tab with the lock ring installed backwards, or weather side in.
19. Visual inspection of the lock ring on the left front wheel assembly revealed that it had been installed in the proper orientation, or weather side out.
20. The plastic hub cap for the Mack truck's right front hub was broken during the accident, allowing the fluid to leak out onto the floor. A large piece of the cap was found in the immediate accident area, near the right side hub.
21. No information on multi-piece rim component matching, tire mounting and demounting procedures, or the manufacturer's recommended inspection criteria for the M Tube-Type (VM Contour) Three-Piece Flat Base Rim was found in the shop.
22. Physical examination of the right front wheel assembly and physical evidence gathered at the accident scene indicated that the lock ring was installed backwards and that the rim separated while the victim was installing the rim clamps onto the spoke wheel. The improperly installed lock ring allowed enough seating contact with the gutter groove in the rim's base to enable the victim to inflate and handle the wheel assembly prior to component separation.
23. The following visible indicators would have shown that the M style lock ring was installed backwards, or weather side in:
The gap in the lock ring would have been about 1 inch instead of the normal gap of about � inch;
The safety tab of the lock ring, intended to be a visible indicator to the installer, would have been in contact with the flange and consequently not visible directly counter-clockwise of the gap; and,
The cutout on the lock ring to accommodate a pry bar during disassembly would have been directly counter clockwise of the gap. The normal position would have been directly clockwise of the gap.
The primary cause of the accident was installing the lock ring of the multi-piece wheel backwards. This prevented the lock ring from seating (locking) into the gutter groove in the rim base resulting in the inability of the lock ring to hold the tire and rim components together when under pressure. A possible contributing factor was the failure to post manufacturer's instructions on the proper assembly of multi-piece rim wheels.
Order No. 7716914 was issued October 30, 1999, under provisions of Section 103(k) of the Mine Act:
A fatal accident occurred at this operation on October 30, 1999, when a mechanic was struck by a split rim wheel assembly which exploded. This order is issued to ensure the safety of persons at this operation until the mine or affected areas can be returned to normal operations as determined by an Authorized Representative of the Secretary. The mine operator shall obtain approval from an Authorized Representative for all actions to recover persons, equipment, and/or return the affected areas of the mine to normal.This order was terminated on November 2, 1999. Conditions which contributed to the accident have been eliminated. The company has purchased single piece rims, and has discontinued use of the split rim wheel assembly for the Mack slinger truck, company number 45, VIN 1M2P198C6JW003333. Normal mining operations can resume.
Related Fatal Alert Bulletin:
Persons Participating in the Investigation
Elam Sand & Gravel, Corp.
David S. Spallina, presidentMine Safety and Health Administration
Dennis A. Yesko, supervisory mine safety and health inspectorAPPENDIX B
Mark A. Barlow, mine safety and health inspector
F. Terry Marshall, mechanical engineer
Elam Sand & Gravel, Corp.
David S. Spallina, presidentIndependent Material Haulers
Joseph P. Ray, mechanic
Franic D. Alloco, president
Victor V. Alloco, dispatcher