MINE SAFETY AND HEALTH ADMINISTRATION
Report of Investigation
Underground Metal Mine
Fatal Powered Haulage Accident
March 13, 2000
Stillwater Mining Company (Mine)
Stillwater Mining Company
Nye, Stillwater County, Montana
ID No. 24-01490
Ronald D. Pennington
Supervisory Mine Safety and Health Inspector
Darrell L. Boyer
Mine Safety and Health Inspector
Eugene D. Hennen
Mine Safety and Health Administration
Rocky Mountain District
P.O. Box 25367, DFC
Denver, CO 80225-0367
Claude N. Narramore, District Manager
Gary L. Everhard, brakeman, age 48, was fatally injured at 6:30 p.m., on March 13, 2000, when he was run over by the leading ore car of a train that was being pushed onto a side track for loading. The accident occurred because management had not established procedures that required the locomotive operator to be in communication or visual contact with the brakeman when pushing rail cars.
Everhard had a total of 30 years mining experience, 7 years as a brakeman at this mine. He had received training in accordance with 30 CFR Part 48.
The Stillwater Mining Company mine, an underground platinum operation, owned and operated by Stillwater Mining Company, was located at Nye, Stillwater County, Montana. The principal operating official was Vernon Baker, vice president of operations. The mine was normally operated three, 8-hour shifts a day, 7 days a week. Total employment was 741 persons.
Ore was extracted using the ramp and fill mining method. Sub-level stoping was also done along with mechanized captive cut- and-fill stoping. Mine access drifts were driven at different elevations. Approximately 60 percent of the ore was transported to the mill via a 1,950-foot vertical shaft. Ore was also transported to the mill by trucks and a rail system which extended about 3 miles. The smelter and base metals refinery were located at a company-owned facility in Columbus, Montana.
The last regular inspection of this operation was completed on December 15, 1999. An inspection was ongoing at the time of the accident.
DESCRIPTION OF THE ACCIDENT
On the day of the accident, Gary Everhard (victim) reported for work at 6:00 p.m., his normal starting time. Timothy Hannifin, mine foreman, instructed Everhard and Robert J. Aafedt, operator II, to move ore cars from outside the mine to the 5000 west level and pull ore from the 7800 chute.
Aafedt was the locomotive operator and Everhard was the brakeman. The two men rode inside the cab of the locomotive and pushed eight empty ore cars into the mine. They arrived at the 7800 crosscut at about 6:18 p.m.. Everhard was dropped off at the switch and Aafedt moved the train until the cars cleared the switch. Everhard then threw the switch for the 7800 track and signaled with his cap lamp for Aafedt to push the train into the crosscut.
After receiving the signal, Aafedt began pushing the cars. When the locomotive reached the track switch, Everhard was not standing where he normally waited. Aafedt continued to push the cars until the locomotive cleared the main haulage track. He then stopped the train, walked to the switch and aligned it for the main line. He called the dispatcher on his radio to report that he was off the main line and was sitting on the 7800 track.
After calling in his location, Aafedt continued to push the cars into the crosscut. The train traveled a few feet and he felt resistance. He walked alongside the train to the end of the trip, where he found the lead car off track and the victim pinned underneath.
Aafedt immediately went to the main track switch and called for help on the pager telephone emergency line. The call notified the emergency response team and the team, along with others, responded. The county coroner arrived a short time later and Everhard was pronounced dead at the scene. Death was attributed to multiple blunt force trauma injuries.
INVESTIGATION OF THE ACCIDENTMSHA was notified at 8:20 p.m. on the day of the accident by a telephone call from Alan Stuart, safety director for the mining company, to Jake DeHerrera, assistant district manager. An investigation was started the next day. MSHA's accident investigation team traveled to the mine, made a physical inspection of the accident site, interviewed a number of persons, and reviewed documents relative to the job being performed by the victim and his training records. An order was issued pursuant to section 103(k) of the Mine Act to ensure the safety of miners. A miners' representative was present during the investigation.
The accident occurred on the 50W7800 crosscut rail haulage. This haulage was 314 feet long as measured from the point of the switch to the center of the ore chute. The mine tunnel for this track haulage varied from 10 feet to 12 feet wide. The tunnel height ranged between 9 and 10 feet. The condition of the haulage was poor. The roadbed, rails and ties were completely covered by mud and water and the walkways along the track were in the same condition.
The length of the train parked in the 50W7800 crosscut was 112 feet. It consisted of a Brookville, 20-ton, diesel locomotive and eight Telluride ore cars. The last ore car was off track and separated from the other seven cars of the train.
The equipment involved in the accident was a 1988, Brookville locomotive, Model BDC-20-UP powered by a Deutz F8L413FW, 185 hp, V-8 diesel engine. The wheel diameter was 28 inches and the track gauge for the steel rails was 36 inches. The locomotive measured 17 feet long, 66 inches high, 58 inches wide and weighed 40,000 pounds. The locomotive's braking systems had four cast-iron brake shoes which contacted each of the four wheels. These shoes were used in both service and park brake systems. The service brakes were air-applied and the park brake was spring-applied and air-released. The compartment of the locomotive had seats for two people.
The Telluride ore cars were manufactured by Mine Fabrication and Machine Company. The capacity of each car was 180 cubic feet. Each car carried 6-1/2 to 7 tons of ore. The weight of an empty car was approximately 7,400 pounds. Each car had two solid axles with two wheels on each axle. Each axle rode on two rubber bushings, one on each side of the car. The length of each car was 10 feet 4 inches. The height of each ore car from the rail to the top of the car was 59-1/2 inches. The coupler disconnects on six of the eight cars were defective, but did not contribute to the accident. The ore car that derailed in the accident was examined to determine if any defects caused it to derail. No defects were found that contributed to the derailment. The railroad tracks near the area of the derailment were also examined for defects. No defects were found that contributed to the derailment.
The number 1724 ore car which derailed in the accident was placed back onto the track and connected to the other cars that were being pushed at the time of the accident. The subject ore car was pushed into the area of the derailment four times and it stayed on the tracks each time. The area of derailment was extremely wet and muddy with some areas of the tracks covered with mud. The mud was sufficiently soft that it allowed the ore car wheels to push through it without resulting in derailment. The number 1724 ore car was taken outside of the mine and turned over. The undercarriage was thoroughly inspected for defects and none were found. It is believed the victim's body caused the ore car to derail.
Three stopping distance tests were conducted with the same cars that were attached to the locomotive at the time of the accident. The operator was instructed to travel the speed the locomotive typically traveled when the cars were being switched from the main haulage track to a chute area and apply the service brake. The average stopping distance for the three stops was approximately 14 feet.
The locomotive and one ore car were transported to the 50W7800 crosscut haulage. A series of measurements were taken to determine if there was sufficient continuous clearance between the farthest projection of moving railroad equipment and the ribs of the haulage tunnel. These measurements showed that the haulage had sufficient clearance.
The use of a single locomotive for movement of trains into this mine was a concern for the accident investigation team. When trains were moved into the mine, the locomotive was placed at the rear of the train and the cars were pushed into the mine. While traveling around curved track, the operator would lose sight of the leading car and was temporarily blind to any hazard that may be in front of him. This situation arose at the time of the accident and was considered to be a contributing factor to the accident. While the empty cars were pushed into the 50W7800 crosscut, the leading car was out of sight of the operator.
The failure of the locomotive operator to immediately stop the train when he realized that his brakeman was not waiting at the switch was also considered a cause of the accident. As the locomotive approached to within 30 feet of the switch, the operator could see into the general location of where the brakeman should have been. He failed to stop there, continued to move through the switch, and traveled another 30 feet before clearing the haulage. The operator moved the train approximately 60 feet without knowing the location of his brakeman. In addition, the operator left the locomotive, walked to the switch and aligned it for the main track. He called the dispatcher to give the location of the train and then pushed the train toward the chute without any additional communication with the brakeman. There was no evidence to indicate that mechanical problems or equipment defects contributed to this accident.
The root cause of the accident was management's failure to implement work procedures that required the locomotive operator to be in communication or visual contact with the brakeman while pushing rail cars.
Failure of the locomotive operator to immediately stop the train when he realized that the brakeman was not at his assigned area was a contributing factor.
Considering the actions taken by the motorman prior to the accident and the wet, muddy conditions of the haulage drift, it was the consensus opinion of the investigators that the brakeman was riding on the lead car.
Order No. 7904809 was issued on March 13, 2000, under the provisions of Section 103 (k) of the Mine Act:
A fatal accident occurred at this operation on March 13, 2000, when a brakeman was run over by a rail car. This order is issued to assure 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 affected areas of the mine to normal operations.
This order was terminated on March 15, 2000. Conditions that contributed to the accident have been corrected and normal mining operations can resume.
Citation No. 7919005 was issued on March 16, 2000, under the provisions of Section 104 (a) of the Mine Act for violation of 30 CFR 57.14219:
A fatal rail haulage accident occurred at 6:30 p.m., on March 13, 2000, when a train operator was run over by the leading rail car of a train that was being pushed into the 7800 chute area for loading. The victim's job was to throw the switch leading into the chute area, then wait for the train to clear and then throw the switch back to its normal position. When the locomotive cleared the switch, the operator noticed that the victim was not at the switch where he should have been. The locomotive operator left the train, threw the switch for the straight, then continued to push the train into the chute area without knowing the location of his brakeman and without any signal to do so.
This citation was terminated on April 7, 2000. The mine operator has changed procedures for the movement of trains. Each train has two locomotives and the crew will know where each member is located at all times. Reinforced safety awareness training was given to all rail haulage employees.
Approved by, Date: June 28, 2000
Claude N. Narramore,
A. Persons Participating in the Investigation
B. Persons Interviewed
Related Fatal Alert Bulletin:
Persons Participating in the Investigation
Persons Participating in the Investigation
Stillwater Mining Company
Vernon Baker, vice president of operationsPaper Allied Industrial, Chemical & Energy Workers International Union (PACE) Local 8-0001
Larry J. Jaudon, superintendent
Alan Stuart, safety director
James P. Daley, superintendent of rail haulage & supply delivery
Donald Beer, union presidentMine Safety and Health Administration
Richard Campbell, incoming union president
Jackson and Kelly PLLC
Katherine Shand Larkin, attorney
Ronald D. Pennington, supervisory mine safety and health inspector
Darrell L. Boyer, mine safety and health inspector
Eugene D. Hennen, mechanical engineer
Stillwater Mining Company
Alan Stuart, safety directorMedCor, Independent Contractor
Thomas Fuell, safety coordinator
Terry LeMasters, mechanic II
James P. Daley, mine superintendent for haulage & supply delivery
David E. Heidle, mill maintenance
Michael Pugh, underground supervisor
Robert J. Aafedt, operator II
Brian Spuhler, Medcor supervisor, EMT, flight nurseStillwater County Office of Sheriff/Coroner
Terry R. Nystul, deputy coroner