Mine Safety and Health Administration (MSHA) - Metal and Nonmetal Mine Fatal Accident Investigation Report: Fatality #27 - June 30, 2000 - Slip/Fall of Person - Sand & Gravel - MI - A&E Agg., Inc., Fyke Washed Sand & Gravel

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UNITED STATES
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 Fall of Person Accident
June 30, 2000

Fyke Washed Sand & Gravel
A and E Agg., Inc.
Pinckney, Livingston County, Michigan
ID No. 20-03000

Accident Investigators

Paul A. Blome
Supervisory Mine Safety and Health Inspector

David E. Niemi
Mine Safety and Health Inspector

Christopher J. Kelly
Civil Engineer

Michael C. Superfesky
Civil Engineer

Ronald Chambers
Mine Safety and Health Specialist

Originating Office
Mine Safety and Health Administration
North Central District
515 West First Street, Room No. 333
Duluth, MN 55802-1302
Felix A. Quintana, District Manager

OVERVIEW
Dennis L. Peters, foreman, age 33, was fatally injured on June 30, 2000, when he fell into the rotating paddles of a log washer. Peters was attempting to reposition a water pipe feeding the log washer. The accident occurred because management failed to provide safe access to the work location. Management's failure to establish procedures requiring machinery to be blocked against motion prior to performing maintenance contributed to the severity of the accident.

Peters had a total of approximately 15 years mining experience, two years and 18 weeks at this mine. He had received training in accordance with 30 CFR Part 48.

GENERAL INFORMATION
The Fyke Washed Sand & Gravel mine, a sand and gravel operation, owned and operated by A and E Agg., Inc., was located in Pinckney, Livingston County, Michigan. The principal operating officials were Eula M. Fyke, president, and William P. Fyke, general manager. The plant was normally operated one, 10-hour shift, five days a week and one, 5-hour shift on Saturday. Total employment was eight persons.

Sand and gravel was extracted from a single bench using a front-end loader. Raw material was screened, crushed, and stockpiled. The finished products were sold primarily for sewer stone, roof stone, landscaping material, and for use in concrete.

The last regular inspection of this mine was completed on April 28, 1999. Another inspection was conducted following the investigation.

DESCRIPTION OF ACCIDENT
On the day of the accident, Dennis Peters (victim) reported for work at 6:00 a.m., his regular starting time. Water from a new well was going to be used for the first time on that shift to determine if everything would work properly with the log washer. Some final hookups and adjustments needed to be made.

As other employees arrived for work, Peters assigned them jobs. Peters sent Joseph Haydu, maintenance man, to a nearby town to have a pipe threaded to complete the piping job. Stanley Sutherland, maintenance man, arrived at about 8:00 a.m and helped on both the electrical work and the piping which had been started earlier.

The log washer, with the new water system, was started at approximately 10:30 a.m. The material discharging from it was too wet and it was decided that the water level in the log washer needed to be reduced. The options had been to raise the head end of the log washer or reposition the water pipe feeding the washer.

The system was filled with material and at approximately 11:30 a.m., it was determined that the pipe should be repositioned. Sutherland intended to move the pipe, but Peters said he would do it. Peters proceeded to climb up onto the lower end of the log washer and walk up the 4 inch wide outside edge. When he reached the cross member (3/8-inch thick angle iron) closest to the water pipe, he stepped from the edge of the operating log washer onto it. While standing on the cross member, over the center of the log washer, he began to vertically raise the discharge end of the pipe by hand to reposition the spray. Haydu had just warned Peters to stop because it looked like the pipe was going to break, when the pipe separated from the valve on the screen plant. Peters lost his balance and fell backward into the log washer. Johnson, who was standing nearby, tried to grab Peters, but was unsuccessful.

Haydu immediately shut down the plant and Sutherland called 911. Local rescuers arrived and tried to extricate Peters, but were unsuccessful until Sutherland cut a side panel from the log washer to gain access to the victim. The county medical examiner investigator pronounced the victim dead at the scene at approximately 1:23p.m.

INVESTIGATION OF THE ACCIDENT
MSHA was notified at 1:20 p.m. on the day of the accident by a telephone call from William P. Fyke, general manager for the mining company, to Gerald Holeman, field office supervisor. An investigation was started the next day. MSHA's accident investigation team traveled to the mine and made a physical inspection of the accident site, interviewed a number of persons, and reviewed training records and work procedures performed at the time of the accident. An order was issued pursuant to Section 103(k) of the Mine Act to ensure the safety of the miners. The miners did not request, nor have, representation during the investigation.

DISCUSSION

• The accident occurred on a log washer located in the coarse material washing section of the gravel plant. The accident occurred shortly after the plant was restarted following a scheduled shut-down to connect the plant to a new water supply well.

• The log washer was a Series 8000 model manufactured by Kolberg-Pioneer, Inc. of Yankton, South Dakota. It was used to clean soil from coarse aggregate that had been crushed and/or screened. It consisted of two side-by-side steel shafts with steel paddles mounted on them, enclosed by a rectangular steel trough. Coarse aggregate from an adjacent screen-shaker was continuously fed into one end of the trough by a conveyor belt. The aggregate was then pushed up the inclined trough by the angled paddles on the rotating shafts while water was fed through the open top of the trough. The water flowed down through the aggregate and opening between the paddles, removing loose soil particles. The water and suspended soils then exited the log washer through a drain at the bottom end of the trough.

• The log washer was 34 feet in length and was mounted on a support frame that raised the outlet end approximately 6 feet above the inlet end (see Appendix C, Figure 1). The trough of the log washer was 80 inches wide, 46.5 inches high, and constructed of 3/8-inch-thick welded steel plates. The sides and bottom of the trough were reinforced by several 4 x 4 x 3/8-inch steel angle ribs. The top edge of the trough was also reinforced along its length by a 4 x 4 x 3/8-inch steel angle. The open top of the trough was cross-braced by several 3 x 3 x 3/8-inch steel angles. Both the braces and reinforcing ribs were placed at a 48-inch center-to-center spacing along the length of the trough. The braces were bolted on each side of the trough to the 4 x 4 x 3/8-inch steel angle that ran along the top edge.

• Steel paddles that extended radially outward were mounted on two, 12-inch diameter steel shafts. The dimensions of the paddles were approximately 10 inches long x 10 inches wide x 2 inches thick. The paddles were arranged in 15 inch wide flights along the length of the shafts with four paddles per flight. The radial clearance between the edge of the paddles and the trough wall was approximately 8 inches. When in operation, the two shafts rotated simultaneously in opposite directions. When viewed from the inlet end of the log washer, the right-hand shaft rotated clockwise and the left-hand shaft rotated counterclockwise. The rotational speed of each shaft was 33 rpm. The log washer was powered by a 100 hp drive motor that provided each shaft with a torque of 8,000 foot-pounds.

• The log washer had two steel mesh guards mounted on the inlet end to limit exposure to the rotating shafts. The guard mounted on the end of the trough was 2 feet high and extended the width of the trough (80 inches). The guard mounted along the side of the trough extended approximately 9.9 feet toward the outlet end of the log washer and tapered from a height of 2 feet to a height of 0.9 feet as the trough rose from ground level. No emergency shut-off mechanism was observed on the log washer.

• A pipe manifold, which conveyed water to various sections of the plant, was affixed to the side of the screen-shaker located alongside the log washer. At the time of the accident, water was being supplied to the log washer by an iron water feed pipe assembly that was connected to a brass valve on the pipe manifold. The water feed pipe assembly was thread connected into the valve and consisted of a 56.5 inch long segment of 1.5 inch diameter iron pipe. The pipe was connected at a right angle, by a 90-degree pipe elbow, to an additional 33 inch long segment of 1.5 inch diameter pipe. The longer segment of pipe was connected to the valve and extended horizontally to a point above the center of the log washer trough. The shorter segment of pipe which was suspended above the center of the trough, was oriented so that the water feed was directed straight down into the trough. The end of the shorter pipe segment was next to one of the 3 x 3 x 3/8-inch steel angle braces that spanned the top of the trough. Connected to this brace was a U-bolt that had previously been used to secure the end of the shorter pipe segment. However, the U-bolt was not fastened to the pipe segment at the time of the accident. Plant employees could not determine the length of time that the pipe segment had been unsecured. The water feed pipe assembly was not supported or secured at any point except for the threaded valve connection at the pipe manifold.

• Based on the dimensions of the pipe assembly and the location of the valve on the pipe manifold relative to the log washer trough, the distance between the bottom edge of the pipe assembly and the top edge of the steel angle brace was calculated to be approximately 6.5 inches. This was the distance that the victim would have needed to vertically raise the free end of the pipe assembly in order for it to clear the top of the brace.

• Information collected at the accident scene indicated that the iron water feed pipe assembly was not fractured or bent. Instead, the entire pipe assembly had been pulled free from the valve on the pipe manifold. The rust pattern on the connecting threads of the pipe assembly indicated that only approximately 3/8 of an inch of the total 1 inch of available threads had been utilized to connect it to the valve. Inspection of the brass valve on the pipe manifold indicated that the outer thread courses located on the bottom portion of the valve were sheared from the body of the valve. At least one thread course was almost completely detached and was extending from the open end of the valve. This damage was consistent with the reported activity of the victim immediately prior to the accident.

• Raising the discharge end of the pipe assembly would cause a lever action at the valve and produce a significant amount of outward shear force in the threaded portion of the bottom of the valve. The combination of the harder iron pipe being threaded into a softer brass valve and the minimal distance that the pipe was threaded into the valve contributed to the pipe coming loose from the valve. CONCLUSION
The accident was caused by management's failure to provide safe access to the work location. Management's failure to establish procedures requiring machinery to be blocked against motion prior to performing maintenance contributed to the severity of the accident.

ENFORCEMENT ACTIONS
Order No. 7803919 was issued on June 30, 2000, under provisions of Section 103(k) of the Mine Act:

A fatal accident occurred at this operation on June 30, 2000 when a miner was attempting to adjust a water spray over the log washer. This order is issued to assure the safety of all persons at this operation. It prohibits all activities at the log washer until MSHA determines that it is safe to assume normal mining operations in the area. The mine operator shall obtain approval from an authorized representative for all actions to recover or restore operations in the affected area. This order was terminated on July 13, 2000. Conditions that contributed to the accident have been corrected and normal operations can resume.

Citation No. 7840403 was issued on August 16, 2000, under provisions of Section 104(d)(1) of the Mine Act for violation of 30 CFR 56.14105:

A foreman was fatally injured at this operation on June 30, 2000 when he fell into the rotating paddles of the Kolberg log washer. The victim was performing maintenance work by attempting to reposition a water pipe over the log washer. He was standing on an angle iron cross member over the log washer when he lost his balance and fell. The log washer was not shut off and blocked against motion. Failure to shut off the power and block against motion while performing maintenance on machinery is a serious lack of reasonable care constituting more than ordinary negligence and is an unwarrantable failure to comply with a mandatory safety standard. Order No. 7840404 was issued on August 16, 2000, under the provisions of Section 104(d)(1) of the Mine Act for violation of 30 CFR 56.11001:

A foreman was fatally injured at this operation on June 30, 2000 when he fell into the rotating paddles of the Kolberg log washer. The victim was performing maintenance work by attempting to reposition a water pipe over the log washer. He was standing on an angle iron cross member over the log washer when he lost his balance and fell. A safe means of access was not provided to the water pipe for the Kolberg log washer. Failure to provide a safe means of access to this area is a serious lack of reasonable care constituting more than ordinary negligence and is an unwarrantable failure to comply with a mandatory standard.

Related Fatal Alert Bulletin:
FAB2000M27

APPENDICES
A. Persons Participating in the Investigation

B. Persons Interviewed

APPENDIX A
Persons Participating in the Investigation:

A and E Agg., Inc.

Livingston County Medical Examiner's Office

Daniel Gee . . . . . . . . . . . . . . . . . . . . .medical examiner investigator Mine Safety and Health Administration

APPENDIX B
Persons Interviewed:

A and E Agg., Inc.


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