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U.S. Department of Labor Mine Safety and Health Administration Protecting Miners' Safety and Health Since 1978 |
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Jump to Overview DEPARTMENT OF LABOR MINE SAFETY AND HEALTH ADMINISTRATION Metal and Nonmetal Mine Safety and Health REPORT OF INVESTIGATION Surface Metal Mill (Alumina) Fatal Fall of Person Accident April 18, 2007 Parish Abatement Co. Contractor ID No. M390 at Almatis Inc. Arkansas Operations Mill Bauxite, Saline County, Arkansas Mine ID No. 03-00257 Investigators Frederick B. Moore Supervisory Mine Safety and Health Inspector Raymond J. Norwood Mine Safety and Health Inspector Originating Office Mine Safety and Health Administration South Central District 1100 Commerce Street, Room 462 Dallas, TX 75242-0499 Edward E. Lopez, District Manager OVERVIEW
On April 18, 2007, Alejandro E. Malo, contract laborer, age 52, was fatally injured when he fell about 57 feet from a scaffold. Malo was standing on a horizontal scaffold member passing scaffold materials to a coworker working above him. The accident occurred because management policies failed to ensure that persons could safely erect scaffolds where there was a danger of falling. The victim was not tied off and floorboards had been removed from the level of the scaffold where he was working. Additional considerations that might prevent future accidents include providing hand rails around all work platforms, covering large openings in the floor while working above them, and hoisting materials to elevated work locations. GENERAL INFORMATION
Arkansas Operations Mill, a surface alumina mill, owned and operated by Almatis Inc., was located in Bauxite, Saline County, Arkansas. The principal operating official was Dinesh Moorjani, operations manager. The mill operated multiple shifts, 24 hours a day, 7 days per week. Total employment was 230 persons. Alumina oxide was shipped by rail to the mill from several sources. The alumina oxide was conveyed to the mill where it was further refined to produce various grades of alumina oxide for industrial uses. Parish Abatement Co. (Parish), located in Donaldson, Hot Spring County, Arkansas, was an asbestos remediation contractor. The principal operating official was Larry Parish, owner. Parish worked almost exclusively at Almatis performing a variety of projects. On the day of accident, Parish had been contracted to erect two scaffolds for use by another contractor. A regular inspection was in progress when the accident occurred. DESCRIPTION OF ACCIDENT
On the day of the accident, Larry Parish arrived at the mill about 8:00 a.m. He and his crew planned to erect two scaffolds on the fifth floor of building 451. Each scaffold was to consist of two 10-foot-high sections set on top of each other. One scaffold was to be situated over a 7-foot by 9-foot opening in the fifth floor walking surface. That opening was directly above similar openings in the fourth, third, and second floors of the building. Parish had Alejandro Malo (victim) and Joel Mendoza, construction worker, pick up some materials that morning before coming to the mill. They arrived at the mill about 8:20 a.m. Malo and Mendoza attended a safety meeting, where Larry Parish discussed 100 percent tie-off with them and Caleb Parish, construction worker. Larry Parish then directed Malo to rig scaffold materials to be hoisted from the ground floor to the fifth floor of building 451. Larry Parish, Mendoza, and Caleb Parish went to the fifth floor of building 451 to receive the materials and erect the two scaffolds. Malo continued to hoist materials from the ground floor until about 3:15 p.m., when he walked up the stairs to the fifth floor to help complete the scaffolds. One scaffold had been completed and the second scaffold only needed hand rails around the top level. The floor boards at the 10-foot level of each scaffold had been removed and placed on the 20-foot level of each respective scaffold, as had been their work practice at Almatis for several years. Almatis personnel that routinely checked on contractors had not instructed Parish to do otherwise in the past and had not checked on them during the day of the accident. Almatis employees, who were working on the ground level of building 451, were subject to injury from tools, equipment, or materials that could have fallen through the floor openings over which one scaffold was built. Almatis management failed to take action to ensure Parish covered the floor opening. Mendoza was standing on the 20-foot level of the incomplete scaffold to receive materials to complete the hand rails. Larry Parish directed Malo to climb to the 10-foot level of the scaffold and pass materials to Mendoza. Malo, who was wearing a full body harness with two lanyards, reportedly climbed up using 100 percent tie-off. He then stood on a horizontal member of the scaffold structure. Still tied off, Malo took an 8-foot hand rail section from Larry Parish and passed it up to Mendoza. Larry Parish then turned to get another section of hand rail from the floor behind him and heard Malo yell. He turned and saw that Malo had fallen into the large opening on the fifth floor. Mendoza and Caleb Parish, who had been passing materials from the materials hoist to Larry Parish, also heard the yell, but did not see Malo fall. Larry Parish called Ken Zuber, guard, at 3:45 p.m. who then called the plant alert team and emergency medical services. Larry Parish, Mendoza, and Caleb Parish went down the stairs to the second floor. They found Malo lying on a cable tray and conduit pipes about 10 feet above the ground floor. Christopher White, alert team member, quickly arrived and attended to Malo who was non-responsive. Emergency medical services arrived about 3:50 p.m. and Malo was pronounced dead at 4:50 p.m. by the Saline County Coroner. The cause of death was listed as multiple injuries. INVESTIGATION OF ACCIDENT
On the day of the accident, MSHA was notified at 4:28 p.m., by a telephone call from Rusty Griffin, environmental heath and safety specialist, to MSHA's emergency hotline. Fred Gatewood, assistant district manager, was notified and 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. While having no bearing on the cause of the accident, a citation was issued for the failure to immediately contact MSHA and report the accident. MSHA's accident investigation team traveled to the mine, made a physical inspection of the accident scene, interviewed employees, and reviewed documents and work procedures relevant to the accident. MSHA conducted the investigation with the assistance of mine management and employees, contractor management and employees, and the miners' representative. DISCUSSION
Location of Accident The accident occurred on the fifth floor of building 451 where two scaffolds were being erected. The victim was standing on a horizontal scaffold support located on the 10-foot level of the second scaffold. The weather was warm and dry with temperatures reaching 75 degrees Fahrenheit. Scaffolds Each of the two scaffolds to be erected was to consist of two 10-foot vertical sections stacked on top of each other. One scaffold had been completed and the other scaffold only needed hand rails around the top level to complete it. Six-inch pads were placed under the corners of each scaffold to provide stability. Each 10-foot section of the scaffolds was 8 feet long and 8 feet wide and was constructed by connecting 2-inch diameter steel tubing sections that were equipped with snap-locks to hold them together. Vertical tubing sections had 6-inch metal rings around the circumference at 24-inch intervals. Each ring had eight holes to accept the pins that secured the different configurations of hand railing, bracing supports, and floorboards. The floorboards consisted of common lumber pieces 2 inches high by 10 inches wide by 10 feet long. Floorboards had been placed at the 10-foot level of each scaffold as they were erected but were removed and placed on the 20-foot level after those support members had been installed. A fixed ladder had been erected on the outside of the incomplete scaffold. It was placed near a corner away from the completed scaffold. The ladder was three feet short of reaching the 20-foot level and was not in use at the time of the accident. Fall Protection At the time of the accident, Malo and Mendoza were each wearing fall protection. Larry Parish and Caleb Parish, who were standing on the fifth floor walking surface, were not wearing fall protection. They had removed their fall protection just prior to lunch and did not put it back on afterward. Larry Parish, Caleb Parish, and Mendoza each had a Phoenix model full-body harness, manufactured by Traclet/FallStop, which was designed for persons weighing up to 300 pounds. The harnesses were equipped with two 6-foot lanyards manufactured by AO Safety. Malo was wearing a full-body harness, manufactured by Elk River, designed for persons weighing up to 400 pounds. It was equipped with two 6-foot shock-absorbing lanyards manufactured by Elk River. The harness and lanyards worn by Malo were inspected and no defects were found. Training and Experience Larry Parish, Malo, and Mendoza had worked as individual contractors at the mill for about 10 years. When Almatis, Inc. bought the mill from the previous owner about two years ago, Larry Parish formed Parish Abatement Co. and hired Malo and Mendoza. In June 2006, Larry Parish hired Caleb Parish. All four individuals had received training in accordance with 30 CFR, Part 46. ROOT CAUSE ANALYSIS
A root cause analysis was conducted and the following root causes were identified: Root Cause: Management policies and procedures were inadequate and failed to ensure that persons could safely erect scaffolds. Floorboards were not maintained at the 10-foot level of the scaffold where persons were directed to perform work. Corrective Action: Management should establish policies and procedures for erecting scaffolds safely. Floorboards should be provided at all levels where persons will work. Prior to beginning work, possible risks should be discussed and procedures should be established to safely complete the task. Root Cause: Management policies and work procedures failed to ensure that fall protection was properly used by persons working where there was a danger of falling. Corrective Action: Management should establish policies and procedures that ensure fall protection is used continuously by all persons working where there is a danger of falling. Management should evaluate the use of retractable lanyard mechanisms that enable users to change positions without unfastening and reconnecting the lanyard. CONCLUSION
The accident occurred because management policies failed to ensure that persons could safely erect scaffolds where there was a danger of falling. The victim was not tied off and floorboards had been removed from the level of the scaffold where he was working. ENFORCEMENT ACTIONS
Almatis Inc. Order No. 6242345 was issued on April 18, 2007, under the provisions of Section 103(k) of the Mine Act:
Citation No. 6240115 was issued on May 11, 2007, under the provisions of Section 104(a) of the Mine Act for a violation of 30 CFR, 56.11027.
Parish Abatement Co. Citation No. 6240113 was issued on May 11, 2007, under the provisions of Section 104(d)(1) of the Mine Act for a violation of 30 CFR, 56.15005:
Order No. 6240114 was issued on May 11, 2007, under the provisions of Section 104(d)(1) of the Mine Act for a violation of 30 CFR, 56.11027:
Related Fatal Alert Bulletin: APPENDIX A
Persons Participating in the Investigation Almatis Inc.
Rusty Griffin .......... environmental health and safety specialist Dinesh Moorjani .......... operations manager John Simpson .......... construction superintendent
Caleb Parish .......... construction worker Larry Parish .......... owner
Raymond J. Norwood .......... mine safety and health inspector |
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