DEPARTMENT OF LABOR
MINE SAFETY AND HEALTH ADMINISTRATION
Report of Investigation
Surface Nonmetal Mine
(Sand & Gravel)
Fatal Machinery Accident
October 17, 2002
Portable Wash Plant
Ellensburg Cement Products, Inc.
Ellensburg, Kittitas County, Washington
ID No. 45-03330
Steve I. Pilling
Supervisory Mine Safety and Health Inspector
Randy W. Horn
Mine Safety and Health Inspector
Anita L. Goodman
Mine Safety and Health Specialist
Michael P. Shaughnessy
Mine Safety and Health Administration
2060 Peabody Road, Suite 610
Vacaville, California 95687
Lee D. Ratliff, District Manager
On October 17, 2002, Patrick J. Strahm, front-end loader operator, age 45, was fatally injured while attempting to hook a chain from the excavator bucket to the frame of a conveyor.
The accident occurred because the victim was working below the raised bucket without blocking the equipment from accidental movement. Failure of the excavator operator to receive task training prior to operating the Volvo Samsung SE350LC-2 Excavator, was a contributory cause.
Strahm had a total of 11 years and 12 weeks of mining experience all at this mine. He had received training in accordance to 30 CFR, Part 46.
Portable Wash Plant, a sand and gravel operation, owned and operated by Ellensburg Cement Products, Inc., was located near Ellensburg, Kittitas County, Washington. The principal operating official was James O. Hutchinson, President. The mine was normally operated one 10-hour shift a day, 6 days a week. Total employment was six persons.
The mine operator had hired a contractor to crush material that had been hauled to this site previously. Two days prior to the accident, the mine operator moved his portable plant onto the site to process material stockpiled by the contractor. The wash plant was fed by a front-end loader. The material was screened, washed, stockpiled, and sold primarily for sanding roads in the winter months.
The last regular inspection of this portable operation was completed on April 16, 2002.
On the day of the accident, Patrick J. Strahm (victim) reported to work at 5 a.m., his normal starting time. He relieved the night shift front-end loader operator. Strahm's assigned task was to operate the front-end loader, feed the plant, and stockpile the finished product.
At about 6:45 a.m., George Seubert (superintendent) and James Strahm (plant operator) discussed raising the conveyor stacker up and rotating the tires so it could be moved from side to side with the loader. The conveyor stacker needed to be moved because the finished product was near the head pulley. Seubert contacted the contractor, Seegert Inc., who had finished crushing for them, to obtain permission to use their excavator that had not yet been removed from the site. Seubert was told by the contractor that the controls operated backwards from Caterpillar. At about 8 a.m., the wash plant was shut off and Seubert positioned the excavator next to the stacker conveyor with the bucket position 3 to 4 feet above the conveyor. The victim and Bradley Hunt (laborer) walked up the conveyor stacker to hook the chains from the bucket to the frame of the conveyor. Seubert decided to leave the cab of the excavator and, as he proceeded to lock out the controls, the joystick accidentally hit his arm causing the boom of the excavator to swing left and down at the same time, pinning the victim between the bucket and conveyor frame.
Seubert immediately raised the bucket off the victim and James Strahm ran up the conveyor belt to assist in getting the victim down. CPR was started and Seubert called 911. Emergency personal arrived about 8:22 a.m. and could not get any response. The county coroner arrived about 9:34 a.m. and pronounced the victim dead at the scene. Death was attributed to blunt force trauma.
The MSHA Bellevue, Washington, office was notified of the accident at 8:30 a.m. on October 17, 2002, by a telephone call from Steve Rhodes, Administrator, to Karen Olanda, secretary. An investigation was started the same day. An order was issued under the provisions of Section 103(k) of the Act to ensure the safety of the miners. MSHA's accident investigation team traveled to the mine, conducted a physical inspection of the accident site, interviewed employees, and reviewed training records and work procedures. MSHA conducted the investigation with the assistance of mine management and miners.
The accident occurred at the wash plant used to process material after it had been crushed and sized. The mobile plant was designed to be moved from one location to another by towing or by transporting it on trailers. The wash plant was transported to this pit and set up on October 15, 2002. The plant consisted of a feed hopper, screen deck and stacker conveyor belt. The conveyor belt, manufactured by Nordberg, was approximately 46 inches wide and 78 feet long. The stacker conveyor was mounted on two tires so it could be moved from one location to another. The tires could be changed from a parallel position to a perpendicular position, which would allow the conveyor to be moved from side to side while stacking sand.
The mobile equipment involved in the accident was a Volvo Samsung Excavator, Model SE350LC-2, Serial Number JAY 1412. The excavator was track mounted, hydraulically operated, and equipped with an articulated boom and a bucket attached. The excavator, manufactured in 1999, was powered by a Cummins M11 diesel engine. Engine driven pumps powered all the hydraulic system components, including the wheel/track tram motors, boom cylinders, arm cylinders, and bucket cylinders.
The tram and steering functions of the machine were controlled by two hand levers/foot pedals. Forward /rearward and left/right movement was controlled by using either the hand levers or the foot pedals. The hydraulic functions of the equipment were controlled by two joystick type levers located near the operator's seat. One lever was located to the left of the operator's seat on a pivoting console, and the other lever was located to the right of the operator's seat on a stationary console. The joystick type controls were spring loaded to return to a neutral position upon release. With the engine running, the hydraulic functions (boom up/down, bucket movement, arm swing, arm in/out, and tram/steering control) were tested. No defects were found in the tram/steering or implement movement, but the left and right implement control levers did not function as specified in the manual.
According to the Operation and Maintenance Manual for this excavator, the left control lever operated the arm swing and arm in/out functions, and the right lever controlled the boom up/down and bucket functions. Testing showed that the left implement control lever operated the boom up/down functions and the arm swing functions, and the right implement control lever operated the arm in/out and bucket functions. Further investigation showed that there was a hand-written note in the machine's manual on the page that explains the operation of the implement control levers. The note read as follows: "NOTE- Controls switched to John Deere Functions July 2001".
The console on which the left implement control lever was mounted was incorporated into a safety hydraulic lockout system. A spring-loaded lever located between the seat and the console released the console when actuated. This action caused the console unit to pivot upward and toward the rear of the operator's compartment. Upon pivoting upward, the console tripped a switch that shut down and locked out the hydraulic system. This procedure placed the console in the hydraulic "LOCK" position rendering the entire machine's hydraulic controls and functions inactive. To restore hydraulic function, the console had to be placed in the hydraulic "UNLOCK" position by pushing the console unit down until the spring-loaded release lever locked into position.
This device was intended to be used in situations when the hydraulic system needs to be shut down but the engine must remain running, such as when inspection and/or maintenance is being performed on the machine. The system was also designed so that the operator cannot enter or exit the seat without first releasing and raising the console unit to the hydraulic "LOCK" position.
With the engine running, the console release lever was actuated, and the console pivoted upward as specified and all hydraulic functions were locked out (inoperative) as specified in the Operation and Maintenance Manual for the Excavator.
During the performance of these tests, the left implement control lever was inadvertently bumped by the operator's left arm when the console release lever was actuated and the console unit pivoted upward. When the left implement control lever bumped the operator's arm, the lever was pushed forward and to the left, causing the boom to move downward and to the left. This action occurred before the console unit could fully pivot to the up (hydraulic "LOCK") position and trip the hydraulic lockout switch. This test was repeated three times and produced the same result. The test was done by the owner, he did not hit his arm because he was aware of this condition and held his arm out of the way. During this examination, the console unit pivoted upward approximately 20 to 30 degrees before it activated the hydraulic lockout switch. According to the Volvo representative, the lockout switch should activate when the console pivots upward approximately 25 degrees.
A root cause analysis was conducted. The following causal factors were identified.
Causal Factor: The victim was positioned under the raised bucket securing a chain.
Corrective Action: Establish a procedure for blocking equipment in a raised position. Require that the raised components of the mobile equipment be secured to prevent accidental lowering prior to persons working under them.
Causal Factor: The company used a borrowed excavator that no one had previously operated or had been properly trained to use.
Corrective Action: Establish a policy that requires a personnel who are unfamiliar with the control functions and operating the equipment for the first time to be provided with new task training. Task train personnel in the safety aspects and safe working procedures specific to the equipment that will be operated.
The accident was caused by the failure to block the raised excavator bucket against movement before working below it. The excavator operator's unfamiliarity with the control console functions resulted in the accidental lowering of the bucket.
Note: Some or all of these violations were affected based on a decision by the Federal Mine Safety and Health Review Commision. See More InformationOrder No. 7999818 was issued on October 17, 2002, under the provisions of Section 103 (k) of the Mine Act:
A fatal accident occurred at this operation on October 17, 2002, when two miners walked up the radial stacker conveyor to rig lifting chains to an excavator bucket to move the conveyor. This order is issued to assure the safety of persons at this operation and prohibits all activity at the mine site until MSHA has determined that it is safe to resume normal mining operations in this area. The mine operator shall obtain prior approval from an Authorized Representative for all actions to recover and/or restore operations to the affected area.This order was terminated on October 19, 2002. The conditions that contributed to the accident have been corrected and normal mining operations can resume.
Order No. 6343801 was issued on October 19, 2002, under the provisions of Section 104 (d)(1) of the Mine Act for violation of 30 CFR 46.7 (a):
A miner was fatally injured at this mine on October 17, 2002, when he was caught between the bucket of a Volvo Samsung SE-350 LC-2 excavator and the frame of a conveyor. The mine Superintendent who was operating the excavator admitted he was unfamiliar with its control functions and was operating the excavator for the first time. He operated the excavator without first having been task trained in the safety aspects and safe working procedures specific to the Volvo Samsung hydraulic excavator as required by 30 CFR Part 46. He was unaware of how the console would move when he attempted to leave the operator's seat. When he moved the console, he bumped a control lever causing the bucket to move and strike the victim. The mine operator engaged in aggravated conduct constituting more than ordinary negligence in that he was aware that he was unfamiliar with the controls of the excavator and he negligently exposed miners to the hazard of his operating the equipment without being properly trained in its safe operation. This violation is an unwarrantable failure to comply with a mandatory regulation.This citation was terminated on October 19, 2002. The mine operator stated that task training would be provided to miners before they operate any equipment for the first time.
Order No. 6343802 was issued on October 19, 2002, under the provisions of Section 104 (d)(1) of the Mine Act for violation of standard 56.14211 (c):
A fatal accident occurred at this operation on October 17, 2002, when a miner was caught between an elevated excavator bucket on the Volvo Samsung SE-350 excavator and the frame of a conveyor. The mine superintendent who was operating the excavator directed two miners to walk up an inclined conveyor belt and attach a chain that was suspended from the elevated bucket to the conveyor structure. This required the miners to work under the raised bucket. As the superintendent moved the excavator console he bumped a control lever causing the bucket to drop and strike the victim. The mine operator engaged in aggravated conduct constituting more than ordinary negligence in that he was aware that the miners were performing work under the raised bucket and he failed to initiate actions to eliminate the hazard by insuring that the raised bucket had been blocked or mechanically secured to prevent accidental lowering. This violation is an unwarrantable failure to comply with a mandatory regulation.The citation was terminated on October 19, 2002. The mine operator provided training to his miners for blocking equipment in a raised position prior to working underneath the raised component of the equipment.
Related Fatal Alert Bulletin:
Ellensburg Cement Products, Inc.
James O. Hutchinson ............. presidentMine Safety and Health Administration
James Jeff Hutchinson ............. vice-president
Steve Rhodes ............. administrator, safety coordinator
George A. Seubert ............. superintendent
Steve I. Pilling ............. supervisory mine safety and health inspector
Randy W. Horn ............. mine safety and health inspector
Michael P. Shaughnessy ............. mechanical engineer
Anita L. Goodman ............. mine safety and health specialist (training)
Aggregate Industries West Central Region, Inc.
George A. Seubert ............. superintendentSeegert Inc.
Bradley J. Hunt ............. labor
Nick Seegert, Sr. ............. owner of Seegert, Inc. and Volvo Samsung excavator