DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
COAL MINE SAFETY AND HEALTH
REPORT OF INVESTIGATION
Surface Coal Mine
Fatal Powered Haulage Accident
July 10, 2002
Yokum Trucking (PDU)
Solar Sources, Inc.
Cannelburg, Daviess County, Indiana
I.D. No. 12-01732
Dennis R. Plab
Coal Mine Safety and Health Inspector
Roger Gene Jewell
Coal Mine Safety and Health Inspector
Mine Safety and Health Specialist (Training)
Originating Office - Mine Safety and Health Administration
2300 Willow Street, Vincennes, Indiana 47591
James K. Oakes, District Manager
On Wednesday, July 10, 2002, at about 2:30 p.m., Robert David Bowles, age 44, a mechanic/truck driver employed by Yocum Trucking, an independent contractor, was fatally injured at the Solar Sources Inc., Craney Mine. There were no eyewitnesses to the accident. Bowles had 1 year 6 months experience at this mine. Reportedly, the transmission on the Autocar (No. 01) tandem-axle end dump haulage truck was locked between reverse and low gear. An attempt to free the transmission by bumping the truck with another vehicle failed. Bowles then began removing the drive shaft to free the transmission. Bowles positioned himself under the truck in front of the right rear tandem axle. The drive shaft was disconnected from the differential and transmission. He then apparently used a pry bar to dislodge the drive shaft and when the drive shaft was removed, the truck rolled forward, crushing him under the right front tandem axle. The truck was not blocked against motion.
The Craney Mine is a surface coal mine located on the Cannelburg Road, two miles south of Cannelburg, Davies County, Indiana. The mine, operated by Solar Sources, Inc., produces bituminous coal and employs 110 people. The mine has two production shifts and one maintenance shift per day and operates six days per week. The average seam thickness is 24 inches, and an average of 3,700 tons of coal is mined per day.
Yocum Trucking, an independent contractor, transports coal from the pit to the raw coal pile. Yocum Trucking had five trucks (one Autocar, two Fords, one International, and one Mack (out of service) at the Craney Mine. Yocum Trucking's business office is located in Birdseye, Indiana. At the time of the accident, Yocum Trucking employed three people. Two of those persons were working at the Craney Mine. Yocum Trucking is a subcontractor for Elmer Buchta Trucking.
Elmer Buchta Trucking is a large trucking contractor located in Ottwell, Indiana. Elmer Buchta Trucking provides haulage services for over-the-road coal transportation and also coal haulage on mine property. At the Craney Mine, Elmer Buchta Trucking was providing services at the mine pit and over-the-road coal transportation. The Elmer Buchta Trucking employees at Craney Mine were being supervised and dispatched from the Elmer Buchta Trucking's Cannelburg terminal.
The principle officers for Elmer Buchta Trucking at Craney Mine during the accident investigation were:
|Robert Elrod||Supervisor Cannelburg Truck Terminal|
|Gary Phillips||Safety Director, Elmer Buchta Trucking|
The last regular safety and health inspection (AAA) by the Mine Safety and Health Administration was completed on March 20, 2002, and another was ongoing at the time of the accident. The Non-Fatal Days Lost (NFDL) Incidence rate for the mine is 2.55. The NFDL rate for the Nation for surface mines is 3.08. The rate for Yocum Trucking is 0.0 and the National rate for all contractors is 3.9.
The principle officer for the Yocum Trucking at the time of the accident was:
The principle officers for the Craney Mine at the time of the accident were:
|Donald Keller||Chief Mining Officer|
|Roger Campbell||Preparation Plant Superintendent|
|Stephen Edwards||Safety Director|
|Ernie Seib||Pit Foreman|
|Tony Chamberlin||Preparation Plant Foreman|
On Wednesday July 10,2002, the day shift began as usual at the Craney Mine. Coal production began at 6:00 a.m. in the Craney Mine Midway Pit. The Craney Mine's employees were under the supervision of Ernie Seib, Pit Foreman. Coal was being hauled out of the Midway Pit by contract truckers, one of which was Yocum Trucking. On this day, there were two Yocum trucks being operated. Stanley Johnson was driving the No. 01 Autocar tandem-axle end dump truck and Robert David Bowles (Victim) was driving an International tandem-axle end dump coal truck. Bowles and Johnson began hauling coal out the Midway Pit to the raw coal pile at approximately 6:00 a.m. The round trip distance was approximately three miles.
Normal mining operation continued with coal being hauled to the raw coal yard by the contract truckers. At the raw coal yard, the coal was dumped and then fed into a hopper by two end loaders and transported to the nearby coal preparation plant via belt conveyor. The end-loaders were operated by Solar Sources' Craney Mine employees, Greg Wineinger and Jim Eilert.
Johnson and Bowles hauled coal to the raw coal yard until approximately 2:00 p.m. when the Autocar truck Johnson was driving reportedly became locked in gear. This occurred when Johnson had stopped and was attempting to shift into reverse to dump the load being hauled. In an attempt to get the transmission out of gear, Johnson asked Wineinger to bump the rear of the truck with the end-loader bucket. Wineinger stated that he bumped the haul truck a couple of times with the end-loader. The transmission did not release. Wineinger then commented to Johnson that he would rather not bump the truck again because it might damage the truck. These communications took place with CB radios. Bowles overheard these discussions and stated over the CB radio that they should not bump the truck anymore from the rear. Bowles asked Wineinger if it was possible to bump the truck from the front end. Wineinger replied to Bowles that he could not because the truck was located too close to a pile of coal. Moments later, Bowles arrived.
Bowles positioned the International truck at the front of the Autocar truck and determined that the front bumpers would line up. Bowles, with Johnson in the Autocar truck, then tried bumping the Autocar truck with the International truck in another attempt to free the Autocar's transmission. This attempt also failed.
Bowles told Johnson that he would need to work on the Autocar truck and for Johnson to leave the truck and take him to the maintenance vehicle located at the Yocum Trucking parking area. Johnson stated that he set the parking brake on the Autocar truck before he left the truck. Bowles instructed Johnson to begin using the International truck. Bowles then returned to the raw coal yard with the maintenance vehicle.
Bowles parked the maintenance vehicle near the Autocar truck. He obtained tools from the maintenance vehicle and apparently crawled under the truck to start repairs. Wineinger was present at the Autocar truck at this time, and stated that Bowles began working on the truck using a pry bar to apply pressure to the drive shaft to free the transmission. This was not successful. Bowles commented to Wineinger that it was really locked up and he would have to loosen the drive shaft. Bowles obtained tools from the maintenance vehicle and crawled under the haul truck and began loosening the bolts securing the drive shaft. Wineinger asked Bowles if he needed any help and Bowles stated that he could get it. Wineinger then returned to his end-loader and began transporting coal to the hopper.
Wineinger stated that he transported several loads of coal and observed Bowles working under the truck. Approximately 10 to 15 minutes later, while passing the truck, Wineinger noticed Bowles' hard hat and thought it was in an unusual position. Wineinger dismounted the end-loader and upon investigation found that Bowles had been run over by the truck. Wineinger immediately returned to his end-loader and called for help over the CB radio. Eilert, who was also working on the raw coal pile, heard Wineinger and traveled to the accident scene. Wineinger had moved his end-loader around to the rear of the Autocar truck and was preparing to lift the truck off the victim when Eilert, who had checked Bowles for a pulse, informed Wineinger that there was no need to move the truck.
The Daviess County Sheriff Department received the 911 call from the Craney Mine at 2:21 p.m. The Cannelburg Fire Department and Southwest Medical Ambulance Service were sent to the scene. Cannelburg Fireman Earl Wagler and Daviess County Sheriff Department Detective Sergeant Gary Allison determined that Bowles had died as a result of his injuries. Lyndon Cullen, Daviess County Coroner, was notified and upon his arrival, the body was removed and transported to the Daviess Community Hospital.
The Mine Safety and Health Administration (MSHA) Vincennes, Indiana, Field Office, District 8, was notified by Stephen Edwards, Safety Director of Solar Sources, Inc., Craney Mine, at approximately 2:50 p.m., Central Standard Time (CST), that a fatal accident had occurred when a haul truck had rolled forward, causing fatal injuries to a mechanic. Emergency personnel from Southwest Medical, Cannelburg Fire Department, and Daviess County Sheriff Department were notified and quickly responded. After being informed of the accident, Elzia Napier, Charles Weilbaker and Dennis R. Plab, Safety and Health Coal Mine Inspectors, were dispatched to the scene to secure the accident site.
MSHA dispatched an accident investigation team with members from the Vincennes, Indiana Field Office, the Mechanical Safety Division, Approval and Certification and the Benton, Illinois Field Office, to the Craney Mine on Thursday, July 11, 2002. Upon arriving at the mine, the accident investigation team made contact with management officials of Solar Sources, Inc., a representative of Yocum Trucking, and management of Elmer Buchta Trucking. This investigation became a joint MSHA-State investigation when Don Fiestal, inspector for the Indiana Bureau of Mines, arrived a little later. Interviews of individuals at the mine known to have actual knowledge of the facts surrounding the accident were conducted at the Craney Mine the morning of July 15, 2002.
The toxicology report from the Daviess County Coroner indicated that mild alcohol intoxication was present. It is uncertain if this represents a factor that contributed to the accident.
The accident occurred on the surface at the raw coal yard. The haulage road surface consisted of highly compacted coal and shale.
The Accident SiteThe Autocar tandem-axle end dump haulage truck was positioned on the haulage road of the raw coal yard. The surface of the haulage road appeared level in this area. The truck was actually parked on approximately a 2% grade. The weight of the empty truck was 39,500 pounds. At the time of the accident, the load of coal on the truck weighed 54,240 pounds. This resulted in a GVW of 93,740 pounds.
Bowles was positioned under the haulage truck attempting to free the transmission that was locked in gear by removing the drive shaft. There were no blocks or chocks installed to prevent the truck from rolling while the repair work was being performed.
The Haulage TruckThe haulage truck on which repair work was being conducted was a 1991 Autocar Model ACL 64B Tandem-axle Truck, VIN No. 4V2SOBJG3MU507719 with a dump bed, S/N 9008174 manufactured by May Metal Products Inc. The truck was equipped with a 400 HP Model NTC-88-BCIV six cylinder Cummins engine and an Eaton-Fuller 10 speed Model RTXF-14470-8LL transmission.
The truck was equipped with s-cam shoe type brakes. The brakes on the rear tandem axles were activated by Type 30 clamp type maxi-canisters. These canisters had two chambers, one was an air activated service brake and the other was a spring-applied air-released parking brake chamber. Type 24 clamp type single chamber air-activated service brake canisters activated the two front brakes.
The parking brake system was tested at the location of the accident. With the drive shaft still removed, the truck was pulled a few feet backward to the location the truck was in when the accident occurred. The parking brake was applied while the towing vehicle was still holding the truck. The parking brake held the machine stationary when the pressure was released from the towing vehicle. When the parking brake was released, the truck rolled forward, simulating the movement that apparently occurred during the accident.
Stanley Johnson, operator of the Autocar (01) haulage truck, stated that the service brakes and parking brakes functioned properly during the shift prior to the accident. Johnson stated that at one time during the shift, he had stalled the loaded truck while traveling on the incline out of the pit. The parking brakes were set to restart the truck and the brakes held properly.
An examination of all the brake components was made and the results of this examination as it pertains to the North American Standard Out-Of-Service Criteria is addressed in Appendix ( C ).
At the time of the accident, the transmission was reportedly locked in gear. Mine personnel believed that the transmission was locked between reverse and low gear. When the ignition was turned on, the back-up alarm was sounding, which indicated the transmission shifter was in the reverse position. With the drive shaft still removed, the truck was started. When the clutch pedal was released, the drive yoke on the transmission turned. With the clutch pushed in, the driver was able to shift between gears in the transmission.
An examination of Bowles' training records revealed that there were no violations of 30CFR Part 48 that contributed to the accident.
Training plan deficiencies revealed during the investigation were cited under another inspection code.
A root cause analysis was performed using the data from the accident. The following causal factors and root causes were identified:
- Causal Factor - Bowles failed to notice the slight grade where the truck was located.
Root Cause - Human Performance Difficulties - Had Bowles followed normal procedures addressed in training, to block the truck from motion, the truck would not have rolled forward.
- Causal Factor - Bowles failed to check to see that the truck brakes were set.
Root Cause - Human Performance Difficulties - Bowles should have recognized the possibility of the truck moving and set the brakes prior to starting work.
- Causal Factor - Bowles failed to raise the hood of the truck when problems occurred.
Root Cause - Human Performance Difficulties - Indicated that management had a policy addressed in the training plan which required persons to raise the hood of vehicles when problems arose, so supervisors would be aware.
The root cause of the accident was the slight grade the truck was parked on. Slight variations in the parking area surface may have contributed to a nearly imperceptible grade.
The cause of the accident was that the victim failed to block the truck against motion while performing maintenance work under the vehicle.
A 103(k) Order (No.7566287) was issued on July 10, 2002, and was terminated on July 16, 2002, under the provision of Section 103(k) of the Mine Act.This mine has experienced a fatal truck haulage accident at the raw coal yard. This order is issued to assure the safety of any person in the coal mine until an examination or investigation is made to determine that the Autocar coal truck (# 01) and the raw coal yard are safe. Only those persons who are selected from company officials, state officials, the miners' representative and other persons who are deemed by MSHA to have information relevant to the investigation may enter the affected area.
A Section 104(a) citation (No. 7566415) was issued on July 16, 2002.Repair work was conducted on the No. 01 Autocar tandem-axle end dump haulage truck. The truck was parked on approximately a 2% grade and was not blocked against motion. The mechanic was positioned under the vehicle working on the drive shaft of the truck. When the drive shaft was removed, the truck rolled forward causing fatal injuries to the mechanic. This condition was observed during the fatal accident investigation.
Related Fatal Alert Bulletin:
Listed below are those persons who participated and/or were present during the investigation:
Roger Campbell .............. Preparation Plant Superintendent
Stephen Edwards .............. Safety Director
Ernie Seib .............. Pit Foreman
Tony Chamberlin .............. Preparation Plant Foreman
Gary Phillips .............. Safety Director
Robert Elrod .............. Terminal Manager (Cannelburg Terminal)
Roy A. Yocum .............. Owner
Joseph L. Hensley .............. Trainer (Contract)
Don Fiestal .............. State Mine Inspector
Charles Weilbacker .............. Supervisory Coal Mine Safety and Health Inspector (Acting)
Dennis R. Plab .............. Mine Safety and Health Specialist (Roof Control)
Roger Gene Jewell .............. Mine Safety and Health Specialist (Surface)
Elzia Napier .............. Coal Mine Safety and Health Inspector (Surface)
Leland Payne .............. Mine Safety and Health Specialist (Training)
Gary Allison .............. Detective Sergeant (Sheriff's Department)
Linden Bowles .............. County Coroner
Greg Wineinger .............. End-loader Operator
Jimmie Eilert .............. End-loader Operator
Stephen Edwards .............. Safety Director
Ernie Seib .............. Pit Foreman
Roy A. Yocum .............. Owner
Stanley Johnson .............. Truck Driver
Joseph L. Hensley .............. Safety Consultant
Robert Elrod .............. Terminal Manager Cannelburg Terminal
Gary Phillips .............. Safety Director
BRAKE COMPONENT EXAMINATION: The following observations were made while checking the brakes at each wheel. NOTE: The maximum allowable push rod travel of 2.0 inches (where adjustment is required) for Type 30 air chambers and 1 � inches (where adjustment is required) for Type 24 air chambers is specified in the North American Standard Out-Of-Service Criteria.
a) Right Front Axle Brake: The brake shoe linings were �- inch thick, and the brake drum wear surface was smooth. A 1/8-inch ridge existed at the edge of the wear surface on the inside end of brake drum, showing the drum was worn. The brake canister push rod travel measured 1 3/8 inches, which was within the maximum recommended adjustment limit of 1� inches for a Type 24 clamp type brake canister. Both the brake lining and the drum wear surfaces were dry and had no signs of grease or oil on them.
b) Left Front Axle Brake: The brake shoe linings were �-inch thick. The brake drum wear surface was clean and smooth with no visible wear ridge. A dust cover was installed on this wheel. The brake canister push rod travel measured 2 3/8 inches, which was 5/8 inches greater than the maximum recommended adjustment limit of 1 � inches for a Type 24 clamp type brake canister. Both the brake lining and the drum wear surfaces were dry and had no signs of grease or oil on them.
c) Right Forward Drive Axle Brake: The brake shoe linings were 3/8-inch thick. The brake drum wear surface was rough and was tapered from the outside end (bolt- hole side) of the drum to inside end of the drum. The brake canister push rod travel measured 1 3/4 inches, which was within the maximum recommended adjustment limit of 2.0 inches for a Type 30 clamp type brake canister. Both the brake lining and the drum wear surfaces were dry and had no signs of grease or oil on them.
d) Left Forward Drive Axle Brake: The brake shoe linings were 1/8-inch thick, and the brake drum wear surface was smooth. The brake canister push rod travel measured 2 9/16 inches, which was 9/16 inches greater than the maximum recommended adjustment limit of 2.0 inches for a Type 30 clamp type brake canister. Both the brake lining and the drum wear surfaces were dry and had no signs of grease or oil on them.
e) Right Rear Drive Axle Brake: The brake shoe linings were �-inch thick, and the brake drum wear surface was smooth. The brake canister push rod travel measured 2 5/16 inches, which was 5/16 inches greater than the maximum recommended adjustment limit of 2.0 inches for a Type 30 clamp type brake canister. Both the brake lining and the drum wear surfaces were dry and had no signs of grease or oil on them. When the air was released from the service brake chamber, the push rod did not fully retract. The push rod was easily stroked in and out by hand.
f) Left Rear Drive Axle Brake: The brake shoe linings were 3/16-inch thick, and the brake drum wear surface was smooth. The brake canister push rod travel measured 2 3/16 inches, which was 3/16 inches greater than the maximum recommended adjustment limit of 2.0 inches for a Type 30 clamp type brake canister. Both the brake lining and the drum were dry and had no sign of grease or oil on them.
AIR SYSTEM: The truck had two air tanks located inside of each frame rail under the front of the dump bed. No air leaks were found during the brake system checks. Tests were conducted in accordance with the North American Standard Out-Of-Service Criteria to evaluate the air compressor and governor. With the pressure in the air system at 80psi (pounds per square inch), the engine idling, and the service brake fully applied, the air system pressure continuously increased. The air compressor governor cut-in and cutout pressures were checked. The air compressor cut-in pressure was approximately 93psi and the cutout pressure was approximately 125psi. The tests showed that the air compressor and governor met the North American Standard Out-Of-Service Criteria.