MINE SAFETY AND HEALTH ADMINISTRATION
Metal and Nonmetal Mine Safety and Health
REPORT OF INVESTIGATION
Surface Nonmetal Mine
(Sand and Gravel)
Fatal Fall of Person Accident
July 22, 1999
Moscow Pit/Sand & Gravel #4/Div 88/Portable
T. M. Development L.L.C.
Moscow, Hilsdale County, Michigan
I.D. No. 20-03090
Donald J. Foster
Supervisory Mine Safety and Health Inspector
Herbert D. Bilbrey
Mine Safety and Health Inspector
Mine Safety and Health Administration
North Central District
515 West First Street, Room 333
Duluth, MN 55802-1302
Felix A. Quintana, District Manager
On July 22, 1999, Harold W. Berry, dragline operator, age 75, was fatally injured when he fell from the elevated walkway of the dragline. Berry was using a pry bar to assist with the repairs to the clutch of the dragline. The bar slipped, causing Berry to lose his balance and fall from the walkway to the ground.
The accident occurred because the elevated walkway of the dragline was not provided with railings.
Berry had a total of 50 years mining experience as a dragline operator, 28 weeks at this mine. He had not received training in accordance with 30 CFR, Part 48.
The Moscow Pit, a surface sand and gravel operation, owned and operated by T.M. Development L.L.C., was located at 8750 Chicago Drive, Moscow, Hilsdale County, Michigan. The principal operating official was Donald J. Falconer, Jr., mine foreman. The mine normally operated one, 9-hour shift a day, five days a week. Total employment was eight persons.
Sand and gravel was extracted from a single bench with front-end loaders and a dragline. The material was transported by conveyor to the plant where it was screened and stockpiled. The finished product was used in the company's asphalt business.
The last regular inspection of this operation was completed on October 28, 1998. Another regular inspection was conducted following this investigation.
DESCRIPTION OF THE ACCIDENT
On the day of the accident, Harold Berry (victim) reported for work at 7:00 a.m., his normal starting time. At about 8:00 a.m., after performing miscellaneous tasks, Berry and Donald Falconer, mine foreman, started to make repairs to the clutch of the dragline. The adjusting bolt on the clutch was frozen. Falconer first attempted to free it using a wrench. When that failed, he tried a punch and hammer. At about 8:30 a.m., Berry placed a pry bar against the adjusting bolt for added pressure while Falconer struck the bolt with a punch and hammer. The bar slipped and Berry fell backwards over the edge of the walkway, striking the crawler track of the dragline before falling to the ground.
Falconer called 911 on his mobile phone and radioed his employees for help. The mine employees attended to Berry until the emergency personnel arrived and transported him to a local hospital. He was later life-flighted to a different hospital where he died on July 23, 1999, at 6:40 p.m.
Death was attributed to hypertensive cardiovascular disease with significant conditions of multiple blunt trauma.
INVESTIGATION OF THE ACCIDENT
MSHA was notified of the accident on July 23, 1999, by a phone call from Donald Falconer, mine foreman, to the North Central District. At the time of the phone call, Falconer informed the district that the injuries did not appear to be life threatening. Falconer was referred to the Lansing, Michigan field office where he informed Gerald Holeman, field office supervisor, that Berry had suffered broken ribs from the fall and the injuries were not life threatening. The company made no attempts to notify MSHA of Berry's death. A Mine Accident, Injury and Illness Report (MSHA Form 7000-1) dated July 26, 1999, was submitted to MSHA. However, the report listed the injuries as broken ribs. MSHA learned of Berry's death on February 28, 2000, when an attorney for the family contacted the North Central District requesting information on the accident.
An investigation was started on March 6, 2000, and was conducted with the assistance of mine management and employees. The miners did not request, nor have representation during the investigation.
The equipment involved in the accident was a Northwest, Model 190D, dragline manufactured in 1965. The dragline was powered by a Detroit 8V92 diesel engine and equipped with a 100-foot boom and a 5-yard bucket.
The dragline, which was located in the pit, was purchased used in October 1998 and had been placed into operation in November 1998. It operated for about a month until it was idled for the winter. Production resumed in March 1999, and continued until July 20, 1999, when the dragline began to experience mechanical problems with the clutch.
The dragline came equipped with a walkway on both sides of the cab. The accident occurred on the right elevated walkway. Railings were not provided, however, the company had purchased the steel and was planning to fabricate them. The walkways were elevated 7 feet 4inches above the ground and 3 feet 10 inches to the top of the crawler track. The right walkway provided access to the clutch and motor compartments, and the operator's cab. Its overall length was 20 feet and the width varied from 24 inches at the entrance to the operator's cab to 42 inches at the clutch and motor compartment entrances. The walkways came equipped with a 5 inch metal toe board attached. Access to this walkway was provided by a fixed ladder at the rear of the dragline. The walking surface was constructed of expanded metal.
At the time of the accident, the crawler tracks of the dragline were positioned parallel to the outer edge of the walkways.
The pry bar was a manufactured steel bar, 5 feet long, 1-3/4 inches in diameter, and beveled on one end.
Railings to both walkways, and an additional 22 inches of walkway width at the operator's entrance to the cab on the right side, were installed on July 29, 1999, seven days after the accident.
The weather on the day of the accident was warm and dry.
The root cause of the accident was management's failure to install railings on the elevated walkway of the dragline before placing it into service.
Citation No. 4548444 was issued on March 23, 2000, under provisions of Section 104(d)(1) of the Mine Act for violation of 30 CFR 56.11002:
A fatal accident occurred at this operation on July 22, 1999, when a dragline operator fell from the elevated walkway of the machine. The walkway was not provided with handrails to prevent persons from falling. The mine operator's failure to provide the handrails is a serious lack of reasonable care which constitutes more than ordinary negligence and is an unwarrantable failure to comply with a mandatory standard.This citation was terminated on March 23, 2000. Handrails were installed on July 29, 1999.
Related Fatal Alert Bulletin:
Persons Participating in the Investigation
T.M. Development L.L.C.
Donald Falconer, mine foremanMine Safety and Health Administration
Donald Foster, supervisory mine safety and health inspectorAPPENDIX B
Herbert Bilbrey, mine safety and health inspector
Donald Stefaniak, mine safety and health inspector
T.M. Development L.L.C.
Donald Falconer, mine foreman
David Hammond, plant operator
Thomas Strauss, equipment operator
Wende Corwin, dragline operator
Kevin Elarton, front-end loader operator