DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
Metal and Nonmetal Mine Safety and Health
Report of Investigation
Surface Nonmetal Mine
Fatal Machinery Accident
May 9, 2000
Crystal Tips No. 1
Jon L. Johnson DBA Hallelujah
Reno, Washoe County, Nevada
ID No. 26-02417
Supervisory Mine Safety and Health Inspector
Richard M. Wilson
Mine Safety and Health Inspector
Stanley J. Michalek
Mine Safety and Health Administration
Rocky Mountain District
P.O. Box 25367 DFC
Denver, CO 80225-0367
Jake H. DeHerrera, Acting District Manager
John D. Lucchesi, Sr., dozer operator, age 51, was fatally injured on May 9, 2000, when the dozer he was operating went over the edge of a steep slope.
The accident occurred because the dozer had pushed material to far beyond the slope edge causing it to loose traction, slide and go out of control.
Lucchesi had a total of 30 years mining experience as a dozer operator. He had worked three weeks at this mine. He had not received training in accordance with 30 CFR Part 48.
The Crystal Tips No. 1 pit, a surface amethyst mine, owned and operated by Jon L. Johnson, DBA Hallelujah Mines, was located about 36 miles northwest of Reno, Washoe County, Nevada. The principal operating official was Jon L. Johnson, owner. The mine was operated intermittently a total of about one month a year. There was no particular work schedule. Total employment was two persons.
Amethyst was extracted from a single bench in the pit. After the overburden was removed, the mineral was extracted with a backhoe and track loader, then hand-sorted. There were no plant or milling facilities. The product was taken to rock shows for sale or trade.
The Mine Safety and Health Administration had not been notified of the mine's existence until the accident was reported. A regular inspection was conducted at the conclusion of the investigation.
DESCRIPTION OF THE ACCIDENT
On the day of the accident, John Lucchesi, Sr., (victim) reported for work at 8:00 a.m.. Lucchesi operated the dozer and began removing large rocks above the pit. This was the second week that Lucchesi had performed this task.
Paul Bringman, a friend of the victim, was at the site to be trained by Lucchesi on operating the new dozer, which had recently been rented.
At 10:30 a.m., Edward Christensen, part owner of the mine equipment, was stationed on the road at the bottom of the slope to prevent access. Lucchesi began to push the large rocks off the outer edge.
At about 11:00 a.m., Bringman was standing near the top of the ridge watching Lucchesi operate the dozer. He did not have a clear view because the dozer was down slope a bit. He could see Lucchesi attempting to back the dozer up the steep slope, however, the left track was spinning without traction, because a rock was positioned underneath it. The dozer appeared to slide sideways. Bringman then moved farther up the slope for a better view. He could hear the engine working hard as if under a load. When he next saw the dozer it had begun to roll down the slope. He immediately traveled to a nearby mine where he summoned help.
Christensen was also watching the dozer push material off the top and saw it roll down the slope. He immediately dialed the local emergency assistance number on his cell phone and then drove to the pit. The victim, who had been ejected, was found on the slope about 440 feet from where the dozer came to rest. He was checked for vital signs, however none were found. Emergency personnel arrived a short time later and Lucchesi was pronounced dead at the scene by a county deputy sheriff/coroner. Death was attributed to head trauma.
INVESTIGATION OF THE ACCIDENT
MSHA was notified at 1:00 p.m., on the day of the accident by a telephone call from Gordon Taylor, State of California (OSHA), to Donald S. Horn, mine safety and health inspector. An investigation was started the same day. MSHA's investigation team traveled to the mine and 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 the equipment he was using. An order was issued pursuant to Section 103(k) of the Mine Act to ensure the safety of miners. The miners did not request, nor have, representation during the investigation.
The equipment involved in the accident was a John Deere, track-type, Model 850C dozer equipped with a dozer blade and ripper attachment. It was powered by a 6-cylinder, 8.1 liter, John Deere Model 6081 engine. The operating weight of the dozer was approximately 45,000 pounds. It was equipped with a Rollover Protective Structure (ROPS) and a seatbelt. The ROPS sustained some damage as a result of the dozer rolling over numerous times on its path down the hillside, but was intact.
The right side seatbelt strap was found partially unwound out of the retractor. When the right side seatbelt strap was pulled manually, it did not readily unwind out of the retractor far enough to allow it to reach the buckle, even without a person in the operator's seat. The buckle was located on the left side of the seat. When the right side seatbelt strap was released, it did not readily retract into the retractor. The seatbelt was subsequently removed to allow closer examination, and it was noted that the retractor mechanism had sustained some bending damage at some point in time. The U-shaped metal frame that supported the seatbelt spool was found to be bent. The open end of the U was bent inward such that the seatbelt spool rubbed against the side of the frame that the rewind spring was mounted to. This impeded the spool rotation and kept it from readily spooling-in the seatbelt strap. The pawl and ratchet locking action of the seatbelt retractor prevented further extension of the seatbelt strap out of the retractor once it was locked. There did not appear to be any damage to the buckle or latch plate and the seatbelt would buckle when the two pieces were engaged.
While the retractor was off the machine it was found that if the right side seatbelt strap was quickly pulled and released several times, it would spool into the retractor. After feeding the strap back into the retractor this way, the seatbelt strap could then be pulled out to its full length. The locking action of the seatbelt from the dozer was compared to the locking action of a new retractor of the same type. Both would lock into position when the seatbelt strap was pulled out and allowed to retract slightly.
It was concluded that the seatbelt strap did not readily extend or retract when examined at the accident site because the retractor frame was bent. The spool to frame interference prevented the spool from readily retracting, and the locking action of the pawl and ratchet assembly prevented the seatbelt strap from extending out any farther. It could not be determined if the damage occurred prior to or as a result of the accident.
The engine speed lever, which adjusts the engine rpm, was found in the 1/8 speed position. This lever was designed to increase the engine rpm when it was pulled back toward the operator and to decrease the engine rpm when it was pushed forward.
Both the decelerator pedal and service brake pedal were found in the fully released position. The decelerator pedal was designed to override the engine speed lever and reduce engine speed. The pedals moved freely and no obstructions were found that interfered with pedal movement.
The FNR (forward-neutral-reverse) lever controlled the direction of travel and steering functions. The FNR lever was hand-operated and was located on the left side of the operator. The forward, neutral, and reverse positions were selected by pushing the lever forward, centering it, or pulling it back. All three positions were detented. The lever was found in the "F" (forward) position. The machine was steered by moving the FNR lever side to side. Regarding side to side movement, this control was found in the center position. The steering control would return to the neutral position (side to side) when released, as it was designed to do.
The transmission speed lever, located on the left side of the operator, was designed to adjust the travel speed. There were three detented positions. Number "3" was high transmission speed and number "1" was low transmission speed. This control was found in the number "1" position.
The two red parking brake handles that extended up from each side of the control panel were found pulled back into the "down" (brake- released) position. The two handles were mechanically linked together with a cross shaft.
The dozer was equipped with a dual path hydrostatic drive system. Each track was individually controlled and powered by a variable displacement pump and motor combination. The system was designed to permit the two hydrostatic drives to be driven in opposite directions to permit spot turns. Hydrostatic retarding was designed to slow the machine when the forward-neutral-reverse lever was moved to neutral.
The service/parking brake consisted of a spring-applied, hydraulically-released, wet, multiple disc system. The brake was designed to apply if the service brake pedal was pushed or if the parking brake handles were pushed forward to the "up" position. The service-parking brake was also designed to automatically apply when the engine stopped.
The dozer was extensively damaged as a result of the accident. The blade and right side track and track frame undercarriage assembly were torn from the machine. The operator's compartment door separated from the machine and the glass in the operator's compartment was broken.
The condition and locations of the machine did not permit operational testing, however, the examination conducted did not reveal any braking, steering, or travel control defects.
The victim lost control of the dozer when he traveled too far down the steep slope, lost traction and traveled sideways. The root cause of the accident was management's failure to establish mining methods that provided for the safe removal of overburden. Management's failure to establish procedures requiring the maintenance and use of seatbelts contributed to the severity of the accident.
Order No. 7967268 was issued on May 11, 2000, under the provisions of Section 103(k) of the Mine Act:
A fatal accident occurred at this operation on May 9, 2000, when a dozer operator was clearing large boulders from the west wall. The dozer went over the wall causing fatal injuries. This order is issued to assure the safety of persons at this operation until the mine can be returned to normal operations as determined by an authorized representative of the Secretary. The operator shall obtain approval from an authorized representative for all actions to recover the dozer and/or return affected areas of the mine to normal operation.This order was terminated on June 26, 2000. The conditions that contributed to the accident no longer exist.
Citation No. 7975452 was issued on June 27, 2000, under the provisions of Section 104(a) of the Mine Act for violation of 30 CFR 56.1000:
The mine operator failed to notify MSHA before operations began. This mine has been working since 1986.This citation was terminated on June 27, 2000. The mine operator committed to future compliance.
Citation No. 7975453 was issued on June 27, 2000, under the provisions of Section 104(a) of the Mine Act for violation of 30 CFR 48.23(a):
The mine operator of the company has not submitted a training plan for this site to the nearest Metal and Nonmetal, MSHA District Office.Citation No. 7975454 was issued on June 27, 2000, under the provisions of Section 104(a) of the Mine Act for violation of 30 CFR 48.26(a):
John D. Lucchesi, Sr., had not received experienced miner training prior to assuming work duties at this mine.This citation was terminated on June 27, 2000. John D. Lucchesi, Sr., is deceased.
Citation No. 7975459 was issued on June 27, 2000, under the provisions of Section 104(a) of the Mine Act for violation of 30 CFR 56.14130(g):
A fatal accident occurred at this operation on May 9, 2000, when a bulldozer overturned on a steep grade. The operator was not wearing a seatbelt.This citation was terminated on June 27, 2000. The mine operator has instituted a policy to use seatbelts.
Citation No. 7975465 was issued on July 26, 2000, under the provisions of Section 104(a) of the Mine Act for violation of 30 CFR 56.9101:
A fatal accident occurred at this operation on May 9, 2000, when the equipment operator was ejected from the bulldozer when it overturned. The bulldozer was operating on a steep grade when the operator lost control and the bulldozer overturned and rolled down the hill. The operator did not maintain control of the bulldozer.This citation was terminated on July 26, 2000. The mine operator has committed to compliance by instructing equipment operators of the hazards associated with working on steep grades or slopes.
Related Fatal Alert Bulletin:
A. Persons Participating in the Investigation
B. Persons Interviewed
C. Accident Investigation Data (Form 7000-50a)
D. Accident Investigation Data - Victim Information (Form 7000-50b)
Crystal Tips No. 1 Mine
Jon L. Johnson, ownerAttorney for Victim's Widow
Fred Ithurburn, LLCState of California, Division of Occupational Safety and Health, Mining and Tunneling
Gerald R. Fulghum, senior engineerMine Safety and Health Administration
Tyrone Goodspeed, supervisory mine safety and health inspector
Richard M. Wilson, mine safety and health inspector
Donald S. Horn, mine safety and health inspector
Ronald Medina, mechanical engineer
Stanley J. Michalek, civil engineer
Crystal Tips No. 1
Jon L. Johnson, ownerCrystal Tips No. 2
Edward Christensen, investor for property owner
Foster Hallman, claim holderVisitor
Paul D. BringmanVictim's Spouse
Hazel K. LucchesiShasta County Sheriff's Department
Sgt. Richard L. PoorLassen County Sheriff's Department
Deputy Kenneth R. Owens