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 Other Accident
May 20, 2000
St. Paul Pit
Batenhorst Gravel Company
St. Paul, Howard County, Nebraska
ID No. 25-00773
Richard R. Laufenberg
Supervisory Mine Safety and Health Inspector
Ronald C. Simpson
Mine Safety and Health Inspector
D. Michael Campbell
Mine Safety and Health Administration
Rocky Mountain District
P.O. Box 25367 DFC
Denver, CO 80225-0367
Irvin T. Hooker, District Manager
On May 20, 2000, Norman N. Henn, dredge operator, age 48, drowned when he lost his balance and fell into the pond while he inspected the dredge cutter head for blockage. He was working from a work boat and was not wearing a life jacket or belt. Henn could not swim.
The accident occurred because management failed to ensure that safe work procedures were being followed by employees while they were working from the work boat. The work boat had not been secured properly where the work was being done at the cutter head of the dredge. The victim was not wearing a life jacket which contributed to the severity of the accident.
Henn had a total of 2-1/2 years mining experience, two years as a dredge operator with this employer. He had not received training in accordance with 30 CFR Part 48.
St. Paul Pit, a sand and gravel operation, owned and operated by Batenhorst Gravel Co., was located near St. Paul, Howard County, Nebraska. The principal operating official was Bernard Batenhorst, president. The mine was normally operated two, 12-hour shifts a day, six or seven days a week. Total employment was six persons.
Sand and gravel was extracted from the pit with a floating dredge. The material was pumped to the plant where it was sized and stockpiled. The finished product was sold primarily for use as road construction aggregate.
The last regular inspection of this operation was completed on November 19, 1998. Another inspection was conducted at the conclusion of this investigation.
On May 19, 2000, the day prior to the accident, Norman Henn (victim) reported for work at 7:00 p.m., and was to operate the dredge until 6:00 p.m., on May 20, 2000. He operated the dredge through the evening and next morning without unusual incident. At about 1:00 p.m., Henn contacted David Auten, front-end loader operator, on the radio, and told him the dredge cutter head was plugged. He instructed Auten to shut down the booster pump. Auten went to the pump, idled it back, and disengaged the clutch. He glanced toward the dredge and saw Henn positioning the work boat at the cutter head which had been raised out of the water. A few minutes later Auten heard Henn calling for help, and when he looked toward the dredge, he saw Henn hanging on to the cutter head with one arm and waving his other. Henn was not wearing a life jacket. The work boat from which he was working was not secured to keep it from moving.
Auten ran to the front-end loader and drove to the east side of the pond. When he got to the east bank he could not see Henn. The work boat had drifted against the east bank, a short distance from the dredge, so Auten got on the boat and began to search for Henn in the water. He then searched the dredge, but could not find Henn. Auten returned to the bank where his loader was parked and drove to the mine office to telephone for assistance.
Local emergency personnel responded within minutes and located the victim floating face down near the east bank of the pond. The victim was transported to a local hospital where he was pronounced dead. Death was attributed to drowning.
MSHA was notified at 9:30 p.m., on the day of the accident by a telephone call from Bernard Batenhorst to Jake DeHerrera, assistant district manager. An investigation was started the next day. MSHA's accident investigation team traveled to the mine and conducted a physical inspection of the accident site, interviewed a number of persons and reviewed information relating to the job being performed by the victim. 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 mining operation involved removing material from an approximate 55 acre pond, using a floating dredge. The material was pumped from the dredge to the screening plant through a 12-inch diameter steel pipe.
The dredge consisted of an Assembler S-7 hydraulic cutter head mounted on a boom that could be lowered or raised. The cutter head and the boom were powered by a diesel engine. A second diesel engine was used to pump the excavated material to a booster pump. Approximately 640 feet of 12-inch diameter steel pipe floated on pontoons between the dredge and the booster pump which was located at the west bank of the pond. The diesel-powered booster pump transported material to the screening plant.
The work boat was constructed of welded steel, approximately 8 feet wide and 18 feet long. The design and construction of the work boat provided a stable deck to stand on and work from when performing various tasks. It was used for access to the dredge, placing pipe, and general maintenance. It was equipped with an Onan 24XSL engine which powered a hydraulic drive unit and a hoist system. There was no access to the internal structure of the boat. The last 8 feet 11 inches of the boat's stern was protected by a steel plate wall that extended 3 feet above the deck. The remaining 9 feet 5 inches of the boat's bow was open except for a 3-inch high railing made out of 5/8-inch diameter steel rod that extended 7 feet 1 inch forward of the steel plate wall. The boat was not provided with an anchor; however, a 20-foot long, 1-inch diameter rope attached to the bow was used to tie-off and secure the boat. Checker steel plating was used for deck construction to provide a nonskid finish. Three life jackets were stored in the cargo box located on the work boat. The jackets were manufactured by Coral, model 9305, adult XX-large size, and purchased by the mine operator in 1995.
The water was approximately 18 feet deep at the dredge. The surface water temperature was measured on May 23, 2000. A reading 65 degrees Fahrenheit was recorded. Upon inspection there were no rocks or debris plugging the cutter head.
The victim was wearing jeans, T-shirt, leather lace boots and baseball cap. Emergency responders who recovered the victim from the pond stated that he did not have on a life jacket.
On Friday, May 19, 2000, Henn began his shift at 7:00 p.m.. He was to operate the dredge until 6:00 p.m. Saturday night.
The root cause of the accident was management's failure to establish safe work procedures for employees working from the work boat. The severity of the accident was because of the failure to wear a life jacket or belt where there was a danger of falling in the water.
Order No. 7927121 was issued on May 21, 2000, under the provisions of Section 103(k) of the Mine Act:
A fatal accident occurred at this operation on May 20, 2000, when the dredge operator fell into the water while trying to dislodge a rock from the cutter head. 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.This order was terminated on May 23, 2000. Conditions that contributed to the accident have been corrected and normal mining operations can resume.
Citation No. 7923670 was issued on June 15, 2000, under the provisions of Section 104(a) of the Mine Act for violation of 30 CFR 56.15020:
A fatal accident occurred at this operation on May 20, 2000, when the dredge operator fell into the water and drowned while attempting to dislodge a rock from the cutter head. He was working from a small boat where there was danger from falling into water and was not wearing a life jacket or belt.This citation was terminated on June 15, 2000. The dangers of working around water and the requirements for wearing life jackets or belts were reemphasized to all employees.
Related Fatal Alert Bulletin:
A. Persons Participating in the Investigation
B. Persons Interviewed
Batenhorst Gravel Company
Bernard Batenhorst . . . .. . . . . . . . . . . . . . . . . presidentMine Safety and Health Administration
Richard R. Laufenberg . . . .. . . . . . . . . . . . . . .supervisory mine safety and health inspector
Ronald C. Simpson . . . .. . . . . . . . . . . . . . . . . mine safety and health inspector
D. Michael Campbell . . . .. . . . . . . . . . . . . . . .civil engineer
Batenhorst Gravel Company
David C. Auten . . . .. . . . . . . . . . . . . . . . . . .front-end loader operatorSt. Paul, Nebraska, Police Department
David E. Schilousky . . . .. . . . . . . . . . . . . . . dredge operator
Robert L. Casper . . . .. . . . . . . . . . . . . . . . . front-end loader operator
Robert C. Kahlandt . . . .. . . . . . . . . . . . . . . .dredge and front-end loader operator
Marcus Paczosa . . . .. . . . . . . . . . . . . . . . . .police sergeantSt. Paul, Nebraska, Volunteer Fire Department
Michael L. Becker . . . .. . . . . . . . . . . . . . . . assistant fire chiefState of Nebraska Road Department
Patrick E. Baroch . . . .. . . . . . . . . . . . . . . . .EMT/fireman
Forrest L. Francis . . . .. . . . . . . . . . . . . . . . supervisor