MINE SAFETY AND HEALTH ADMINISTRATION
COAL MINE SAFETY AND HEALTH
REPORT OF INVESTIGATION
Surface Preparation Plant
Fatal Powered Haulage Accident
March 21, 2000
Big Ridge Mine Preparation Plant
Big Ridge, Inc.
Harrisburg, Saline County, Illinois
I. D. No. 11-02879
Steven M. Miller
Coal Mine Safety and Health Inspector
Charles J. Conaughty
Coal Mine Safety and Health Inspector
Gary O. McDaniel
Coal Mine Safety and Health Inspector
Approval & Certification Center - Technical Support
Originating Office - Mine Safety and Health Administration
2300 Old Decker Road, Vincennes, Indiana 47591
James K. Oakes, District Manager
On March 21, 2000, at approximately 1:25 p.m., James R. Elkins, Mechanic, was fatally injured while he was operating a forklift truck on the Scale House Road. Elkins had left the mechanic shop traveling east, and then turned north onto Scale House Road to pick up an electric motor and gear box located at the warehouse. The forklift truck was traveling along the west side of the roadway when the left wheels dropped off the edge of the roadway causing Elkins to lose control and allowing the forklift truck to overturn. Elkins was pinned between the front left post of the falling object protective structure and the roadway.
The accident occurred as a result of the left side of the forklift truck dropping approximately nine inches off of the paved roadway onto the gravel shoulder. The forklift truck became unstable, and when steering corrections were made, the forklift truck overturned.
Elkins had a total of thirty-two years mining experience, with the last nine years and nine months at this mine. He was classified as a mechanic and operated this forklift truck on a regular basis. He had received training in accordance with 30 CFR Part 48.
The Big Ridge, Inc., Big Ridge Mine Preparation Plant, is located three miles east of Harrisburg on Route 13 in Saline County, Illinois. The mine, Big Ridge #1, which this plant accommodated originally, ceased production in May of 1998. Recovery operations began immediately and were completed in early August 1998. On August 14, 1998, the mine's operating status was changed from an underground mine to a surface operation. Final sealing of all the openings to Big Ridge #1 was completed on November 21,1998.
The Big Ridge Mine Preparation Plant is now utilized to clean coal from the Big Ridge Mine Portal No. 2 (I.D. No. 11-02997) located two miles north of the plant. Six to ten coal trucks are used on two shifts a day (6:00 a.m.-2:00 p.m. & 3:00 p.m.-11:00 p.m.), seven days a week to transport approximately 10,000 tons of raw coal a day to the preparation plant. From 2:00 p.m.-3:00 p.m. the front-end loaders are fueled and serviced. Thirty-five to seventy-five coal trucks are used one shift a day (5:00 a.m. - 5:00 p.m.), five days a week to transport clean coal to their barge load-out facility on the Ohio River in Shawneetown, Illinois. Thirty to fifty thousand tons of clean coal are hauled to this facility a week. The preparation plant washes coal three shifts a day, seven days a week. The only time the plant is not operating is for scheduled maintenance, holidays, and breakdowns.
The principal officers for Big Ridge Mine Preparation Plant at the time of the accident were:
President............................................. ..........................George Joe PiersonAn MSHA Safety and Health Inspection (AAA) began on March 21, 2000, and was ongoing at the time of the accident. The previous Safety and Health Inspection (AAA) began on September 20, 1999, and was completed on September 22,1999.
Vice President................................................................Calvin Dale Quertermous
Preparation Plant Superintendent..................................Anthony Glen Chrisman
Safety Director................................................................Anthony Glen Chrisman
The Non-Fatal Days Lost (NFDL) incident rate for January 1, through December 31, 1999, was 3.20 for coal preparation plants nationwide and 2.33 for Big Ridge Mine Preparation Plant.
DESCRIPTION OF ACCIDENT
Tuesday, March 21, 2000, was James Elkins', victim, first day back from a five-day vacation. His shift began at approximately 7:00 a.m. and was to end at 5:00 p.m. There were 39 people on site at the preparation plant area performing scheduled maintenance. Nine of these people were contract employees with Lane Erectors (M7S) from Harrisburg, Illinois. The plant was shut down on Monday, March 20, 2000, at 11:00 p.m. and was to start back up on Wednesday, March 22, 2000, at 11:00 p.m., when all the scheduled maintenance was completed.
James Elkins, Mechanic, and Rex Parks, Mechanic, were assigned the task of belt maintenance. At the start of the shift, they traveled to the belt tail-roller area of the Overland Gob belt and removed the belt tail-roller. The roller was sent to Star Welding in Shawneetown, Illinois to have the shaft replaced. They also inspected the belt drive, chain sprockets, belt rollers and guards in this area. They stopped for lunch from 11:30 a.m. to 12:00 noon in the shop area with other employees.
After lunch they traveled to the Overland Gob belt head roller area to check the head roller assembly and replace both sprockets and the drive chain. While making these repairs, they found that the gear box for the head roller also needed replaced. Elkins and Parks traveled back to the shop and informed Garry Clendenin, Shop Foreman, they were going to replace the motor and gear box on the Overland Gob belt head roller. Clendenin and Billy Reeder, Electrician, said they would begin disconnecting the motor so the motor and gear box could be removed and brought to the shop. It was decided that Parks would place the tools in his pickup and travel to the Overland Gob belt head roller area and assist Clendenin and Reeder in removing the motor and gear box that needed replaced. Elkins was to take the forklift truck to the warehouse and transport the new motor and gear box to the shop.
Elkins left the warehouse traveling east and stopped at the intersection of the Scale House Road to allow two loaded coal trucks to proceed in front of him to the scales. Both trucks were proceeding north, very slowly, on the Scale House Road. Elkins turned in behind the second truck and was approximately 40 feet behind this truck and driving along the west side of the roadway. The driver of the second truck, Tony Morris, stated that he heard a loud clang, and looked out the window to see Elkins' forklift truck off the west side of the roadway. Morris stated that the forklift truck was turned sideways along the west edge of the paved roadway, and that the rear wheels of the forklift truck were off the west side of the roadway. He indicated that it appeared Elkins was trying to regain control of the forklift truck as it was rocking back and forth before overturning. Morris called for help on his CB radio before exiting the truck and running back to assist Elkins. Morris found Elkins pinned between the front left post of the falling object protective structure (FOPS) and the roadway. Rescue efforts began immediately.
The first truck driver, Donnie Merritt, was standing outside his truck at the scale house when he also saw the forklift truck rocking back and forth before overturning. Merritt started running towards the accident site when Danny Moore, Heavy Equipment Operator, yelled for Merritt to go call an ambulance. Morris and Moore tried to lift the forklift truck off Elkins by hand, but could not lift it. When Reeder and Jon Robinson, Laborer, arrived on the scene, they also tried to lift the forklift truck by hand. The 560 Huff front-end loader, operated by Jeff Guard, was brought to the scene and Larry Angelly, Surface Foreman, placed a chain on the forklift truck to lift it off Elkins. Reeder checked Elkins for a pulse and found none. The seat belt was wrapped around Elkins' leg and had to be cut before he could be removed. Elkins was removed from under the front left post of the falling object protective structure and the forklift truck was lowered back in the same location. Reeder again checked Elkins for any vital signs and found none.
Saline County Ambulance arrived on the scene at 1:41 p.m. Paramedics Doris Holsinger and Jerry Whiteapple placed Elkins on a backboard and connected him to a heart monitor. No vital signs were detected. Saline County Coroner Kenneth Sloan arrived on the scene and pronounced Elkins dead at 2:00 p.m. Elkins was taken to the Harrisburg Medical Center. The coroner stated that the cause of death was trauma to the head and neck.
INVESTIGATION OF THE ACCIDENT
The Mine Safety and Health Administration (MSHA) Sparta, Illinois Field Office, District 8, was notified by Roger G. Jewell, MSHA Coal Mine Inspector, on Tuesday, March 21, 2000, at approximately 1:40 p.m. Central Standard Time (CST), that a fatal accident involving a forklift truck operator had occurred at the Big Ridge Preparation Plant at approximately 1:25 p.m. CST. Saline County Ambulance Paramedics had been notified and quickly responded. Inspector Jewell was onsite conducting the AAA inspection. After being informed of the accident, Jewell secured the accident site and issued a 103(k) Order to ensure the safety of the miners.
MSHA dispatched an accident investigation team from the Benton, Illinois Field Office which arrived at Big Ridge Preparation Plant at approximately 3:15 p.m. CST. Upon arriving at the mine, all parties were briefed concerning the circumstances surrounding the accident. MSHA and State of Illinois mine inspectors jointly began the investigation, assisted by mine management personnel. Interviews of individuals at the mine known to have actual knowledge of the facts surrounding the accident were conducted at the Big Ridge Preparation Plant office the afternoon of March 21, 2000. Ronald Medina, Mechanical Engineer from the MSHA Pittsburgh Safety and Health Technology Center, arrived March 22, 2000 and assisted in the investigation. James Wallace, Union Safety Representative, also participated in the investigation.
Elkins had operated this forklift truck on a regular basis for approximately nine years and had operated a similar forklift truck prior to being employed at this mine. At approximately 1:25 p.m., the forklift truck was traveling in a forward direction on the Scale House Road, which is an oil and chip surface. The surface was dry and level and the forklift truck was not carrying a load. The accident occurred along the west edge of the road where there was a nine-inch drop to the gravel shoulder. The crown of the road in the area where the accident occurred was three percent when measured from the centerline of the 26 1/2- foot wide roadway. The left side of the forklift truck dropped off the roadway, causing the forklift truck to become unstable. When steering corrections were made, the forklift truck overturned. Following the accident, the forklift truck was picked up with a crane (cherry picker), placed on a trailer, and taken to the shop for inspection. The inspection of the forklift truck revealed no defects that would have contributed to the accident.
1. The forklift truck is a 1989 Toyota forklift truck, Model Number 5FG30, Serial Number 5FG30-40279, powered by a Toyota Model 4Y, 4 cylinder, 2.2 liter, 54 horsepower, gasoline engine.
2. The rated weight (no load) of the forklift truck is 9,729 lbs. The weight distribution when empty is 3,970 lbs. on the front axle and 5,750 lbs. on the rear axle. The transmission has one gear forward and one gear reverse with a maximum rated speed of 12.1 mph in both forward and reverse.
3. The forklift truck is a two-wheel drive machine with power to the front axle only. The rear axle is the steering axle. The steering system is a power assisted system. The steering wheel is 15 inches in diameter and mechanically connected to the steering gear box by the steering shaft. A drag link connected from the steering box to the steering axle allowed steering action. A hydraulic control valve attached to the bottom of the steering gear box controlled the flow to the power assisting cylinder. The steering system was inspected and no defects were found that would have contributed to the accident.
> 4. The forklift truck is equipped with a service brake and a parking brake. The brake systems were inspected and no defects were found.
5. The forklift truck is equipped with a neutral start switch. The switch was functioning properly and prevented the engine from being started unless the transmission was in the neutral position.
6. The forklift truck light controls, horn, and back up alarm were all working properly. The forklift truck tilt forward/back and raise/lower controls operated normally and returned to the neutral position when released. No accelerator pedal linkage binding or other defects were found that would have contributed to the accident.
7. After the forklift truck was lifted up-right, the engine started easily and ran normally during testing of the machine. All fluid levels were checked and found in the normal operating ranges.
> 8. The operator's seat is mounted to a hinged engine access cowling. When the cowling latch is released, the cowling and operator's seat swing up and toward the back of the machine. The cowling was found halfway open when the rescuers arrived on the scene. The distance from the intersection of the back of the seat and the bottom of the seat to the overhead guard, where the victim's head was reportedly pinned, is approximately 48", regardless of whether the cowling is open or closed.
> 9. After the forklift truck was lifted up-right, the engine cowling would close and latch shut. The latch release mechanism was inspected and it operated as designed. The cowling latch could be released by two means; either by pulling the cowling latch control upward, which is located in the operator's compartment, or by pushing the release bar, which is located on the floor of the forklift truck. It could not be determined if the engine cowling unlatched due to the victim unintentionally bumping the release lever as the forklift truck overturned, or if the flexing of the engine cowling during the rollover allowed the latch to release. The left side of the cowling was damaged as a result of the rollover.
10. The forklift truck was equipped with falling object protective structure. (FOPS)
11. The forklift truck was equipped with a seat belt, however, it was not being worn when the accident occurred. The seat belt had been cut during the rescue because the seat belt was wrapped around the victim's knee. An examination of the male and female portions of the belt buckle revealed that they were only partially engaged, and pulled apart with approximately 20 pounds of force. An attempt to re-buckle the seat belt showed that the latching mechanism did not operate properly, and the seat belt could not be securely buckled. Neither the male nor female part of the seat belt buckle appeared to have been damaged during the accident.
12. The under clearance on this forklift truck is 4 inches at the mast, 5 inches at the front axle, 6 inches at the rear axle, 7 1/2 inches at the counterweight, and 8 1/4 inches at the center of the wheelbase.
13. Witness statements indicated that the forklift truck was traveling at half full speed, or approximately 6 mph, and was being operated on a paved roadway. The roadway was dry and level in the area of the accident. The roadway had been built up over the years with crushed stone, and later oil and chip.
14. There were three small depressions south of the accident site. The first depression measured 14 inches by 13 inches by 1 3/8 inches deep. The second depression measured 18 inches by 29 inches by 1 3/4 inches deep. The third depression measured 20 inches by 24 inches by 1 1/2 inches deep. There was a smooth transition in and out of these areas.
15. There was a 9-inch drop off from the edge of pavement to the gravel shoulder. The rock along the edge of the paved road had been displaced for a distance of 15 feet, indicating that the forklift truck had traveled off the roadway in this area before it overturned.
16. There were two loaded coal trucks on the east side of the Scale House Road. One truck was sitting on the scales at the scale house and the other truck was traveling very slowly towards the scale house when the accident occurred. Elkins had allowed both trucks to turn in front of him and was traveling along the west edge of the Scale House Road, preparing to pass one of the trucks as he proceeded toward the warehouse. The accident occurred approximately forty (40) feet from the rear of the second truck Elkins was preparing to pass.
17. The roadway measured 26 1/2 feet wide in the area of the accident. The coal trucks were over-the-road type trucks and measured eight feet in width. The forklift truck measured 44 inches in width. The roadway was wide enough for the vehicles to pass easily on the paved surface.
18. The forklift truck was not carrying a load and the forks were approximately 12 inches above the roadway. The tips of the forks were tilted upwards.
19. Elkins had received training in accordance with 30 CFR Part 48, and had operated a similar forklift truck prior to coming to this mine. The victim operated this forklift truck on a regular basis during his employment at the mine for approximately the past nine years.
For an unknown reason, the victim was traveling along the outer edge of the roadway. The accident and resultant fatality occurred when the rear wheels of the forklift truck left the paved roadway. The operator was unable to maintain full control of this piece of equipment because a 9-inch drop off was present at the edge of the paved roadway where the accident occurred. The forklift truck became unstable and overturned as the victim was attempting to bring the forklift truck back onto the paved roadway. The forklift truck overturned and pinned the victim's head between the front left post of the falling object protective structure (FOPS) and the pavement.
Physical evidence indicates that a functional seat belt was not provided, nor was the seat belt worn by the victim at the time of the accident. Considering that the forklift truck was provided with a falling object protective structure, it is likely that the victim would have not received such severe injuries if a functional seat beat had been provided and used at the time of the accident.
The following order was issued due to conditions revealed during the investigation.
103(k) Order No. 7572103 was issued on March 21, 2000, and terminated on March 27, 2000.
The mine has experienced a surface fatal haulage accident along the Scale House Road. This order is issued to assure the safety of any person in the affected area or operating other equipment of this type until an investigation is completed to determine that the area or other equipment of this type is safe. Only those persons selected from company officials, state officials, miner's representative, and other persons who are deemed by MSHA to have information relevant to the investigation may enter or remain in the affected area.104(a) Citation No. 7572127 was issued for violation of CFR 77.1607(b) on July 17, 2000, and terminated on July 17, 2000.
The operator of the Toyota forklift truck, Serial No. 5FG30-40279, involved in a fatal accident, was unable to maintain full control of this piece of equipment when it was in motion because a 9-inch drop off was present at the edge of the paved roadway in the vicinity of the accident site. The forklift truck's left wheels traveled off the west edge of the pavement, and while attempting to regain control of the forklift truck, it overturned, resulting in fatal injuries to the operator. The accident occurred on March 21, 2000, on the Scale House Road between the shop and the warehouse.Related Fatal Alert Bulletin and Accident & Injury Report(s):
FAB00C07 A & I Reports - (File is PDF)
List of persons participating in the investigation:
BIG RIDGE INC., BIG RIDGE PREPARATION PLANT - OFFICIALS
George J. Pierson ................... President - Operations
Calvin D. Quertermous ................... Vice President - Operations
William D. Winters ................... Superintendent - Big Ridge Mine
Bartley W. Schiff ................... Surveyor - Big Ridge Mine Portal No.2
Anthony G. Chrisman ................... Preparation Plant Superintendent Safety Director
Gordan P. Ingram ................... Engineer
Ronald Pickering ................... Engineer
Terry L. Lands ................... Engineer
ILLINOIS DEPARTMENT OF NATURAL RESOURCES
OFFICE OF MINES AND MINERALS
OFFICE OF MINES AND MINERALS
Kim Underwood ................... Director of Mines and Minerals
Art Rice ................... Administrative Assistant
Tom Patterson ................... Inspector Supervisor
> Gary Roberts ................... Mine Inspector
Mary Jo Bishop ................... Mine Inspector
Pat Campbell ................... Mine Inspector
Gary Janello ................... Lab Supervisor
Mary Bauer ................... Executive Secretary
MINE SAFETY AND HEALTH ADMINISTRATION
Steven R. Kattenbraker ................... Supervisory Coal Mine Safety and Health Inspector
Steven M. Miller ................... Coal Mine Safety and Health Inspector
Roger G. Jewell ................... Coal Mine Safety and Health Inspector
Gary O. McDaniel ................... Coal Mine Safety and Health Inspector
Charles J. Conaughty ................... Coal Mine Safety and Health Inspector
Leland Payne ................... Mine Safety and Health Specialist (Training) Team Leader
Ronald Medina ................... Mechanical Engineer Technical Support
Listed Below are Those Persons Who Were Interviewed or Provided Information That Was Pertinent to the Investigation:
BIG RIDGE, INC., BIG RIDGE PREPARATION PLANT - EMPLOYEES
Larry D. Angelly ................... Surface Foreman
Garry W. Clendenin ................... Shop Foreman
James N. Wallace ................... Laborer - Union Safety Representative
Jon W. Robinson ................... Laborer
Billie D. Reeder ................... Electrician
Danny L. Moore ................... Heavy Equipment Operator
Jeffery D. Guard ................... Heavy Equipment Operator
John M.Culley ................... Workmens Compensation
UNDERWRITERS SAFETY & CLAIMS - EMPLOYEES
Art E. McReaken ................... Manager - Claims Adjuster
Clint A. Becker ................... Claims Adjuster
MERRITT TRUCKING - EMPLOYEES
Donnie R. Merritt ................... Owner - Operator
RONALD LARRY STREET - RLS TRUCKING - EMPLOYEES
Tony J. Morris ................... Truck Driver
SALINE COUNTY OFFICIALS
Kenneth M. Sloan ................... County Coroner
SALINE COUNTY AMBULANCE SERVICE
Doris J. Holsinger ................... Paramedic
Jerry L. Applewhite ................... Paramedic