DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
Metal and Nonmetal Mine Safety and Health
REPORT OF INVESTIGATION
Surface Nonmetal Mine
Fatal Machinery Accident
May 3, 2002
J&G Heavy Equipment Company
Miami, Dade County, Florida
Contractor I.D. E333
Rinker Materials of Florida Incorporated
Miami, Dade County, Florida
Mine I.D. 08-00519
Supervisory Mine Safety and Health Inspector
Frederick B. Moore
Mine Safety and Health Inspector
Mine Safety and Health Administration
135 Gemini Circle, Suite 212; Birmingham, AL 35209
Martin Rosta, District Manager
On May 3, 2002, Filiberto Leon, dozer operator, age 62, drowned when he trammed a Komatsu Crawler Dozer, model number D85E-21, over the edge of a dragline workpad and into approximately 66 feet of water. Leon was using the dozer blade to back-drag the workpad to prepare the area for the dragline to be relocated.
There is no conclusive evidence to determine the cause of the accident. Leon had a total of 20 years mining experience, with three months at this location all as a dozer operator with J&G Heavy Equipment Company. Leon had received training in accordance with 30 CFR, Part 46.
FEC Quarry and Plant, a crushed limestone operation, owned and operated by Rinker Materials of Florida, Incorporated, was located at 13292 NW 118th Avenue, Miami, Miami-Dade County, Florida. The principal operating official was Johnny R. Arellano, operations manager, south region. The mine normally operated three eight-hour shifts a day, seven days a week. Total employment was 169 persons.
After removing overburden, the area to be mined was normally below the water table. Broken limestone was placed on top of the mining site where it was leveled and compacted to form a working pad that was slightly above the water table. This working pad supported the draglines, drills, front-end loaders, haulage trucks, and other equipment.
Limestone was drilled and blasted, then excavated by dragline from under water and stockpiled in windrows for drying. The material was then loaded by front-end loader into haul trucks and transported to the milling area to be crushed, sized, screened, and stockpiled. The product was sold for use as construction aggregate.
The last regular inspection at this operation was completed March 5, 2002. A regular inspection was conducted following the investigation.
DESCRIPTION OF ACCIDENT
On the day of the accident, Filiberto Leon (victim) reported to work at 07:00 a.m., his regular starting time. At 7:30 a.m. David Cochran, Supervisor of Strip, Pad, and blasting operations instructed Leon to push the berm in at lake six east and north so the drill could start drilling. Leon completed this job and between 12:30 p.m. and 1:00 p.m., Cochran observed Leon traveling to Lake five west to begin working on the dragline pad so the 480 dragline could be moved to the west corner of Lake Five.
At 12:00, Felix Traveras, the 480-dragline oiler, observed Leon fueling and servicing his dozer. After servicing the dozer, Leon arrived at Lake Five west. Traveras, acting as the interpreter for Jeff Shaffer, supervisor of pads, told Leon he needed him to back drag the backside or muck side of the pad where the 480 dragline was preparing to relocate. Traveras stated that Leon told him he had to leave at 02:30 p.m. and can't finish the job. Shaffer stated he told Leon to stay and back drag a bit, because he needed to move the 480 dragline to that corner that afternoon. He stated Leon agreed to do it. After their conversation, Shaffer transported Traveras to another location to get a forklift to pull the dragline cable and returned with it at 2:20 p.m. Upon his return, Traveras stated Leon and the dozer where gone.
Shaffer told Brian Throckmorton, the 480-dragline operator, to throw more back fill material up for the pad. During this time, Throckmorton observed Shaffer and Traveras talking to Leon. When Shaffer and Traveras left to get the Forklift, Throckmorton observed Leon stop his dozer, get out, and pick up a dig line stake he had knocked over. He then observed Leon pushing the berm in on the north side corner of the lake. At 2:10 p.m., Brian noticed that Leon and the dozer was gone. Throckmorton stated at around 3:00 p.m. they had set up to move to the northwest corner of Lake Five after Traveras had finished pushing material around in the corner. We positioned the dragline and began digging at 5:00 p.m. We continued digging until the shift change at 6:00 p.m.
Claudius Davis, dragline operator, came to work at 6:00 p.m. and arrived at Lake Five west at 6:30 p.m. Throckmorton and Traveras told Davis that they had moved into the cut, but did not finish it. Davis and Teddy, dragline oiler, serviced the dragline and started digging at approximately 6:30 p.m. Davis stated he saw a lunch box pop up, then a hard hat, seat cushion and funnel, and also observed black oil on the water surface. Teddy retrieved these items. The next bucket brought up the dozer hood with muffler. They dug two or three more buckets with no more items brought up. After the fourth bucket, they saw fuel on the surface of the water. The next bucket brought up the dozer side door. The next three to four buckets produced more fuel on the water. Davis, realizing what was coming up, called Charley Davidson, Leadman, who in turn called Danny Blomme, Assistant Quarry Manager. Blomme arrived twenty minutes later and the digging was stopped 10:45 p.m., and the area was secured. Blomme identified the items recovered as belonging to the victim. He called 911 and the Miami Dade County Police arrived at the scene along with their dive team around 11:30 p.m. The search of the Lake and surrounding area were unsuccessful and the rescue efforts were called off at 4:00 a.m. May 4, 2002 and resumed again at 10:00 a.m. the next morning. A cadaver dog was brought to the scene when the search resumed. There was no indication of how or why the dozer fell into the lake. The body was recovered at 6:30 a.m. by Johnny Arellano, Regional Operations manager.
INVESTIGATION OF THE ACCIDENT
At about 7:15 a.m. on May 4, 2002, Harry Verdier, assistant District Manager, Southeast District Office was notified of the accident by a telephone call from Alan MacVicar, Safety Manager, CRS Rinker Materials. A 103k order, to ensure the safety of the miners and to preserve the evidence, was issued by Leroy Ford, Mine Safety and Health Inspector from the Bartow Florida Field Office, at 2:51p.m. May 4, 2002. An MSHA accident investigation team traveled to the mine, made a physical inspection of the accident scene, interviewed employees, and reviewed conditions and work procedures relevant to the accident. There was no designated miners' representative at the mine.
The Lake five area, where the accident occurred, was shaped like a rectangle. The area had an average width of 90 feet (north to south) and an average length of 500 feet (east to west). The western side of the lake was irregular because some areas had been drilled and blasted and the material mined. The accident occurred on the northwestern corner of the lake.
Water on the northwestern side of the lake had an approximate depth of 65 feet. On the western side of the lake, mined material had been removed and stockpiled approximately mid-way between the north and south side.
There were no berms provided along the western side of the lake since this is the area that the active mining was occurring. Also about one hundred feet of the berm on the northwestern edge was removed to facilitate the dragline swing radius.
MACHINE INFORMATION: The track dozer involved in the accident was a Komatsu Model D85E-21 Crawler Dozer, Serial Number 35064. The dozer was equipped with a dozer blade but not the ripper attachment. The operating weight of the dozer was approximately 62,000 pounds. It was equipped with a six-cylinder Komatsu S6D125E-2 diesel engine. The transmission had three forward speeds and three reverse speeds with a maximum operating speed of 7.3 MPH (forward) and 8.9 MPH (reverse).
MACHINE CONDITION: The machine was severely damaged from being struck by the dragline bucket numerous times before it was determined that the dozer was in the water. The machine could not be operated during the field investigation due to the damage sustained.
CAB: The cab, as manufactured, was fully enclosed and equipped with an air conditioner. A Komatsu ROPS, meeting applicable standards and regulations was installed. No seatbelt was found.
CONTROLS: A decelerator pedal and brake pedal were provided. The decelerator pedal is used to override the governor and reduce engine speed. Both pedals moved freely and no obstructions were found that interfered with pedal movement. The brake pedal is designed so that either the right or left brakes can be applied individually or both at once.
A brake lock lever is used to lock the brake pedal when parking. When the brake pedal is depressed, the lock lever can be placed in the "LOCK" position to keep the brake applied.
A Steering Lever is used to steer the machine. If the lever is moved partially in the direction of turn of the machine, the steering clutch is disengaged and the machine turns gradually. If the lever is turned more, the steering brake is applied and the machine will turn on the spot. Following the recovery of the machine, the steering control was found in the neutral position.
The Gear Shift Lever changes the transmission gear range. The operator may choose any of three forward speeds, three reverse speeds, or neutral.
A Fuel Control Lever is used to control the engine speed and output. It is also used to stop the engine.
The dozer blade is controlled by a separate joystick lever using the right hand.
STEERING/BRAKES: The lever-controlled, wet, multiple disc steering clutches are hydraulically boosted and hand operated. Wet, contracting band, foot operated steering brakes are designed to allow easy light touch steering/braking actions. The steering clutches and brakes are interconnected and utilize a hydraulic brake booster.
When either the right or the left steering lever is pulled part way, the corresponding steering valve operates to disengage the steering clutch. Since some power transmission of the steering clutch remains because of the rotation of the disengaged clutch, the machine will make a gradual turn.
When the steering lever is pulled fully, the brake valve corresponding to the steering lever being pulled opens a passage through which oil flows to the brake booster and actuates the steering brake. The machine will turn on the spot.
When the brake pedal is depressed, the brake booster applies the brake by contracting the brake band smoothly. When the brake is fully applied, the booster supplies full system pressure to the brake.
No independent parking/emergency brake is supplied. The brake lock lever is used to lock the service brake pedal in place when the machine is parked.
BRAKE INSPECTION: The linkages from the brake pedal to the band brake were intact and showed no signs of binding. With the brake pedal depressed, the brake lining was checked according to the procedure outlined on page 3-31 of the Operation and Maintenance Manual. This procedure indicates the setting of the brake adjustment bolt should be a minimum of 71 mm. The adjustment was found to be 76 mm on the right side and 77 mm on the left side. As long as the adjustment is greater than 71 mm, the brake lining is sufficient.
BRAKE TEST: Following the recovery of the dozer from the water, the holding capability of the brake was tested by pulling on the dozer with a Front End Loader. Since this test was done with the dozer engine not running, the band brake could only be applied manually without the aid of the hydraulic booster pressure. Under these conditions, as expected, the dozer moved.
There were no accurate determining causes of the accident.
Order No. 6067333 was issued on May 4, 2002, under provisions of Section 103 (k) of the Mine Act: A fatal accident occurred at this mine on May 3, 2002, when a miner apparently attempted to back drag the area around the NW corner of the Lake 5 area. This order is issued to assure the safety of all persons at this operation. It prohibits all activity at the Lake 5 area until MSHA has determined that it is safe to resume normal mining operations in the area. The mine operator shall obtain approval from an authorized representative for all actions to recover and/or restore operations to the affected area.
This order was terminated on May 8, 2002. This action is taken to allow the operator to resume normal operations.
Related Fatal Alert Bulletin:
Persons Participating in the Investigation
Rinker Materials Corporation
Johnny Arellano .......... plant managerJ&G Heavy Equipment Co.
Alan G. MacVicar .......... safety manager
Danny M. Blomme .......... assistant quarry manager
Bob Merkel .......... attorney at law
Erin Gaskin .......... attorney at lawMiami-Dade Police Department
Jose Gonzalez .......... president
Javier Gonzalez .......... son of owner
Enrigue Schavarry .......... homicide detectiveMiami-Dade County Medical Examiner Department
Dr. Ray Fernandez .......... medical examinerIndustrial Divers Corporation
Shawn Rogers .......... diverMine Safety and Health Administration
Hector Verdi .......... diver
Drew Guy .......... diver
Mitchell Adams .......... supervisory mine safety and health inspector
Frederick B. Moore .......... mine safety and health inspector
Rich Skrabak .......... mechanical engineer
APPENDIX BPersons Interviewed Rinker Materials Corporation
David Crockran .......... supervisor of pads, strip and blasting
Felix Traveras .......... dragline oiler
Brian Throckmorton .......... dragline operator
Jeff Shaffer .......... supervisor
Claudius Davis .......... dragline operator
Danny Blomme .......... assistant quarry manager