Mine Safety and Health Administration (MSHA) - Metal and Nonmetal Mine Fatal Accident Investigation Report: Fatality #19 - June 06, 2000 - Slip/Fall of Person - Limestone (CB) - MO

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

REPORT OF INVESTIGATION

Underground Nonmetal Mine
(Limestone/Cement Plant)

Fatal Fall of Person Accident
June 6, 2000

Dunn Industrial Group, Inc. (9VL)Kansas City, Missouri

at

Sugar Creek UG Mine and No. 2 Plant
Lafarge Corporation
Sugar Creek, Jackson County, Missouri
ID No. 23-02171

Accident Investigators

Arthur L. Ellis
Supervisory Mine Safety and Health Inspector

Vernon E. Miller
Mine Safety and Health Inspector

Rodney L. Rice
Mine Safety and Health Inspector

Terence M. Taylor, P.E.
Civil Engineer

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

OVERVIEW

On June 26, 2000, Dolen Glen Breedlove, Jr., journeyman boiler maker, age 42, was fatally injured when he fell approximately 63 feet to a concrete floor. Breedlove was stepping onto an improperly secured I-beam at the 108-foot level of the pre-heater tower to prepare the area for installing a section of the pre-heater tower inlet duct when the accident occurred.

The cause of the accident was the failure to provide safe access to the work area. A contributing factor to the severity of the accident was the failure to tie-off before leaving the scaffolding.

Breedlove had twelve weeks and two days mining experience, all at this operation, and a total of twenty years experience as a boiler maker. He had received hazard training in accordance with 30 CFR, Part 48.

GENERAL INFORMATION
The Sugar Creek UG Mine and No. 2 Plant, an underground limestone mine, owned and operated by Lafarge Corporation, was located at Sugar Creek, Jackson County, Missouri. The principal operating official was James McCaffrey, senior project manager. The mine was normally operated one shift, eight to ten hours a day, five days a week. Total employment was 175 persons.

The mine and mill were under development and construction. The cement plant was approximately 50% completed. Limestone will be drilled, blasted and crushed underground. The crushed material will then to be transported from the mine shaft by conveyor belt to the mill for processing into cement. The finished product will be stored in silos for bulk shipment to customers.

The victim was employed by Dunn Industrial Group, Inc., a general contractor, located in Kansas City, MO., which was hired to construct the mill. The principal operator official was Robert F. Burcham, president and CEO.

Lico Steel Inc., a subcontractor, located in Kansas City, MO, was hired to erect the steel at the mill. The principal operator official was Carl J. Caldarella, vice president and general manager.

A regular inspection was in progress on the day of the accident.

DESCRIPTION OF ACCIDENT
On the day of the accident, Dolen G. Breedlove, Jr. (victim) reported to work at 7:00 a.m., his normal starting time. He was assigned by Frank King, boiler maker foreman, to assist with the installation of a 21,000-pound section of the kiln inlet duct. Breedlove moved welders and gathered tools in preparation for that task. At about 8:45 a.m., Breedlove and James Hedges, boiler maker, proceeded up a stair/scaffold from the roof of the electrical room to the 108-foot level of the pre-heater and precalciner kiln. To install the duct, the pair separated. At the top of the stair/scaffold, Hedges went to the I-beam on the north side of the scaffold to access structure 43, and Breedlove went to the I-beam on the east side of the scaffold. Hedges and Breedlove were each wearing a safety harness with two lanyards attached. While out of Hedges' sight, Breedlove was stepping onto the beam when he fell 63 feet to a concrete floor.

Several employees rushed to him immediately and began first-aid. Breedlove was transported by ambulance to a location where they transferred him to a helicopter. He was flown to the hospital and pronounced dead at 11:01 a.m. Death was attributed to blunt trauma.

INVESTIGATION OF THE ACCIDENT
Vernon Miller and Rodney Rice, mine safety and health inspectors, were at the mine conducting a pre-inspection conference when the accident occurred. At 8:50 a.m., they were notified by Brian Smith, Dunn Industrial Group safety coordinator, that an accident had occurred and they immediately went to the scene of the accident. An order was issued under the provisions of section 103(k) of the Mine Act to ensure the safety of the miners.

An investigation was started the same day. MSHA conducted the investigation with the assistance of mine management, general contractor management, and employees. The miners did not request, nor have, representation during the investigation.

DISCUSSION

• The accident occurred at the partially constructed pre-heater tower's 108-foot level. On July 12, 1999, Licos Steel, Inc., a sub-contractor to Dunn Industrial Group, Inc., began construction. Scaffolding was used to access the 108-foot framing level, the highest level where floor beams had been erected. The scaffolding was erected using staggered construction with the landings alternating between the north and south sides of the scaffold tower. It was anchored to the superstructure on the north and east sides with wire ties for lateral stability. The total scaffolding height from the concrete pad above the electrical room to the landing near the 108-foot level was approximately 60 feet. Cable climbers (portable hoist platforms) were installed on the main tower columns to assist the erection crew with the construction process. One cable climber was installed on column A-2 and was accessible at the 108-foot level from the north-south beam.

• Dunn Industrial Group, Inc. utilized construction I-beams, referred to as the north and the east I-beams, to provide access to the superstructure of the pre-heater at the 108-foot framing level. The east I-beam ran north and south while the north I-beam ran east and west. Static lines, secured above the beams, were provided for fall protection.

• The victim attempted to walk onto the east I-beam. It was reportedly erected in mid- April, 2000. The walking surface was the flange width of 14-1/2 inches. The beam measured 9 feet, 10-1/2 inches long. To connect the ends of the beam to the columns, two clip angles were welded to the web at each end of the beam. The angles were 4 x 3-1/2 x 2-inch on the north end and 4 x 3-1/2 x 3/8-inch on the south end. Each clip angle was pre-drilled with three bolt holes. The beam and its attached hardware were fabricated by Cives Steel Company for Dunn Industrial Group, Inc.

• The north-south beam was field erected with one bolt in the north end connection and two bolts in the south end connection. All three bolts were on the west side of the beam. The north end of the beam was connected to the column with one, 3/4-inch diameter A325 high-strength bolt placed through the middle bolt hole on the west side of the beam. The nut on the bolt was very loose and there was a noticeable gap between the nut and the plies (clip angle and column flange) of the connection. The two bolts on the south end were placed in the lower two bolt holes. The top bolt was hand tight and the bottom bolt was wrench tight. There was no noticeable gap between the two nuts and the clip angle surface. However, there was a gap between the clip angle and the column flange at the upper bolt hole location, due to damage/deformation to the angle during erection.

• Prudent erection standards require at least two bolts to be placed in each end connection of a beam, and the bolts be drawn wrench-tight for beam stability. The stability of the north-south beam was tested by standing on the scaffold, grasping the top of a 4-foot high stub-column welded to the top flange of the beam and pulling on the column. It was possible to rotate the beam with little effort. The lack of an additional bolt in the north end of the beam; failure to make the bolts wrench tight; the gap between the plies of the connection at each end of the beam and at the quarter point; and the slotted characteristic of the bolt holes allowed the beam to rotate 1-1/8 inches downward toward the east. Since the beam was not installed by the personnel using it, the condition should have been checked before being used as a walkway.

• Tie-off for the east beam was a horizontal 3/8-inch diameter steel line lashing that was wrapped around the W14x370 column (referenced as column A-2) near the corner of the landing. The tie-off line was secured above the beam about 40 inches. Lanyards could be attached prior to leaving the scaffold area. The tie-off point for the north I-beam (which could serve as an alternate tie-off point for the east beam) was a DBI/SALA self-retracting lifeline (SRL) extending horizontally and secured above the I-beam. According to the manufacturer, the use of the self-retracting lifeline mounted in a horizontal position was not an acceptable application of the product in terms of strength. There was reasonable doubt this lifeline would have held the accelerating weight of the victim had he used it.

• The Lafarge Corporation had a policy requiring fall protection to be worn by every employee, contractor and visitor at all times when they were over six feet above ground level and could not maintain 3-point contact with the walk area, handrails, etc. According to Brian Thorne, the Lafarge project safety manager, the policy was discussed specifically during the safety orientation that Dunn Industrial conducted for its workers on March 22, 2000. The signature of the victim, Dolen Breedlove, was on an attendance record of that orientation.

• The 4-foot stub-column welded to the top of the north-south beam was designated as a W21x68 section weighing 272 lb. It was located 2 feet 3 inches from the north end of the beam. An 8-5/8 x 10-3/8 x 2-inch gusset plate was welded perpendicular to the web of the stub-column on its south side. Immediately north of the stub-column, there was an 11-inch diameter bucket of A325 bolts weighing approximately 70 lb. All three objects were obstructions on the top flange of the east I-beam near its north end where the victim was attempting to walk.

• The victim was wearing a full-body harness manufactured by DBI-SALA, model number 1102000. The victim's employer had provided the harness. Two 6-foot shock absorbing lanyards were attached to the harness D-ring. The lanyards were DBI-SALA Model 4300DPG and Spider Model Unit C-2. The harness and lanyards were in good condition. The snap hooks on the ends of the lanyard were unattached.

• The wind was calm, with the maximum wind speed measuring 9 miles per hour from the south, on the day of the accident. CONCLUSION
The root cause of the accident was the failure to provide safe access to the work area. A contributing factor to the severity of the accident was the failure to tie-off before leaving the scaffolding.

ENFORCEMENT ACTIONS
Lafarge Corporation

Citation No. 4460901 was issued on October 3, 2000, under provisions of Section 104(a) of the Mine Act for violation of 30 CFR 57.15005:

A fatal accident occurred at this operation on June 6, 2000, when an employee fell about 63 feet while attempting to walk onto an I-beam from a construction scaffold. The victim was wearing a full body harness for fall protection, but it was not attached to the safety line. This citation was terminated on October 3, 2000. Refresher training in the use of fall protection was given on August 1, 2000 to all employees at the site required to do scaffolding/overhead work.

Dunn Industrial Group, Inc.

Order No. 7885744 was issued to Dunn Industrial Group, Inc. on June 7, 2000, under provisions of Section 103(k) of the Mine Act:

A fatal accident occurred at the pre heat tower shop 43 at the 108 elevation level. A miner fell to his death from the 108 elevation level to the 45 elevation level. This order is issued to assure the safety of all persons at this operation. It prohibits all activity at the 43 pre heat tower shop area until MSHA has determined that it is safe to resume normal work in this area. The mine/contractor shall obtain prior approval from an authorized representative for all actions to recover and/or restore operations to the affected area. This order was terminated on June 15, 2000, after it was determined that conditions contributing to the accident had been corrected and normal mining operations could resume.

Citation No. 4460579 was issued on October 3, 2000, under provisions of Section 104(a) of the Mine Act for violation of 30 CFR 57.15005:

A fatal accident occurred at this operation on June 6, 2000, when an employee fell about 63 feet while attempting to walk onto an I-beam from a construction scaffold. The victim was wearing a full body harness for fall protection, but it was not attached to the safety line. This citation was terminated on October 3, 2000. Refresher training in the use of fall protection was given on August 1, 2000 to all employees at the site required to do scaffolding/overhead work.

Citation No. 4460580 was issued on October 3, 2000, under provisions of Section 104(a) of the Mine Act for violation of 30 CFR 57.11001:

A fatal accident occurred at this operation on June 6, 2000, when an employee fell about 63 feet while attempting to walk onto an I-beam from a construction scaffold. The I-beam was a primary means of access for construction workers to the superstructure of the pre-heater at the 108-foot framing level. The I-beam was missing anchor bolts at each of its attachment points. The only bolt holding the north end of the beam in place was very loose. This allowed the beam to rotate downward when stepped on. In addition, the beam was partially obstructed with an 11-inch diameter bucket and other material. This citation was terminated on October 3, 2000, after it was determined that the I-beam had been secured with all required bolts, and that the bolts were wrench-tight.

Related Fatal Alert Bulletin:

FAB2000M19

APPENDICES

APPENDIX A
Persons Participating in the Investigation
Lafarge Corporation

Dunn Industrial Group, Inc.

International Brotherhood of Boilermakers (IBB), Local 83

Roger Erickson . . . . . . . . . . . . . . . . . . . . .president and financial secretary Mine Safety and Health Administration

APPENDIX B
Persons Interviewed
Dunn Industrial Group, Inc.

Lico Steel


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