MSHA - Metal and Nonmetal Mine Fatal Accident Investigation Report: 01/26/1999 - Fatality #55 - Powered Haulage - Sand & Gravel - TX - Trinity Minerals, Inc.

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UNITED STATES
DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
Metal and Nonmetal Mine Safety and Health

REPORT OF INVESTIGATION

Surface Nonmetal Mine
(Sand and Gravel)

Fatal Powered Haulage Accident
September 29, 1999

Cleburne S&G Plant #282 A & B
Trinity Materials, Inc.
Cleburne, Johnson County, Texas
ID No. 41-01164

Accident Investigators

Arthur L. Ellis
Supervisory Mine Safety and Health Inspector

Mark J. Albrecht
Mine Safety and Health Inspector

Originating Office
Mine Safety and Health Administration
South Central District
1100 Commerce Street, Room 4C50
Dallas, TX 75242-0499
Doyle D. Fink, District Manager

OVERVIEW

On January 26, 1999, Johnny H. Fisher, Jr., haul truck driver, age 41, reported having pain in his neck from operating a Euclid B-30 haul truck. Six years earlier, he had undergone a surgical procedure in which several of his neck vertebrae were fused together. He was examined and treated by several doctors from January 27, 1999, until September 22, 1999, when he underwent further neck surgery. On October 1, 1999, Fisher died of obstructed blood supply to the brain.

The cause of the accident was the inability to determine the extent of the pre-existing neck problems. The aggravation of the pre-existing condition while operating a haul truck was a contributing factor.

Fisher had eight years mining experience, with three weeks as a haul truck driver. He had not completed training in accordance with 30 CFR, Part 48.

GENERAL INFORMATION
Cleburne S&G Plant #282 A & B, an open-pit sand and gravel operation, owned and operated by Trinity Materials, Inc., was located about ten miles southwest of Cleburne, Johnson County, Texas. The principal operating official was Ronnie Goodman, plant manager. The mine normally operated two, 10-hour shifts per day, five days per week. Total employment was 22 persons.

Raw material was extracted from two pits, one on each side of the Brazos river. A dragline or excavator was used to extract and load the raw material onto trucks. The material was transported to the plant where it was either dumped into the feed hopper for processing or stockpiled. Finished products were sold primarily for use in concrete production and road construction.

The last regular inspection of the operation was completed on January 4, 1999. A regular inspection was conducted following this investigation.

DESCRIPTION OF THE ACCIDENT
On January 26, 1999, Johnny H. Fisher, Jr. (victim) arrived at the mine site at 7:00 a.m., his normal starting time. He proceeded to operate the Euclid B-30 haul truck, hauling sand and gravel from the pit to the plant. Fisher had been given a temporary assignment to operate the Euclid B-30 haul truck in addition to his normal duties as a quality control/ quality assurance (QC/QA) technician. He had operated the haul truck no more than three shifts for a total of 16 hours. The longest shift he had operated the truck was six hours. The truck was operated on a relatively level gravel road for a round-trip distance of about two miles. Shortly after starting the shift, Fisher complained to the plant manager, Ronnie Goodman, that he had a "stiff neck" from the jerking of the haul truck and having to turn his head while operating the vehicle. Goodman instructed Fisher to go home for the remainder of the day and report to the company physician the following day.

Fisher was treated by the company physician on January 27, 1999 and immediately returned to work on restricted work duty as a QC/AC technician. Over the next several months, he continued to experience neck pain and was seen by another physician, who performed surgery on his neck on September 22, 1999. Complications following the operation led to liver and kidney failure, and obstructed blood supply to the brain. He never left the medical center following surgery, and died on October 1, 1999.

INVESTIGATION OF THE ACCIDENT
MSHA was notified of the victim's death at 11:30 a.m. on October 1, 1999, by a telephone call from Arturo Munoz, safety manager, to Charles H. Sisk, acting assistant district manager. An investigation was started on October 6, 1999. MSHA's accident investigation team traveled to the mine and made a physical inspection of the haul road and equipment involved in the accident, interviewed a number of employees, and reviewed documents relative to the job being performed by the victim, including his training records.

DISCUSSION

• The equipment involved in the accident was a Euclid B-30 haul truck, model B30ITDT, serial no. 86017-66997, manufactured in 1975. The haul truck seat at the time the victim was operating the truck was an air cushion-type. It was replaced on September 10, 1999 with a shock-absorbing, spring-type seat.

• The known medical history of the victim's neck problems began on September 23, 1991, when Fisher reported having a sore left elbow while performing the duties of quality control manager at the Brazos Point, Inc. mine, ID No. 41-03255, operated by Brazos Point, Inc. Fisher was seen by a doctor and diagnosed with tennis elbow. He saw several different doctors during the next six months and none could determine what was causing the pain in his left arm and elbow. Fisher was then sent to a neurologist, who determined that calcium was forming around three ruptured discs in Fisher's neck, which was causing pressure on the nerves to the left arm.

• In January 1993, Dr. William R. Bernell, M.D., performed spinal neck surgery on Fisher. On March 15, 1993, Bernell gave Fisher a release to return to full duty and Fisher returned to work as quality control manager.

• Trinity Materials, Inc. purchased Brazos Point, Inc., in December, 1994. Fisher was hired by the Cleburne S&G #282 A & B mine on October 30, 1995, with the job title of machine operator/material handler.

• On January 26, 1999, Fisher reported neck soreness after operating the Euclid B-30 haul truck. On January 27, 1999, he was seen by the company physician, J. Stan Johnson, M.D., and diagnosed with an acute strain and cervical spine degenerative joint disease. Johnson's examination also revealed Fisher's pre-existing spinal surgery, which was previously unknown to site management. Johnson released Fisher to return to work on January 28, 1999, with the following restrictions:

• Fisher returned to work on January 28, 1999, and performed the duties of QC/QA technician. He did not operate the Euclid B-30 haul truck upon his return to work.

• On February 3, 1999, Fisher returned to Johnson for evaluation. Johnson instructed him to continue to work within restricted duty guidelines indefinitely.

• On March 26, 1999, Fisher consulted John B. Payne, D.O., at the Neurosurgical Clinic, 6100 Harris Parkway, Suite No. 130, Fort Worth, Texas. Fisher's complaint was neck and arm pain. Payne ordered a cervical MRI [magnetic resonance imaging]. After reviewing the MRI results, Payne's recommendations were that Fisher receive a series of injections, neck traction at home, continue on anti-inflammatories, and limit the amount of lifting. He also oredered mild physical therapy and a soft neck collar at night. Subsequently, Payne recommended Fisher undergo further spinal surgery.

• On September 22, 1999, Dr. Payne performed the scheduled surgery on Fisher. From September 25 until October 1, 1999, Fisher was in the intensive care unit of the Osteopathic Medical Center for liver and kidney failure. On October 1, 1999, he was pronounced dead. Death was attributed to brain swelling and hemorrhaging.
CONCLUSION
The root cause of the accident was the inability to determine the extent of the pre-existing neck problems. The aggravation of the pre-existing condition while operating a haul truck was a contributing factor.

Related Fatal Alert Bulletin:

FAB99M54

APPENDIX A

Persons Participating in the Investigation

Trinity Materials Inc.

Mine Safety and Health Administration

APPENDIX B

Persons Interviewed

Trinity Materials Inc.


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