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 Slip or Fall of Person Accident
November 20, 2000
Limberlost Sand and Gravel
St. Henry Tile Company, Inc.
Geneva, Adams County, Indiana
I.D. No. 12-00698
Donald J. Foster, Jr.
Supervisory Mine Safety and Health Inspector
Herbert D. Bilbrey
Mine Safety and Health Inspector
Michael P. Shaughnessy
Frankie J. Mullins
Mine Safety and Health Specialist
Mine Safety and Health Administration
North Central District
515 West First Street, Room 333
Duluth, MN 55802-1302
Felix A. Quintana, District Manager
On November 20, 2000, Charles Lefeld, superintendent, age 43, was fatally injured when he fell about 37 feet from the top of the wash plant. A piece of angle iron had become lodged against the head pulley of the 180-foot conveyor, located at the discharge box at the top of the wash plant. Lefeld climbed the framework of the box to remove the angle iron, lost his balance, and fell to the ground.
The accident occurred because management failed to ensure that safe access was provided to the discharge box. An opening in the travelway adjacent to the discharge box was not provided with railings and/or a cover which contributed to the severity of the injuries.
Lefeld had a total of 15 years of mining experience, all at this mine. The mine operator had a training plan in accordance with 30 CFR Part 46.3. Lefeld had not received annual refresher training in accordance with 30 CFR Part 46.8(a)(1).
The Limberlost mine, a surface sand and gravel operation, owned and operated by St. Henry Tile Company, Inc., was located in Geneva, Adams County, Indiana. The principle operating officials were: Robert Homan, president; Gene Subler, vice president; and Charles Lefeld, superintendent. The mine was normally operated one, 9-hour shift per day, five days a week, and five hours on Saturdays. Total employment was four persons.
Sand and gravel was extracted from a water-filled pit by a dredge and a dragline. The material mined by the dredge was piped to the plant for processing. The material mined by the dragline was stockpiled and later transported to the plant feed hopper by a front-end loader. That material was transported by conveyors to the plant, where it was screened, sized, and stockpiled. The finished products were used in the construction industry.
The last regular inspection of this operation was completed on May 3, 2000. Another inspection was conducted following this inspection.
DESCRIPTION OF THE ACCIDENT
On the day of the accident, Charles Lefeld (victim) reported for work at 7:30 a.m., his normal starting time. Lefeld performed his normal duties throughout the morning. At about 12:30 p.m., Lefeld started the plant for the day and loaded stockpiled material into the plant feed hopper with a front-end loader. He also loaded customer trucks as they arrived at the mine.
At about 1:00 p.m., Steven Grile, who was operating the dredge about 270 feet away, observed Lefeld traveling on the walkway, adjacent to the 180-foot conveyor, toward the discharge box at the top of the wash plant. Grile stated the plant was still running and he continued to operate the dredge. During this time period, Brian Hall, contractor truck driver, entered the mine property to get a load of material. Hall observed Lefeld leave the front-end loader and travel the walkway to the top of the wash plant. Hall stated that Lefeld looked at the head pulley located at the discharge box, started back toward the walkway a few feet, and then returned to the discharge box. Hall waited in his truck and did not see Lefeld again.
A few minutes later, Hall heard the outside buzzer for the mine telephone ringing. When it continued to ring, Hall traveled over to the plant to inform Lefeld that it was ringing. Hall found Lefeld laying on the ground at the base of a sand screw. Hall ran to the mine office and answered the phone. Gene Subler, vice-president, was calling to talk with Lefeld. Hall informed Subler that Lefeld had fallen from the plant. Subler called 911 and traveled to the mine. Emergency personnel arrived within a short time and determined that Lefeld did not have a pulse. The Adams County Coroner pronounced Lefeld dead at the scene. Death was attributed to multiple blunt force trauma caused by the fall.
INVESTIGATION OF THE ACCIDENT
MSHA was notified at 3:00 p.m., on November 20, 2000, by a telephone call from Nancy Subler, office manager for St. Henry Tile Company, Inc., to Steve Richetta, assistant district manager. An investigation began the same day and an order was issued pursuant to Section 103(k) of the Mine Act to insure the safety of the miners.
MSHA's accident investigation team conducted a physical inspection of the accident site, interviewed a number of persons, and reviewed training records and work procedures being performed at the time of the accident. The investigation was conducted with the assistance of mine management and mine employees. The miners did not request, nor have, representation during the investigation.
� The accident occurred at the discharge box located at the top of the wash plant. The discharge box was a metal chute, 37 inches wide by 19 inches long. Materials entered the box from the slurry pipe from the dredge and the 180-foot Barber Greene conveyor belt. The head pulley of the 180-foot conveyor was located within the confines of the box.
� Mine employees traveled to the discharge box area on a regular basis to service the head pulley and remove debris and material buildup. The south side of the discharge box and 180 foot conveyor head pulley was the location from which work was performed because the north side was blocked by the slurry pipe from the dredge.
� Access was provided to the top of the wash plant by an inclined travelway adjacent to the north side of the180 foot conveyor and by steps from the ground to a level directly below the discharge box. A vertical, fixed ladder provided access from the triple deck screen to the travelway adjacent to the south side of the discharge box.
� A 40-inch x 36-inch opening existed in the floor of the travelway adjacent to the south side of the 180-foot conveyor head pulley. The opening served as passage to access the ladder to the triple deck screen. A railing was not provided on the west side of the opening, creating a fall hazard of 36 feet to the ground. Lefeld fell through this opening when he lost his footing while standing on the framework of the discharge box.
� The travelway adjacent to the discharge box was 36 feet above ground level. The framework and support beams of the discharge box that Lefeld had climbed on were 37 feet above the ground and were covered with ice and frozen sand and gravel.
� A piece of angle iron was found lodged in the south side of the head pulley of the 180-foot conveyor against the inside corner of the discharge box. The angle iron had damaged the entire south edge of the 180-foot conveyor belt. Numerous pieces of the conveyor belt, up to 6 inches long and 2 inches wide, were found on the ground below the conveyor. It is believed that Lefeld observed the falling pieces of belt while operating the front-end loader.
� Lefeld did not shut the conveyor off prior to attempting to remove the lodged angle iron. There were two shut-off devices on the 180-foot conveyor. One was located on the north side of the discharge box and the other at the tail pulley area. There was no evidence that indicated he had contacted the moving conveyor prior to the fall.
� The weather at the time of the accident was 27 degrees Fahrenheit with a wind chill of -5 degrees Fahrenheit. Light snow was reported with winds out of the west at 24 mph, gusting to 30 mph.
� Evidence observed at the scene indicated that Lefeld had placed his left foot on a support beam located west of the discharge box and his right foot on the framework of the discharge box. The support beam had a buildup of frozen sand and gravel covered with ice on it, except for one section about 12 inches long. There were fresh marks on the surface of the beam that indicated Lefeld had placed his foot on the frozen material and it gave way. The framework had marks on the frozen material that indicated the position of his right foot. It is the conclusion of the investigators that the material on the beam failed, Lefeld lost his balance and fell over the support beam to the ground.
The root cause of the accident was management's failure to provide safe access to the discharge box. Failure to provide a cover and railings on the ladder opening adjacent to the discharge box contributed to the severity of the accident. The coating of ice that was present on the plant was also a contributing factor.
Order No. 7826992 was issued on November 20, 2000, under the provisions of Section 103(k) of the Mine Act:
A fatal accident occurred at this operation on November 20, 2000, when an employee fell from the top of the wash plant. This order is issued to assure the safety of all persons at this operation. It prohibits all activity at the wash plant until MSHA has determined that it is safe to resume normal operations in the area. The mine operator shall obtain prior 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 December 5, 2000, when it was determined that conditions that contributed to the accident no longer existed and that normal operations could resume.
Order No. 7832619 was issued on November 25, 2000, under the provisions of Section 104(d)(2) of the Mine Act for a violation of 30 CFR Part 56.11001:
A fatal accident occurred at this operation on November 20, 2000, when the mine superintendent fell from the top of the wash plant. A piece of angle iron had lodged in the head pulley of the 180-foot conveyor located at the discharge box on top of the wash plant. Safe access was not provided to the discharge box. The superintendent had to climb the support beams and framework of the discharge box to access the lodged angle iron. The beams and framework were covered with ice and material. This violation is an unwarrantable failure to comply with a mandatory standard.This order was terminated on December 5, 2000. A walkway has been installed adjacent to the discharge box of the wash plant. This action will permit work to be performed on the head pulley of the 180 foot conveyor and the discharge box, from a safe location. All spilled material and ice has been removed from the support beams and framework of the discharge box.
Citation No. 7832620 was issued on November 25, 2000, under the provisions of Section 104(a) of the Mine Act for a violation of 30 CFR Part 56.11012:
A fatal accident occurred at this operation on November 20, 2000, when the mine superintendent fell from the top of the wash plant. A piece of angle iron had lodged in the head pulley of the 180-foot conveyor located at the discharge box on top of the wash plant. A 36-inch x 42-inch opening existed in the travelway adjacent to the discharge box area where the mine superintendent was attempting to remove the lodged angle iron. The opening was 36 feet above the ground and was not provided with railings or a cover. The mine superintendent fell over the edge of the opening.This citation was terminated on December 5, 2000. The opening in the travelway adjacent to the discharge box at the top of the wash plant has been permanently covered and railings have been installed around the entire elevated area.
Related Fatal Alert Bulletin:
Persons Participating in the Investigation
St. Henry Tile Company, Inc. - Limberlost Sand and Gravel
Robert Homan .......... presidentAdams County Sheriff Department
Gene Subler .......... vice president
Nancy Subler .......... office manager
Gene Dailey .......... truck driver
William Johnson .......... dragline operator
Steven Grile .......... dredge operator
Gary Burkhart .......... deputy sheriffAdams County Coroner
Leslie Cook .......... coronerMine Safety and Health Administration
Donald Foster .......... supervisory mine safety and health inspector
Herbert Bilbrey .......... mine safety and health inspector
Michael Shaughnessy .......... mechanical engineer
Frankie Mullins .......... mine safety and health specialist
St. Henry Tile Company, Inc. - Limberlost Sand and Gravel
Gene Subler ......... vice presidentBerne Ready Mix
Gene Dailey ......... truck driver
William Johnson ......... dragline operator
Steven Grile ......... dredge operator
Brian Hall .......... truck driver