DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
Metal and Nonmetal Mine Safety and Health
Report of Investigation
Surface Nonmetal Mine
Fatal Fall of Person Accident
February 26, 2001
CDK Contracting Company (L35)
Farmington, San Juan County, New Mexico
Portland Plant and Quarry
Florence, Fremont County, Colorado
ID No. 05-00037
Ronald D. Pennington
Supervisory Mine Safety and Health Inspector
Richard L. Arquette
Mine Safety and Health Inspector
Mine Safety and Health Specialist
Mine Safety and Health Administration
Rocky Mountain District
P.O. Box 25367 DFC
Denver, CO 80225-0367
Ismael Jimenez Ponce, an ironworker helper, age 50, was fatally injured on February 26, 2001, when he fell from a scaffold ladder.
The accident was caused by the failure to provide either a backguard, lifeline or a railed landing on the scaffold ladder.
Ponce had a total of 3 years mining experience, 41 weeks as an ironworker helper with this employer. He had received training in accordance with 30 CFR, Part 46.
Portland Plant and Quarry, a surface limestone mine with an associated cement mill, owned and operated by Holnam, Inc., was located 2 miles south of Florence, Fremont County, Colorado. The principal operating official was Robert R. McGilvray, plant manager. The mine worked two, 12-hour shifts, 7 days a week. Total employment was 170 persons.
The victim was employed by CDK Contracting Company of Farmington, New Mexico, who was contracted to build a new dry process cement plant. The construction commenced on August 5, 1999. The principal operating officer for CDK Contracting Company was Paul Judkins, project manager. CDK Contracting Company employed 640 persons working two, 12- hour shifts, 7 days a week.
The last regular inspection of this operation was completed on August 3, 2000. Another regular inspection was conducted at the conclusion of this investigation.
DESCRIPTION OF THE ACCIDENT
On the day of the accident, Ismael Ponce (victim) reported for work at 6:30 a.m., and attended a 45-minute safety meeting. At 7:25 a.m., Ponce and Carpio Benito Casares, ironworker, were directed by Kenneth Jones, foreman, to go to the 1st and 2nd levels of the preheat tower and install port doors on the cyclones. Upon arrival at the assigned work area, the two men discovered that the bolts for the doors were missing and they could not start the task. They notified the foreman who directed them to go to the supply room and get the proper bolts. The supply room was out of the bolts and the employees went into the preheat tower to look for bolts.
Ponce and Casares went to the northeast corner of the 4th floor where scaffold No. 112 was located. Ponce climbed to the top of the scaffold ladder. A short time later he was descending the ladder and fell to his death while carrying a self-retracting lanyard.
First aid was administered and the local emergency rescue personnel responded within minutes. The victim was pronounced dead at the scene by the Florence County Coroner. Death was attributed to blunt force trauma.
INVESTIGATION OF THE ACCIDENT
MSHA was notified at 10:00 a.m., on the day of the accident by a telephone call from Charlie Casey, corporate safety, health and environmental manager, to Jake DeHerrera, assistant district manager. An investigation was started the same day. An order was issued pursuant to Section 103(k) of the Mine Act to ensure the safety of miners.
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. The miners did not request nor have representation during the investigation.
The fatal accident occurred on the 4th floor of the preheat tower that was under construction. Scaffold No. 112 was located in the northeast corner on the 4th floor and was used by contractors to construct and access the plumbing and electrical race on this floor. The scaffold was manufactured by Safway Steel Products, Inc., and was assembled by CDK Contracting Company on September 9, 2000. The scaffold parts were made of 2-inch diameter steel tubing for both its vertical upright support and its horizontal handrail members. It was free-standing and not attached to the tower structure. The scaffold had overall dimensions of 4 feet by 7 feet and was 42 feet high.
Safway Steel Products, Inc., manufactured the ladder in 6-foot sections, and CDK Contracting Company attached the ladder sections to the scaffold with clamps. The ladder was comprised of 1-5/8-inch by 7/8-inch steel box tubing that formed vertical uprights and 1-inch diameter steel tubing that formed the rungs. There were seven of the 6-foot ladder sections attached to the scaffold for a total length of 42 feet. The height of the ladder terminated at a point near the top handrail on the highest work platform. The ladder was attached to the scaffold on a 30 degree angle. The right vertical support cleared the scaffold by 10 inches and the left vertical support cleared the scaffold by less than 3/16 of an inch.
The contractor had 287 scaffolds erected at this construction project and many of these scaffolds were not constructed according to the applicable safety requirements of Federal, State and local regulations. During the course of the investigation it was determined that scaffold No. 112 failed to comply with many of the requirements. In addition, the contractor failed to inspect the scaffolds for safety defects to ensure that the structure was not altered for safe use. The scaffold foreman stated that he stopped inspecting the scaffolds and had not recorded any inspections since November 2000.
The retractable lanyard lying near the victim's body was a MSA Rose Dyna-Lock Self-Retracting Lanyard manufactured by Rose Manufacturing Company. It was comprised of a reel of cable (wire rope) contained inside metal housing. The cable could be pulled through an opening in the housing and then retracted back into the housing when it was released. The action of the lanyard was similar to an automobile seatbelt. A latch hook was attached to the end of the cable and was designed to attach to the D-ring of a safety harness. An oblong eyelet hole located at the top of the lanyard housing provided a place where the device could be attached to a substantial anchoring support. The lanyard was designed to hang and operate in a vertical position.
The retractable lanyard weighed 23 pounds. The galvanized wire rope was 3/16-inch in diameter and 30 feet long. The lanyard had a rating for a human working load of 75 to 310 pounds and the maximum fall arrest load force was 900 pounds; the maximum fall arrest distance for this unit was 40 inches.
Prior to the fatal accident, the retractable lanyard was attached to the upper handrail on scaffold No. 112 by using a 3/8-inch diameter by 2 feet long wire rope sling and a 1-inch clevis. Attaching retractable lanyards to scaffold handrails is not a recommended practice and may not prevent serious injury or death if a fall occurs.
Upon visual inspection of the sling assembly, the pin was completely threaded into the clevis and there was no sign of physical separation or failure of the sling or the clevis. Mechanical failure of the sling assembly did not contribute to the accident.
Since there was no mechanical failure in the sling assembly, it was apparent that the lanyard was physically removed from the sling and the victim was carrying the retractable lanyard on his person while descending the ladder. Ropes, winches or hoists were not provided for raising or lowering tools and supplies on this scaffold and the lack of such devices contributed to the fatal fall.
Upon visual inspection of the lanyard housing, there was no sign of physical damage around the eyelet opening where the lanyard was attached to the sling assembly. Mechanical failure of the lanyard eyelet opening did not contribute to the accident.
The initial inspection of the lanyard revealed that it was not working and the cable inside the housing would not pay out or retract. A length of cable, approximately 20 inches long, was exposed outside the housing and could neither be pulled out or retracted into the housing. The cable reel inside the housing was jammed and rendered the unit defective.
The retractable lanyard was taken to the MSHA Approval and Certification Center in Tridelphia, West Virginia, for testing. The testing was completed on April 11, 2001, after both the exterior and interior of the device were examined.
The testing laboratory found that the exterior housing was dented on one side and the housing diameter was altered. The damaged housing measured 8-1/16 inches in diameter compared to a similar undamaged unit that measured 8-3/8 inches. The damage caused the unit to become smaller. The dent was deep enough to impinge against the interior cable reel. The cable reel assembly was bent and deformed and prevented the reel from turning. The other mechanical parts inside the housing were in good condition and worked normally.
The victim was wearing proper clothing and all personal protective equipment necessary for safe performance of his job to include a full-body fall protection harness.
The accident was caused by the failure to ensure that the scaffold ladder was equipped with either a backguard, lifeline or a railed landing. Failure to provide a means to hoist and lower tools and supplies that would eliminate the need to carry them while using the ladder was a root cause. The failure to require a competent person to examine this work area for conditions that affect safety was a contributing factor.
The following violations were issued to CDK Contracting Company:
Order No. 7942511 was issued on February 26, 2001, under the provisions of Section 103(k) of the Mine Act:
A fatal accident occurred at this operation on February 26, 2001, when a miner was descending a scaffold ladder and fell to the ground. This order is issued to ensure the safety of all persons at this operation. It prohibits activity at the preheat tower until MSHA has determined that the affected area is safe to resume normal operations. The mine operator shall obtain prior approval from an authorized representative of the Secretary to recover and or restore operations to the affected area.This order was terminated on February 28, 2001. The investigation of the accident area has been completed and the area has been released for normal mining operations.
Order No. 7935401 was issued on April 23, 2001, under the provisions of Section 104(d)(2) of the Mine Act for violation of 30 CFR 56.11011:
A fatal accident occurred at this operation on February 26, 2001, when an employee fell from a scaffold ladder. The victim was descending a 42-foot high ladder that was attached to scaffold No. 112 and did not have both hands free. He used one hand to hold onto the ladder while his other hand secured a retractable lanyard draped over his shoulder. Failure to provide a means to hoist and lower tools and supplies that would eliminate the need for miners to carry them while climbing or descending ladders constitutes more than ordinary negligence and is an unwarrantable failure to comply with a mandatory safety standard.Order No. 7935402 was issued on April 23, 2001, under the provisions of Section 104(d)(2) of the Mine Act for violation of 30 CFR 56.11025:
A fatal accident occurred at this operation on February 26, 2001, when a contractor employee fell from a scaffold ladder. The victim was descending a 42-foot high ladder that was attached to scaffold No. 112 when he lost his balance and fell. The ladder was not equipped with railed landings, backguards or equivalent protection. Failure to require that this protection was available and utilized by all persons who used this ladder constitutes more than ordinary negligence and is an unwarrantable failure to comply with a mandatory standard.Order No. 7935407 was issued on April 23, 2001, under the provisions of Section 104(d)(2)of the Mine Act for violation of 30 CFR 56.18002:
A fatal accident occurred at this operation on February 26, 2001, when a contractor employee fell from a scaffold ladder. The accident investigation revealed that the scaffold was defective and citations were issued for these defects. The scaffold foreman stated that he stopped documenting the scaffold inspections in November 2000, and he did not know when the last examination for defects on scaffold No. 112 was conducted. The contractor displayed a high degree of negligence for allowing persons to use defective equipment and this is an unwarrantable failure to comply with a mandatory safety standard.Related Fatal Alert Bulletin:
Persons Participating in the Investigation
CDK Contracting Company
Charlie Casey ........... Corporate Safety, Health & Environmental ManagerHolnam, Inc.
Paul Judkins ........... CDK Project Manager
Andy J. Manzanares ........... Manager of Safety
Fred Sauceda ........... Site Inspector
Philip Stroppel ........... Supervisor Preheat Tower
Connie M. Person ........... Safety Assistant
Chris E. Kay ........... Safety SupervisorJackson and Kelly PLLC, Attorneys at Law
Loel Gray ........... Holnam Project
David York ........... Holnam Project Safety
Karen L. Johnston ........... CDK AttorneyState of Colorado
William C. York-Feirn ........... Coordinator Mine Safety & TrainingFremont County Colorado
James L. Beicker ........... Detective Sergeant Sheriff's DepartmentUnited States Department of Labor - Office of the Solicitor
Gregory W. Tronson ........... AttorneyMine Safety and Health Administration
John Rainwater ........... Attorney
Ronald D. Pennington ........... Supervisory Mine Safety & Health Inspector
Richard L. Arquette ........... Mine Safety & Health Inspector
Barbara Renowden ........... Mine Safety and Health Specialist
Michael Shaughnessy ........... Mechanical Engineer
CDK Contracting Company
Andy J. Manzanares ........... Manager of SafetyNUCO International
Richard Etsitty ........... Scaffold Foreman
Herman Sleuth ........... Structural Welder
Fernando Rios ........... Structural Welder
Marshall Morgan ........... Structural Welder
Carpio Benito Casares ........... Ironworker
Gary Hardaway ........... Leadman, Iron Fitters & Welders
Kevin Leon Deese ........... Ironworker Foreman
Kenneth Ray Jones ........... Ironworker Foreman
Donald Day ........... Welder General Foreman
Connie M. Person ........... Safety Assistant
Fred Sauceda ........... Safety Site Inspector
John R. Wilson ........... Safety Site Inspector
David Rauch ........... General ForemanFreemont County, Colorado, Sheriff's Department
Catherine Begge ........... Laborer
David Morris ........... Bricklayer
Jack Sliger, Jr. ........... Bricklayer
Rhett Belser ........... Safety Representative
James L. Beicker ........... Detective Sergeant