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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 Nonmetal Mine (Cement) Fatal Fall of Person Accident October 25, 2007 Oro Grande Constructors-Amec-Zachry Joint Venture Contractor I.D. No. M255 at Oro Grande Quarry Riverside Cement Company Oro Grande, San Bernardino County, California Mine I.D. No. 04-00011 Investigators Larry Larson Mine Safety and Health Inspector William Enderby Mine Safety and Health Inspector Isabel Williams Mine Safety and Health Specialist Originating Office Mine Safety and Health Administration Western District 2060 Peabody Road, Suite 610 Vacaville, California 95687 Arthur L. Ellis, District Manager OVERVIEW
On October 25, 2007, Manuel Isidro Hernandez-Armendariz, a contractor iron worker helper, age 19, was fatally injured at a coal mill tower. He stepped on wooden planking covering an opening on the coal mill tower deck. The planking gave way and he fell through the hole 57 feet to the ground below. The victim and two co-workers were attempting to line up an air receiver tank for a dust collector on the fifth level of the tower. The accident occurred because the contractor's policies and procedures were inadequate and failed to identify possible hazards to persons working at elevated locations where there was a danger of falling. The wooden planking covering the opening was not substantially constructed and maintained in good condition. No warning signs or barricades were posted where hazards were not immediately obvious to employees. The victim was wearing fall protection but the lanyards were not secured. GENERAL INFORMATION
Oro Grande Quarry, a surface quarry and cement plant owned and operated by Riverside Cement Company (Riverside) was located at 19409 National Trails Highway, Oro Grande, San Bernardino County, California. The principal operating official was Gordon Johnson, plant manager. The mine normally operated three 8-hour shifts per day, seven days a week. Total employment was 228 persons. Limestone was drilled and blasted from multiple benches. The broken rock was transported by haul trucks to a primary crusher. The material was conveyed to the plant where it was mixed with other materials to produce cement. Finished products were sold in bulk and bag for use in the construction industry. Oro Grande Constructors - Amec-Zachry Joint Venture (OGC - Zachry), located in Oro Grande, San Bernardino County, California, was a construction contractor. The principal operating official was Ben Sims, project manager. Riverside contracted with OGC - Zachry to construct a new cement plant at the mine and the project started on August 29, 2005. OGC - Zachry employed 600 persons who normally worked two 10-hour shifts per day seven days a week at this site. The last regular inspection at this operation was completed on August 9, 2007. DESCRIPTION OF THE ACCIDENT
On the day of the accident, Manuel Isidro Hernandez-Armendariz (victim) reported for work at 6:30 a.m., his normal starting time. Hernandez-Armendariz, Jose Hernandez, iron worker, and Hervey Tavarez, sheet metal helper, were erecting steel when the crane they were using developed operating problems, so Hernandez-Armendariz and Tavarez stopped for lunch. Obednon Tanez, general foreman, instructed Darin Begay, boilermaker foreman, to meet Jose Hernandez on the fifth level of the coal tower platform. Begay was to explain where to place the air receiver tank because it had to be placed in a specific position relative to the baghouse and air duct piping. The air duct piping was to pass through the opening in the deck. Hernandez-Amendariz and Tavarez went to the fifth level and met Jose Hernandez and they prepared to set the air receiver tank. About 1:15p.m., Hernandez -Amendariz positioned the air receiver tank and stepped on wooden planking that had been placed over an opening in the deck to allow the duct work to pass through. The planking gave way and he fell approximately 57 feet to the ground. Hernandez-Armendariz was wearing a harness with two lanyards; however, the lanyards were not secured. Several persons including Steve Rogers, mine safety and health inspector, who was conducting an inspection at the mine, were in the immediate area of the accident at ground level and assisted Hernandez-Armendariz. Emergency medical personnel arrived and transported the victim to a local hospital where he was pronounced dead at 3:56 p.m. by the attending physician. Death was attributed to blunt force trauma. INVESTIGATION OF THE ACCIDENT
Steve Rogers notified Art Ellis, district manager, at 1:37 p.m. and an investigation was started the same day. An order was issued under the provisions of 103(k) of the Mine Act to ensure the safety of the miners. MSHA's accident investigation team traveled to the mine, made a physical inspection at the accident site, interviewed employees, and reviewed conditions and work procedures relevant to the accident. MSHA conducted the investigation with the assistance of mine and contractor management and employees, and the California Occupational Safety and Health Administration (CAL OSHA). DISCUSSION
Location of the Accident The accident occurred on a deck on the fifth level of the coal mill tower. The deck was 57 feet above ground level and measured 12 feet by 11 feet 6 inches. An opening 4 feet 10 inches by 5 feet 9 inches was left in the deck to allow for the installation of the duct work. A wooden platform, consisting of seven 2-inch by 10-inch by 6-foot wooden planks laid adjacent to one another, had been placed over the hole. Two 2-inch by 4-inch by 6-foot boards were placed above and perpendicular to the planks. The planks were connected to the boards with 3-inch nails. Wire was used to attach the two boards to the deck to keep the wooden platform from moving. After the accident, investigators found that only three planks were across the opening on the deck. The planks came loose when some of the nails used in construction failed to hold the planks and boards together as the victim stepped on the platform. One of the boards was still nailed to the planks. The other board was lying upside down with the nails sticking up across the three remaining planks. Fall Protection Two lanyards were required to comply with the 100% tie-off policy in effect at the construction area. Hernandez-Armendariz was wearing a harness style safety belt with two D-rings for the two lanyards but the lanyards had not been attached to any tie off points. Weather Conditions Weather conditions were clear and calm with a temperature of about 75 degrees Fahrenheit. Weather was not considered to be a factor in the accident. Lighting The deck was completely open to the outside. Lighting was not considered to be a factor in the accident. Training and Experience Manuel Isidro Hernandez-Armendariz had 20 weeks of experience all with OGC - Zarchy at this site. He had received training, provided in Spanish, in accordance with 30 CFR, Part 46. ROOT CAUSE ANALYSIS
A root cause analysis was performed and the following causal factors were identified. Causal Factor: Contractor management policies and procedures were inadequate and failed to ensure that persons could safely work on the deck of the fifth level of the coal mill tower. The wooden platform covering the opening was not substantially constructed and maintained in good condition. Corrective Actions: Contractor management should establish policies and procedures to ensure that persons are trained to substantially construct and maintain platforms in good condition. Prior to beginning work, potential risks should be discussed and procedures established to safely complete the task. Causal Factor: Contractor management policies and work procedures failed to ensure that fall protection was properly used by persons where there was a danger of falling. Corrective Action: Contractor management should establish policies and procedures that ensure fall protection is used continuously by all persons where there is a danger of falling. Management should monitor employees to ensure the policies and procedures are followed. Causal Factor: Contractor management policies and work procedures failed to ensure that persons were aware of safety hazards not immediately obvious. No barricades or warning signs were posted at the approaches to the opening on the deck. Corrective Action: Contractor management should establish policies and procedures to ensure that barricades or warning signs were posted to make persons aware of safety hazards not immediately obvious. CONCLUSION
The accident occurred because the contractor's policies and procedures were inadequate and failed to identify possible hazards to persons working at elevated locations where there was a danger of falling. The wooden planking covering the opening was not substantially constructed and maintained in good condition. No warning signs or barricades were posted where hazards were not immediately obvious to employees. The victim was wearing fall protection but the lanyards were not secured. ENFORCEMENT ACTIONS
Riverside Cement Company Order No. 6431058 was issued on October 25, 2007, to Riverside Cement Company under the provisions of Section 103(k) of the Mine Act:
Oro Grande Constructors - Amec-Zachry Joint Venture Citation No. 6439706 was issued on February 5, 2008, under the provisions of Section 104(a) of the Mine Act for a violation of 30 CFR 56.15005:
Citation No. 6439707 was issued on February 5, 2008, under the provisions of Section 104(a) of the Mine Act for a violation of 30 CFR 56.11027:
Citation No. 6439708 was issued on February 5, 2008, under the provisions of Section 104(a) of the Mine Act for a violation of 30 CFR 56.20011:
Related Fatal Alert Bulletin: APPENDIX A
Persons Participating in the Investigation Riverside Cement Company
Larry Ratliff ............... safety manager-cement Ronnie Waxler ............... maintenance manager
Earl Chapman ............... safety director Richard Gibson ............... area safety manager Jesse Rodrigues ............... safety manager Jerry Roepke ............... site safety manager Kenneth Thornton ............... structural steel superintendent Willie Powe ............... structural steel superintendent Adam Spiewak ............... council for OGC-Zachry Timothy Olson ............... council for OGC-Zachry
Lacy Pittman ............... associate safety engineer
William Enderby ............... mine safety and health inspector Isabel Williams ............... mine safety and health specialist |
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